Infection Control in Home Settings

Infection control in home health is fundamentally different from hospital-based care. In a hospital, there is an infection prevention team, an environmental services crew that cleans rooms on a schedule, a stocked supply closet, and colleagues to remind you when you forget. In a patient's home, you are on your own. You bring your own supplies, you clean up after yourself, and you are often the only healthcare worker the patient sees. Preventing infections is your responsibility. This guide gives you the comprehensive knowledge to do it right.

Why Infection Control Matters in Home Health

Home health patients are frequently elderly, immunocompromised, or recovering from surgery or illness. They are vulnerable. At the same time, the home environment is not designed for healthcare: there may be pets, family members with their own illnesses, carpeted floors that are hard to disinfect, and limited handwashing facilities.

Healthcare-associated infections (HAIs) are not limited to hospitals. Home health patients can develop:

• Urinary tract infections (UTIs) from catheter care
• Wound infections from improper dressing changes
• Respiratory infections transmitted by caregivers
• Skin infections (MRSA, fungal) from contaminated surfaces or equipment
• Gastrointestinal infections (C. difficile, norovirus) from poor hand hygiene

Every infection in a vulnerable patient can mean a hospitalization, a setback in recovery, or in severe cases, death. Prevention is always better and cheaper than treatment.

Hand Hygiene - The Most Important Skill You Have

If you do nothing else from this guide perfectly, do hand hygiene perfectly. It is the single most effective measure for preventing the spread of infection. Study after study confirms this.

When to Perform Hand Hygiene

In home health, you should perform hand hygiene at these specific moments:

1. When you arrive at the patient's home - before touching anything
2. Before any patient contact - before taking vital signs, assisting with care, preparing food
3. Before a clean or aseptic task - before wound care, catheter care, preparing medications
4. After body fluid exposure - after toileting assistance, emptying a catheter bag, wound care, handling soiled linens
5. After patient contact - after completing a care task
6. After touching the patient's surroundings - after handling the bed linens, cleaning the bathroom
7. After removing gloves - always. Gloves do not replace hand hygiene. Micro-tears in gloves allow pathogens through.
8. Before preparing food - after any other activity
9. After using the restroom yourself
10. Before leaving the patient's home

In a typical home health visit, you may perform hand hygiene 15-20 times. That is normal and expected.

Alcohol-Based Hand Rub (ABHR) - The Default Method

ABHR is the preferred method when hands are not visibly soiled. It is faster, more effective against most pathogens, and less damaging to skin than soap and water.

Correct technique:

1. Apply a palmful of product (about the size of a quarter) to one palm.
2. Rub palms together.
3. Rub the back of each hand with the opposite palm, interlacing fingers.
4. Rub palm to palm with fingers interlaced.
5. Rub the backs of the fingers by clasping hands.
6. Rub each thumb in the opposite palm using a rotational movement.
7. Rub the tips of fingers in the opposite palm in a circular motion.
8. Rub each wrist.
9. Continue rubbing until hands are completely dry (at least 20 seconds).

ABHR does NOT work against:

• Clostridioides difficile (C. diff) spores - must use soap and water
• Norovirus - must use soap and water
• Visibly soiled hands - must use soap and water

Soap and Water Handwashing

Required when:

• Hands are visibly soiled (dirt, blood, body fluids)
• After caring for a patient with C. difficile or norovirus
• After using the restroom
• When ABHR is not available

Correct technique:

1. Wet hands with warm running water (not hot, which dries and damages skin).
2. Apply soap to palms.
3. Lather all surfaces thoroughly: palms, backs of hands, between fingers, around and under nails, thumbs, wrists.
4. Scrub for at least 20 seconds (sing "Happy Birthday" twice as a timer).
5. Rinse thoroughly under running water, hands pointed down.
6. Dry with a clean towel or paper towel.
7. Use the towel to turn off the faucet, then discard the towel.

Hand Hygiene Challenges in the Home

• The patient's bathroom may not have soap. Bring your own hand soap.
• The sink may be in another room. Carry a travel-sized ABHR in your pocket or bag.
• Patients may feel you are being rude by washing your hands so often. Explain that it protects them: "I wash my hands a lot to make sure I do not bring any germs to you."
• In winter, frequent handwashing dries and cracks skin. Use a moisturizer after hand hygiene. Cracked, broken skin is both an infection risk to you and a source of pathogens.

Personal Protective Equipment (PPE) - Detailed Guide

What to Bring

Stock your home health bag with:

• Non-latex exam gloves (multiple sizes in case a family member assists)
• Surgical masks
• N95 respirators (if you are assigned to patients on airborne precautions)
• Disposable gowns or fluid-resistant aprons
• Eye protection (goggles or face shield)
• Shoe covers (for heavily soiled environments)
• Biohazard bags (red) for contaminated waste

When to Wear Each Item

Gloves:
Wear when touching or when there is a reasonable chance of touching:

• Blood
• Body fluids (urine, feces, vomit, wound drainage, saliva, sputum)
• Mucous membranes (mouth, nose, eyes)
• Non-intact skin (wounds, rashes, skin tears)
• Contaminated surfaces or equipment

Change gloves:

• Between different care tasks on the same patient (for example, between perineal care and oral care)
• When gloves become visibly soiled or torn
• Before touching clean surfaces or equipment after a dirty task

Never:

• Wash and reuse disposable gloves (washing damages the material and does not remove pathogens from micro-pores)
• Touch your face, phone, clipboard, or clean surfaces while wearing contaminated gloves
• Wear the same pair of gloves for an entire visit

Gowns or aprons:
Wear when:

• Your clothing may come in contact with blood or body fluids
• Caring for a patient on contact precautions (MRSA, VRE, C. difficile)
• Giving a bed bath to a patient with an open, draining wound
• Cleaning up a large spill

Surgical masks:
Wear when:

• Caring for a patient on droplet precautions (influenza, pertussis, respiratory illness)
• The patient is actively coughing or sneezing
• You have a respiratory illness and must provide care (and cannot find a replacement caregiver)
• During high-risk procedures (wound irrigation, suctioning)

N95 respirators:
Wear when:

• Caring for a patient with known or suspected tuberculosis (TB)
• Caring for a patient with measles or chickenpox (if you are not immune)
• Your agency designates the patient as requiring airborne precautions

You must be fit-tested for an N95 before using it. A poorly fitting N95 provides little more protection than a surgical mask. Men must be clean-shaven for a proper seal.

Eye protection:
Wear when there is a risk of splashing:

• Wound irrigation
• Suctioning
• Cleaning up vomit or large body fluid spills
• Any procedure where body fluids could become aerosolized

Donning (Putting On) PPE - Correct Order

1. Perform hand hygiene
2. Put on the gown (tie at the neck and waist)
3. Put on the mask or respirator (form the nose piece to your face, ensure a snug fit)
4. Put on eye protection (goggles or face shield)
5. Put on gloves (the cuffs should cover the gown's wrists)

Doffing (Removing) PPE - Correct Order

This is the most dangerous step. Most contamination exposure occurs during doffing. Go slowly and deliberately.

1. Remove gloves (most contaminated item):
   • Grasp the outside of one glove at the wrist
   • Peel it off, turning it inside out
   • Hold the removed glove in the still-gloved hand
   • Slide a finger under the wrist of the remaining glove
   • Peel it off, turning it inside out over the first glove
   • Discard both gloves
2. Remove eye protection by handling only the earpieces or headband (the front is contaminated). Place in a bag or discard.
3. Remove the gown:
   • Untie the neck and waist ties
   • Pull the gown away from your body by the shoulders
   • Roll it up with the contaminated side inward
   • Discard
4. Remove the mask or respirator:
   • Remove by the ear loops or ties only (the front is contaminated)
   • Discard
5. Perform hand hygiene immediately

PPE Disposal in the Home

• Place all used PPE in a plastic bag, tie it closed, and place it in the patient's trash
• For blood-soaked or heavily contaminated items, double-bag them
• In homes with immunocompromised patients, ask the nurse about specific disposal protocols
• Never leave used PPE lying around the patient's home

Sharps Safety

Many home health patients use insulin syringes, lancets for blood glucose testing, or other sharps. You may also encounter used needles from previous injections.

Sharps Handling Rules

• Never recap a used needle. This is the leading cause of needlestick injuries.
• Never bend, break, or remove needles from syringes.
• Dispose of sharps immediately after use in a puncture-resistant container with a secure lid.
• The ideal container is an FDA-approved sharps disposal container (red, hard plastic, with a locking lid).
• If no sharps container is available, use a heavy-duty plastic container with a screw-on lid, like a laundry detergent bottle. Label it "SHARPS - DO NOT RECYCLE."
• When the container is three-quarters full, seal it and follow local disposal guidelines (drop-off locations, mail-back programs, or special trash collection).
• Never put sharps in the regular trash, recycling bin, or flush them down the toilet.

If You Get a Needlestick

1. Wash the wound immediately with soap and water. For eye or mucous membrane exposure, flush with water for at least 5 minutes.
2. Do not squeeze the wound to force bleeding.
3. Report the incident to your supervisor immediately.
4. Seek medical evaluation within 1-2 hours if possible. Post-exposure prophylaxis (PEP) for HIV is most effective when started quickly.
5. Complete an incident report per your agency's policy.
6. Follow up with occupational health for bloodwork and monitoring.

Cleaning and Disinfection in the Home

Routine Cleaning

Clean surfaces that you use for patient care during each visit:

• Bathroom surfaces after bathing or toileting assistance
• Kitchen surfaces after meal preparation
• Any surface where you placed care supplies

Cleaning vs. disinfecting:

• Cleaning removes visible dirt and some germs using soap and water
• Disinfecting kills germs on surfaces using chemical agents
• Always clean before disinfecting. Disinfectants do not work well on dirty surfaces.

Disinfection Solutions

• 1:10 bleach solution (1 part household bleach to 9 parts water): effective against most pathogens including C. difficile, MRSA, and norovirus. Make fresh daily (bleach solution loses potency after 24 hours). Use in a labeled spray bottle.
• EPA-registered disinfectant wipes (such as Clorox or Lysol wipes): convenient for wiping down equipment and hard surfaces.
• Alcohol wipes (70% isopropyl alcohol): effective for equipment like stethoscopes and blood pressure cuffs.

Cleaning Up Blood or Body Fluid Spills

1. Put on gloves and a gown.
2. If the spill is large, use absorbent material (paper towels, disposable cloths) to soak up the bulk of the fluid. Place the soiled material in a plastic bag.
3. Clean the area with soap and water.
4. Apply the 1:10 bleach solution. Let it sit for at least 10 minutes.
5. Wipe up and dispose of all materials in a plastic bag.
6. Remove gloves and gown, perform hand hygiene.

Reusable Equipment Disinfection

Disinfect these items between patients:

• Blood pressure cuff: wipe all surfaces with a disinfectant wipe
• Stethoscope: wipe the diaphragm, bell, earpieces, and tubing with an alcohol wipe
• Pulse oximeter: wipe with an alcohol wipe
• Thermometer: follow manufacturer's instructions (usually an alcohol wipe or probe cover)
• Gait belt: if visibly soiled, wash with soap and water and air dry. If contaminated with body fluids, consider replacing it.
• Your bag: wipe down the exterior regularly. Never place your bag on the floor or the patient's bed.

Laundry and Linen Handling

• Wear gloves when handling soiled linens.
• Do not shake soiled linens. Shaking can aerosolize pathogens.
• Hold soiled linens away from your body and uniform.
• Place soiled linens in a plastic bag or directly into the washing machine.
• Wash in hot water (at least 160 degrees F if the fabric allows) with regular detergent.
• Dry on the hottest setting the fabric allows.
• Keep clean and soiled linens completely separate.
• If linens are heavily soiled with blood or body fluids, pre-soak in cold water (hot water sets blood stains and may not remove all organic material).

Isolation Precautions in the Home Setting

Contact Precautions (MRSA, VRE, C. difficile, Scabies)

• Wear gloves and a gown for all direct patient contact and contact with the patient's environment.
• Dedicate equipment (blood pressure cuff, stethoscope, thermometer) to this patient. Do not use the same equipment on other patients without thorough disinfection.
• For C. difficile: always wash hands with soap and water (ABHR does not kill C. diff spores). Clean environmental surfaces with the bleach solution.
• Educate the patient and family about hand hygiene, especially after using the bathroom.

Droplet Precautions (Influenza, COVID-19, Pertussis)

• Wear a surgical mask (or N95 if your agency requires it) when within 3-6 feet of the patient.
• The patient should wear a mask if you need to transport them or if other household members are at risk.
• Encourage respiratory hygiene: covering coughs, using tissues, disposing of tissues immediately.
• Increase ventilation if possible (open a window).

Airborne Precautions (Tuberculosis, Measles, Chickenpox)

• Wear a fit-tested N95 respirator for all contact.
• Increase ventilation in the room.
• The patient should not leave the home until cleared by the physician.
• If the patient must leave (for a medical appointment), they should wear a surgical mask.
• You should be tested for TB regularly if caring for TB patients.

Preventing Common Infections

Urinary Tract Infections (Catheter-Related)

• Perform hand hygiene before and after catheter care.
• Clean the catheter insertion site daily as ordered (usually with soap and water, cleaning away from the body).
• Keep the drainage bag below the level of the bladder at all times.
• Do not let the drainage bag touch the floor.
• Empty the drainage bag regularly (at least every 8 hours or when two-thirds full) using clean technique.
• Do not disconnect the catheter from the drainage bag unless instructed by the nurse.
• Report any signs of UTI: cloudy or foul-smelling urine, blood in urine, fever, pain, increased confusion.

Wound Infections

• Follow the wound care protocol exactly as ordered.
• Use clean or sterile technique as specified.
• Do not touch the wound or dressing with bare hands.
• Report signs of infection: increased redness, swelling, warmth, drainage (especially if green or foul-smelling), increased pain, fever.

Respiratory Infections

• If you are sick (coughing, sneezing, fever), do not visit patients. Call your supervisor for a replacement.
• Stay current on your flu vaccine and any other recommended immunizations.
• Practice respiratory hygiene yourself: cover coughs, wash hands after blowing your nose.
• Encourage the patient to get their flu and pneumonia vaccines as recommended by their physician.

Waste Disposal

• Regular trash: non-contaminated waste, food waste, paper towels used for cleaning
• Biohazard waste: items soaked or dripping with blood or body fluids. Place in a red biohazard bag if available, or double-bag in regular plastic bags and label.
• Sharps: puncture-resistant container only. Never in regular trash.
• Medications for disposal: do not flush medications unless specifically indicated on the label. Check with the pharmacy for drug take-back programs.
• Follow your agency's policy and local regulations for disposal. Rules vary by jurisdiction.

Protecting Yourself

• Keep your immunizations current (flu, Tdap, hepatitis B, COVID-19, and others as recommended).
• Get a TB test annually if you work with high-risk populations.
• Do not eat, drink, or apply cosmetics during patient care.
• Change your clothes before going home if they are contaminated during a visit. Keep a spare set in your car.
• If you have an open cut or wound on your hands, cover it with a waterproof bandage and wear gloves.
• Report any occupational exposure (needlestick, splash to eyes or mouth, contact with a patient's blood or body fluids on broken skin) immediately.