Point-of-Care-Risk Assessment (PCRA) is performed by all healthcare workers to determine the appropriate infection prevention and control measures for safe client care and to protect the worker from exposure to micro-organisms. Recall how infections are spread, as this can help you better do a PCRA and break the chain of infection.

Prior to every client interaction, you, as an HCA, have a responsibility to assess the infectious risk posed to yourself and other clients, visitors and workers by a client, situation, or procedure. The PCRA is an evaluation of the risk factors related to the interaction between you, the client, and the client’s environment to assess their potential for exposure to infectious agents and identify risks for transmission

Point of Care Risk Assessment (PCRA) is when you assess the risk involved in providing care to a client who appears sick, or letting them interact with other clients. Sound complicated? In reality, healthcare workers conduct general point of care assessments many times a day, often without thinking about it. For example, when you approach a client, you automatically note their mental status, ease of breathing, skin colour, etc. An infection control PCRA is simply an extension of this. The next section offers you some questions to consider and Figure 2.6.1 shows the steps for deciding the precautions you would take.

 Questions you should ask yourself during a PCRA include:

• What contact will I have with the resident? (direct hands-on care vs. no hands-on care; contact with mucus membranes or non-intact skin)
• What task(s) or procedures(s) am I going to perform? Is there a risk of splashes/sprays? Likely to stimulate a cough? Or gagging?
• If the resident has diarrhea, is she/he continent? If incontinent, can stool be contained in an adult incontinence product?
• Is the resident able and willing to perform hand hygiene? Or respiratory hygiene (covering their cough/sneeze)?
• Is the resident able to follow instructions?
• Is the resident in a shared room? Is there a better room/space that I should use to provide this care?
• Is there personal protective equipment that I should put on prior to this task?

Who should do PCRAs?

Everyone that interacts with clients should be doing a PCRA. It can be as simple as noting if they’re coughing today when they weren’t yesterday. Healthcare workers should routinely perform PCRAs throughout the day to apply control measures for their safety and the safety of clients and others in the healthcare environment.

For example, a PCRA is performed when a healthcare worker evaluates a client’s situation to:

• Determine the priority for single rooms, or for roommate selection, if rooms are to be shared by clients.
• Determine the possibility of exposure to blood, body fluids, secretions and excretions and non-intact skin, and select appropriate control measures (e.g., PPE) to prevent exposure
• Determine the need for additional precautions when routine practices are inadequate to prevent exposure.

Have a look at Table 2.6.1 that uses Clostridium difficile (C. difficile) as an example of infection with contact spread to better understand the PCRA you might use in your work. It provides you with greater understanding of what would be higher risk, and helps you make better choices for the need of additional precautions to go along with your routine practices.

Table 2.6.1 PCRA Example using C. Difficile

Additional Precautions Practices

Another practice used in healthcare is the use of Additional Precautions. Additional precautions is usually determined by the infection control nurse  (Perry et al., 2014). When a client is suspected of having or is confirmed to have certain pathogens or clinical presentations, additional precautions are implemented by the healthcare worker in addition to routine practices (PIDAC, 2012).

The type of additional precautions to use along with the Routine Precautions will depend on how the particular pathogen is spread and this will determine the type of additional precautions to be used. There are generally three types of infection spread that require consideration for additional precautions: Contact, Droplet, and Airborne. For example, Methicillin Resistant Staphylococcus Aureus (MRSA) requires contact precautions as the bacteria is spread by both direct and indirect contact. The infection control nurse will advise which additional precautions staff will use. Table 2.6.2 provides you with some examples you will likely see in your practice and to understand when additional precautions are used.

Some infections may need a combination of additional precautions (contact, droplet, airborne) since some micro-organisms can be transferred by more than one route. Regardless of the additional precautions, you still need to use the routine practices even with the additional precautions.

Table 2.6.2 Additional Precautions

(image courtesy of the Provincial Infection Control Network of British Columbia (PICNet, 2014, p. 18)  Long description]

Long Description for Figure 2.6.1 PCRA Decision Algorithm

The following is a flowchart PiCNET (2014, p. 15) describes the decision-making process around PCRA:

1. Notice the Symptoms
   • Cough
   • Diarrhea
   • Vomiting
   • Rash
2. Do they also have a fever?
3. If yes, are the symptoms new?
4. If yes:
   1. Is there something I should do? E.g., personal protective equipment.
   2. Is there something I should advise the client to do? E.g. respiratory etiquette, or mask.
   3. Whom should I tell? E.g., physician or charge nurse.
   4. Have I seen more than one person with these symptoms today?
      • Could this be an outbreak?
      • Implement outbreak control strategies and contact Public Health

Long Description for Table 2.6.1 PCRA Example using C. Difficile

This table was from the Public Health Agency of Canada (2016)

Infectious Agent/ Infected Source

Higher transmission versus lower transmission infectious agent risk symptoms:

1. 1. • Frequent diarrhea versus formed stools
      • Incontinence versus continence
      • Poor hygiene versus good hygiene
      • Not capable of self-care due to physical condition, age, or cognitive impairment versus capable of self-care

Environment

Higher transmission versus lower transmission environmental risks:

1. 1. • High patient/ nurse ratio versus low patient/ nurse ratio
      • Shared bathroom, shared sink versus single room, private in-room toilet, designated patient handwashing sink
      • Shared commode without cleaning between patients versus dedicated commode
      • No hand hygiene at point of care versus hand hygiene at point of care
      • No designated staff handwashing sink or sink is used for other purposes or sink is dirty versus an accessible, designated, clean staff handwashing sink.
      • Inadequate housekeeping versus appropriate housekeeping

Susceptible Host (patient)

1. 1. • Receiving direct patient care versus capable of self-care
      • Poor personal hygiene versus good personal hygiene

[Back to Table 2.6.11

Long Description for Table 2.6.2 Additional Precautions

Depending on the mode of transmission, additional precautions should be taken:

If the mode of transmission is by contact:

Extra precautions would include wearing gloves and gown. Common infections that are spread by contact are Norovirus and other GI infections, C. difficile, MRSA, and Scabies. Symptoms of these infections, and possible points of entry for infection, are diarrhea or vomiting, open wounds, or patches of open skin.

If the mode of transmission is by droplet:

Extra precautions would include wearing gloves, a gown, a surgical mask and eye protection. Common infections that are spread by droplets are Influenza (flu), the common cold, and whooping cough. Symptoms of these infections are coughing and sneezing.

If the mode of transmission is airborne:

Extra precautions would include wearing an N95 respirator. Common airborne infections are Tuberculosis, measles, chicken pox, and rubella. Symptoms of these types of infections are a chronic cough and fever with an unidentified rash.

[Back to Table 2.6.2]

Chapter 2 Attributions and References

Unit 2.2 Image Attributions

1. 1. • Figure 2.2.1 Infections Spread Quickly! (https://pxhere.com/en/photo/1079549) from PxHere, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/) licence.
      • Figure 2.2.2 School Sores, or Impetigo, is Highly Contagious (https://pxhere.com/en/photo/937257) from PxHere, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/) licence.
      • Figure 2.2.3 Bacteria Infection (https://pxhere.com/en/photo/718582) from PxHere, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/) licence.
      • Figure 2.2.4 Antibiotics Can Disrupt the Balance of Normal Pathogens (https://pxhere.com/en/photo/566564) from PxHere, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/) licence.
      • Figure 2.2.5 The Chain of Infection © All rights reserved.  Routine Practices and Additional Precautions for Preventing the Transmission of Infections in Healthcare Settings.   Public Health Agency of Canada.  modified: 2017-09-05. URL: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings – Canada.ca  Adapted and reproduced with permission from the Minister of Health, 2023.

Unit 2.4 Image Attributions

1. 1. • Figure 2.4.1 Left 4 Germs : One about scrubbing your hands… (https://www.flickr.com/photos/tbsmith/3654276952) by tbSMITH, via Flickr, is used under a CC BY-NC-ND 2.0 (https://creativecommons.org/licenses/by-nc-nd/2.0/) licence.
      • Figure 2.4.2 Female hands with lunar black manicure (https://depositphotos.com/335598704/free-stock-photo-female-hands-lunar-black-manicure.html) by FineShine, via depositphotos.com , is used under an Attributed Free License (https://depositphotos.com/free-license-with-attribution.html).
      • Figure 2.4.3 My boo-boo 3 (https://www.flickr.com/photos/thomwatson/4695965) by Thom Watson, via Flickr, is used under a CC BY-NC-SA 2.0 (https://creativecommons.org/licenses/by-nc-sa/2.0/) license.
      • Figure 2.4.4 Person Washing Hands (https://www.pexels.com/photo/person-washing-hands-3943901/) by Anna Shvets, via Pexels, is used under the Pexels license.
      • Figure 2.4.5 Wash Your Hands Thoroughly (https://pxhere.com/en/photo/1395311) from PxHere, is used under a CC0 Public Domain licence (https://creativecommons.org/publicdomain/zero/1.0/).
      • Figure 2.4.6 Dispenser Photo (https://pixnio.com/people/female-women/hand-sanitizer-from-an-automatic-dispenser) by Amanda Mills, USCDCP, via Pixnio, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/)licence.
      • Figure 2.4.7 Question Mark Question Answer Search Engine Icon (https://pixabay.com/illustrations/question-mark-question-response-1019993/) by Peggy_Marco, via Pixabay, is used under the Pixabay License (https://pixabay.com/de/service/terms/).
      • Figure 2.4.8 Five Moments of Hand Hygiene from WHO () IPC Training tools, is used under a CC BY-NC-SA 3.0 IGO (https://creativecommons.org/licenses/by-nc/3.0/igo/) license.
      • Figure 2.4.9 Hand hygiene with ABHR (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.10 Remove gloves from box (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.11 Apply first glove (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.12 Apply second glove (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.13 Non-sterile gloved hands (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.14 Grasp glove on the outside 1/2 inch below the cuff (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.15 Pull glove off …(https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.16 … inside out (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.17 Gather inside-out glove in remaining gloved hand (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.18 Insert finger under cuff of gloved hand (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.19 Remove second glove (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.20 Discard used non-sterile gloves (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.
      • Figure 2.4.21 Hand hygiene with ABHR (https://opentextbc.ca/clinicalskills/chapter/1-6-hand-hygiene/) by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) licence.

Unit 2.5 Image Attributions

1. 1. • Figure 2.5.1 Personal Protective Equipment (PPE) (https://pxhere.com/en/photo/1648569) from PxHere, is used under a CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/) licence.
      • Figure 2.5.2 Donning Personal Protective Equipment (https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-d.html#D.X) by the Public Health Agency of Canada (2016, Appendix X).
      • Figure 2.5.3 Doffing Personal Protective Equipment (https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-d.html#D.X) by the Public Health Agency of Canada (2016, Appendix X).

Unit 2.6 Image Attributions

1. 1. • Figure 2.6.1 PCRA Decision Algorithm (https://www.picnet.ca/resources/rescarebooklet/) from the Provincial Infection Control Network of BC (PICNet, 2014, p. 15), is used under a CC BY-NC-ND 4.0 (https://creativecommons.org/licenses/by-nc-nd/4.0/) licence.
      • Table 2.6.1 PCRA Example Using C. Difficile is from Table 2 (https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections) in the Public Health Agency of Canada (2016), via Government of Canada website, and is used under the non-commercial reproduction Terms and Conditions (https://www.canada.ca/en/transparency/terms.html) on the website.
      • Table 2.6.2 Additional Precautions PPE (https://www.picnet.ca/resources/rescarebooklet/) from the Provincial Infection Control Network of BC (PICNet, 2014, p. 18), is used under a CC BY-NC-ND 4.0 (https://creativecommons.org/licenses/by-nc-nd/4.0/) licence.

Videos

• Soap and Water by Learning Hub (2022) on YouTube
• Alcohol Based Hand Rub by Learning Hub (2022) on YouTube
• PPE Donning for Medical Mask by Learning Hub (2022) on YouTube
• PPE Doffing for Medical Mask by Learning Hub (2022) on YouTube

References

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Braswell, M. L., & Spruce, L. (2012). Implementing AORN recommended practices for surgical attire. AORN Journal, 95(1), 122-140. doi: 10.1016/j.aorn.2011.10.017.

Centers for Disease Control and Prevention (CDC). (2007). Part III: Precautions to prevent the transmission of infectious agents. Retrieved from http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html.

Centers for Disease Control (CDC). (2012). Frequently asked questions about Clostridium difficile for healthcare providers. https://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

Doyle, G. R., & McCutcheon, J. A. (2015, November 23 ). Clinical procedures for safer patient care. British Columbia Institute of Technology (BCIT)/ BCCampus. https://opentextbc.ca/clinicalskills/

Learning Hub. (2022, February 28). Alcohol based hand rub [Video]. YouTube. https://www.youtube.com/watch?v=_WCzsSC18Io

Learning Hub. (2022, February 28). PPE doffing for medical mask [Video]. YouTube. https://www.youtube.com/watch?v=pL8blsiZfF8

Learning Hub. (2022, February 28). PPE donning for medical mask [Video]. YouTube. https://www.youtube.com/watch?v=FcCbvnxT0vI

Learning Hub. (2022, February 28). Soap and water [Video]. YouTube. https://www.youtube.com/watch?v=19Rpe5wmqYE

Longtin, Y., Sax, H., Allegranzi, B., Schneider, F., & Pittet, D. (2011). Hand hygiene. New England Journal of Medicine, 34(13) 24–28. http://www.nejm.org/doi/pdf/10.1056/NEJMvcm0903599.

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Poutanen, S. M., Vearncombe, M., McGeer, A. J., Gardam, M., Large, G., & Simor, A. E. (2005). Nosocomial acquisition of methicillin-resistant Staphylococcus aureus during an outbreak of severe acute respiratory syndrome. Infection control and hospital epidemiology, 26(2), 134–137. https://doi.org/10.1086/502516

Provincial Infection Control Network of British Columbia [PICNet]. (n.d.). Guidelines & toolkits. Provincial Health Services Authority (PHSA). https://www.picnet.ca/practice-guidelines

Provincial Infection Control Network of British Columbia [PICNet]. (2014). Infection control quick-reference guide for residential care facilities (Volume 2) [PDF]. PHSA. https://www.picnet.ca/resources/rescarebooklet/ www.picnet.ca/practice-guidelines

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). Elsevier-Mosby.

Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Routine practices and additional precautions in all health care settings (3rd ed.). Public Health Ontario.  http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf.

Public Health Agency of Canada (PHAC). (2012a). Hand hygiene practices in healthcare settings. Government of Canada. http://publications.gc.ca/site/eng/430135/publication.html.

Public Health Agency of Canada (PHAC). (2012b). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Government of Canada. http://www.phac-aspc.gc.ca/nois-sinp/guide/ summary-sommaire/tihs-tims-eng.php

Public Health Agency of Canada. (2012). Routine practices and additional precautions assessment and educational tools: Protecting Canadians from illness [PDF]. File HP40-65-2012). Government of Canada.  https://publications.gc.ca/collections/collection_2013/aspc-phac/HP40-65-2012-eng.pdf

Public Health Agency of Canada. (2016). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Government of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-a.html [Date modified: 2017-09-05]

Public Health Agency of Canada. (2016). Appendix X: Technique for putting on and taking off personal protective equipment [images]. In Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Government of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-a.html [Date modified: 2017-09-05] [Images Reproduced with permission from the Ontario Ministry of Health and Long-Term Care.]

Rees, J. (2017, October 2). Putting on sterile gloves VIMEO (2017 remake) [Video]. The University of Edinburgh. Media Hopper Create. https://media.ed.ac.uk/media/Putting+on+sterile+gloves+VIMEO+%282017+remake%29/1_wjlyrirj CC BY-NC-SA 3.0

Sorrentino, S., Remmert, L., & Wilks, M. (2019).  Mosby’s Canadian textbook for the support worker (4th ed.). Elsevier Canada.

World Health Organization (WHO). (2009a). WHO guidelines for hand hygiene in health care: First global patient safety challenge. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf?ua=1.

World Health Organization (WHO). (2009b, May 5). Figure 2. My five moments for hand hygiene [Image]. In Hand hygiene technical reference manual: to be used by health-care workers, trainers and observers of hand hygiene practices [PDF]. https://www.who.int/publications/i/item/9789241598606