Respiratory Hygiene/Cough Etiquette in Healthcare Setting

1. Visual Alerts
Post visual alerts, in appropriate languages, at the facility's entrance (e.g., emergency departments, physician offices, outpatient clinics) instructing all persons who enter to inform healthcare personnel of symptoms of a respiratory infection and to practice Respiratory Hygiene/Cough Etiquette. Visual alerts should:

• Encourage all persons including visitors to report flu symptoms.Discourage visitation by persons who are ill. Remind everyone to cover when coughing or sneezing.Encourage coughing persons to keep atleast 3 foot distance from others. Encourage use of tissues and masks by persons who are coughing or sneezing.Encourage handwashing or alcohol base hand rubs after coughing or sneezing.
• Demonstrate the sequences for donning and removing personal protective equipment.

2. Respiratory Hygiene/Cough Etiquette Reminders/Supplies

• Cover the nose/mouth when coughing or sneezing.Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use.Perform hand washing or alcohol based rubs after contact with respiratory secretions and contaminated objects/materials.Provide tissues and no-touch receptacles for used tissue disposal.
• Provide conveniently located dispensers of alcohol-based hand sanitizers. Where sinks are available, ensure that supplies for hand washing (i.e., soap, disposable towels) are consistently available.

3. Masking and Separation of Persons with Respiratory Symptoms
During periods of increased respiratory infection activity in the community (e.g., when there is increased absenteeism in schools and work settings and increased medical office visits by persons complaining of respiratory illness), offer masks to persons who are coughing. Either procedure masks (i.e., with ear loops) or surgical masks (i.e., with ties) may be used to contain respiratory secretions. Respirators such as N-95 or above are not necessary for this purpose. When space and chair availability permit, encourage coughing persons to sit at least three feet away from others in common waiting areas. Some facilities may find it logistically easier to institute this recommendation year-round.

4. Droplet Precautions
Advise healthcare personnel to observe Droplet Precautions (i.e., wearing a surgical or procedure mask for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present. These precautions should be maintained until it is determined that the cause of symptoms is not an infectious agent that requires Droplet Precautions.

5. Restrictions for ill Visitors and Health-care Personnel

If there is no, or only sporadic, influenza activity occurring in the surrounding community:

• Discourage persons with symptoms of a respiratory infection from visiting patients. Inform the public about restricted visitation policies and procedures through educational posters and activities.
• Evaluate health-care personnel with influenza-like illness and perform rapid influenza tests to confirm the causative agent is influenza. Determine whether they should be removed from duties that involve direct patient contact, especially those who work in certain patient-care areas (e.g., intensive care units [ICUs], nurseries, organ-transplant [protective environment]) units, and long-term care facilities. If excluded, they should not provide patient care for 5 days after the onset of symptoms.

If widespread influenza activity is in the surrounding community:

• Confirm that influenza is the cause of the outbreak by performing rapid or other influenza tests on a subset of ill persons.Actively communicate to the public at large (e.g., via public service announcements) and visitors (e.g., via posted notices) not to visit for 5 days following the onset of a respiratory illness.
• In high-risk areas (e.g., ICUs, nurseries, and organ-transplant [especially protective environment] units, and long-term care facilities), actively screen unvaccinated health-care personnel for symptoms of respiratory infection and exclude those with symptoms for 5 days following the onset of symptoms.