2.6 Point-of-Care-Risk Assessment (PCRA)

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?
image description linked in caption
Figure 2.6.1 PCRA Decision Algorithm [Image description]

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[1]
Source Higher transmission risk Lower transmission risk
Infectious agent/infected source Frequent Diarrhea Formed stools
Incontinence Continence
Poor hygiene Good hygiene
Not capable of self-care due to physical condition, age, or cognitive impairment Capable of self-care
Environment High patient nurse ratio Low patient nurse ratio
Share bathroom, shared sink Single room, private in-room toilet, designated patient handwashing sink
Shared commode without cleaning between patients Dedicated commode
No hand hygiene at point-of-care Hand hygiene at point-of-care
No designated staff handwashing sink or sink is used for other purposes or sink is dirty Accessible, designated, clean staff handwashing sink
Inadequate housekeeping Appropriate housekeeping
Susceptible host (patient) Receiving direct patient care Capable of self-care
Poor personal hygiene Good personal hygiene

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[2]
Mode of transmission Contact Droplet Airborne
Precautions
  • gloves
  • gown
  • gloves
  • gown
  • surgical mask
  • eye protection
  • N95 respirator
Common Infections
  • Norovirus & other GI infections
  • C. difficile
  • MRSA
  • Scabies
  • Influenza
  • Common cold
  • Whooping Cough
  • Tuberculosis
  • Measles
  • Chicken pox
  • Rubella
Examples of symptoms
  • Diarrhea or vomiting
  • Open wounds
  • Patches of open skin
  • Coughing
  • Sneezing
  • Chronic cough
  • Fever with unidentified rash

Summary:

  1. Following infection preventative and control practices and guidelines prevents or stops the spread of infections to healthcare workers, clients, and visitors.
  2. Infection prevention and control starts with good hand hygiene!
  3. Infection prevention and control practices guide healthcare workers to practice safely. Using routine practices and conducting point-of-care-risk assessments can eliminated the transmission of micro-organisms and knowing how and where to use additional precautions can help you as an HCA to stop the spread of infection.

Image descriptions

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

[Back to Figure 2.6.1]

Chapter 2 Attributions and References

Unit 2.2 Image Attributions

Unit 2.4 Image Attributions

Unit 2.5 Image Attributions

Unit 2.6 Image Attributions

Videos

References

BC Centre for Disease Control (BCCDC). (2014). Hand hygiene. Retrieved from http://www.bccdc.ca/prevention/HandHygiene/default.htm.

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.

Patrick, M., & Van Wicklin, S. A. (2012). Implementing AORN recommended practices for hand hygiene. AORN Journal, 9(4), 492–507. https://doi.org/10.1016/j.aorn.2012.01.019

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

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

  1. Courtesy of the Public Health Agency of Canada, 2016). ↵
  2. Courtesy of the Provincial Infection Control Network of British Columbia (PICNet, 2014, p. 18) ↵
definition

License

Icon for the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License

Personal Care Skills for Health Care Assistants Copyright © 2023 by Tracy Christianson and Kimberly Morris, Thompson Rivers University. is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

Share This Book