New CF Infection Control Guidelines


It was 2003 when the initial infection control recommendations were published as a result of doctors Saiman, Siegle and the Cystic Fibrosis Foundation Consensus Conference.1 The new Infection Prevention and Control Guideline (IPC) published in June of 2014 is a further advancement in how to help protect patients with cystic fibrosis. The primary goals of the guideline are crystal clear-to help people with Cystic Fibrosis preserve and protect their health, inform families so wise decisions related to daily activities can be made, and lastly give healthcare providers details on how to help and advise patients and their families.2

The guideline is a result of a multidisciplinary committee consisting of CF physicians, nurses, research scientists, infection control experts, parents of children with CF and adults with CF. The 2014 IPC document is well written and full of detail. From this comprehensive new guideline the Cystic Fibrosis Foundation published tips for patients and health care providers. Below is a recap of the message from the tip sheet titled: 11 Ways For Health Care Providers to Guard Against Germs in Health Care Settings.3 I have expanded on some areas specific with emphasis related to pulmonary testing.

Risks
Risk of infection is always a concern, but the new guideline highlights that a greater risk exists of persons with CF spreading dangerous organisms to each other. This possible bacterial spread is often the cause of pulmonary infections and the additive effect of multiple exacerbations leads to declining pulmonary function and possibly death.

Problem Organisms
The bacteria of most concern?

  • Methicillin-resistant Staphyoccus aureus (MRSA)
  • Burkholder cepacia
  • Pseudomonas arruginosa
  • Nontuberculous mycobacteria (NTM)
  • Message to Health Care Providers-What to do.

The new guideline outlines 11 ways health care providers can protect patients in the health care setting.2 Health care providers should collaborate with their Infection Control Team. This should include the clinic, pulmonary lab, inpatient unit and all other services that are involved with providing care. Working with the infection control team providers to develop protocols, checklists and audits to standardize practices. This will require initial and ongoing education of staff to emphasizing key points in order to become effective.

1. Surfaces Need To Be Disinfected. Although seemingly common sense, we need to do a much better job at being aware and vigilant of items patients touch. Although this sounds like overkill, we have to remember we are not only protecting patients with CF, we are protecting all patients. This includes:

  • Oximeter cables and probes.
  • Spirometer components
  • Stethoscopes
  • Exam room tables, desks, chairs
  • Stadiometers and scales
  • Electronic controls, tablets and computers
  • Sinks, showers, exercise equipment
  • Doorknobs
  • Light switches
  • Bed rails and controls.

2. Hand Hygiene for All. The updated guideline states to make alcohol based sanitizer or antimicrobial soap and water available in all patient rooms, PFT rooms and waiting area.4
It is imperative to wash our hands or use alcohol based sanitizers prior to and after seeing patients. One practice that makes it obvious to patients is to perform the hand hygiene in the presence of the patient; if using hand gel you can offer some to the patient also. Hand hygiene must also occur before donning gloves and when making contact before or after direct contact with patient, e.g., body fluids or contact with objects with potential for contamination. Explain to patients and family members the importance of being aware of hand hygiene. Offering patients hand gel after upon completion of pulmonary function testing may be awkward at first, however it is important especially if they have been coughing into their hand or tissue.

3. Wear Gloves and Gown as a Standard Practice on All Patients with CF. It is important to treat all patients with CF same! We are wearing gloves and gowns to not only prevent contamination of our hands and clothing, but to prevent us from passing pathogens to these patients.

4. Wear a Mask and Eye Protection in Special Circumstances. What are these special circumstances? Per the CDC (Centers for Disease Control) guidelines eye and mask protection should be used when delivering care to patients when:

  • Droplet Precautions exist-patients maybe suspected of or have confirmed droplet pathogens.
  • Standard Precautions exist-if splashes and/or sprays are likely.
  • Airborne Precautions exist-donn a N95 mask or PAPR (Powered Air Purifing Respirator) if airborne Mycobacterium or droplet nuclei pathogens are suspected or confirmed.

5. Patients with CF Should Maintain a 6-Foot Distance Between Others with CF. Remember, the new guideline highlights that a greater risk exists of persons with CF spreading dangerous organisms to each other, maintaining distance between patients is a strategy to help prevent cross contamination. Other components to this recommendation include:

  • Stagger the clinic schedule.
  • Place patients in exam rooms as soon as possible after arriving to clinks.
  • Maintain patient with CF in the exam room and rotate caregivers in.
  • Recommend persons with CF to avoid sharing common items like clinic computers.

If newly diagnosed with CF or under two years of age, keep these patients separated until explaining the Infection Prevention and Control Guideline to them and the family.
Use a pager or personal cell phone to notify patients when an exam room is available. In busy pulmonary or CF clinics will require thoughtful planning to meet these recommendations. It is important to recognize and be sensitive to the fact that patients with CF may feel isolated or shunned as a result of some of these recommendations. Caregivers must explain the intent of the guidelines with empathy and emphasize the protective component.

6. Reduce Chance of Infection During Pulmonary Function Testing. Although the risk of infection from pulmonary function equipment is thought to be low, the possibility remains.4 Persons being seen for sick visits to clinics frequently cough and might contaminate spirometry equipment after recovery of the forced expiration. Pulmonary labs and clinics performing testing need to have a standardized approach to ensure the risk of cross-infection is minimized. The use of bacterial-viral filters and wiping down all patient related equipment using an EPA approved hospital disinfectant is a must. Related specifically to clinic and pulmonary testing, the IPC guidelines request the following environmental conditions:

  • Perform spirometry or pulmonary testing in a lab equipped with a portable or integrated HEPA filter.
  • Perform pulmonary testing in an Airborne Infection Isolation Room (AIIR) or negative pressure room.

If the above are not available, allow a 30 minutes break between patients with CF when conducting testing in exam or pulmonary rooms without a HEPA filter. Having negative pressure pulmonary function testing and exam rooms are a luxury, so again-timing and workflow considerations are important. We post a note on the door of the PFT testing room indicating what time the room will become available.

7. One Patient Per Room. This is a straightforward way to help reduce cross-infection of persons with CF.

  • One patient per clinic exam room
  • In-patients with CF should always be in private rooms.

8. Evaluate Patient Activity on a Case by Case Basis. This recommendation is targeted primarily at the inpatient population. There are multiple factors to consider before allowing patients to travel throughout a medical facility.

  • Is the patient capable of containing any respiratory secretions when coughing?
  • Are they compliant with hand hygiene and wearing a mask before exiting their room?
  • What level and type of pathogens are known to exist in the medical facility?
  • Can the hospital monitor the patient and ensure items touched are cleaned using the correct disinfectants?

Hospitals / Medical Centers can be vast areas, monitoring patient activity is likely not feasible in all situations. This makes it even more important that patients are well versed in proper hand hygiene as move through all environments.

9. Nebulizer Care. Patients need instruction on proper methods to maintain and disinfect nebulizers. Nebulizers should never be shared and treatments should occur in individual rooms. Other nebulizer tips:
If using a disposable nebulizer, discard after 24 hours.

10. Recommend Vaccinations for Patients and Their Families. This is common sense for all patients with pulmonary disease. The flu virus vaccination should be maintained annually and clinicians should reference the CDC’s site for a complete list. www.cdc.gov/Vaccines/Schedules.

Matthew O’Brien manages the Pulmonary Diagnostic Lab at the University of Wisconsin Hospital and Clinics in Madison Wisconsin. The Pulmonary Lab provides testing for inpatients and outpatients seen in the UW Cystic Fibrosis Center in the American Family Children’s Hospital as well as Adult Cystic Fibrosis Clinic in UW Hospital.

References
1. Saiman L, Siegel J. Infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission. Infect Control Hosp Epidemiol 2003;24:S6-S52.
2. Saiman L, Siegel J. Infection prevention and control guideline for cystic fibrosis: 2013 update. Infect Control Hosp Epidemiol 2014; Vol 35; No. S1
3. http://www.cff.org/LivingWithCF/InfectionPreventionControl/Tipsheets/GuardAgainstGerms/
4. Hiebert T, Miles J, Okeson G. Contaminated aerosol recovery from pulmonary function testing equipment. Am J Respir Crit Care Med 1999; 159:610-612

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