Ambulatory Care Quarterly

Respiratory section added to Standard Precautions

Updated CDC guidelines also address SARS

Under updated infection control guidelines from the Centers for Disease Control and Prevention (CDC), Standard Precautions now include respiratory/cough etiquette instructions.

The transition of health care delivery from primarily acute care hospitals to other health care settings, including freestanding ambulatory surgery centers, created a need for recommendations that can be applied in all health care settings using common principles of infection control practice, yet can be modified to reflect setting-specific needs.

"The biggest concern with an ambulatory surgery center is that the individual patient doesn't know they have the infection, nor does the ambulatory surgery personnel," says Joan Blanchard, RN, MSS, CNOR, CIC, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN) in Denver. Blanchard served as the liaison from AORN to the Healthcare Infection Control Practices Advisory Committee (HICPAC), which developed the guidelines.

In ambulatory surgery, you don't have the patient under observation for long afterward and may not know if your efforts at infection control prevention have been successful, says E. Patchen Dellinger, MD, professor and vice chairman of the department of surgery and chief, division of general surgery, at the University of Washington in Seattle. Dellinger also served on HICPAC. "You may not have same awareness of what's going on" as inpatient providers, he says. "You may not know if the infection control issues are not being adequately dealt with."

The CDC's respiratory/cough etiquette guidelines grew out of the 2003 outbreaks of severe acute respiratory syndrome (SARS), which indicated a need for infection control measures at the first point of encounter in a health care setting, such as the reception desk of outpatient facilities and physician offices, the guidelines say. The strategy targets patients, family members, and friends with an undiagnosed respiratory infection that can be transmitted, and it applies to any person showing signs of illness, including cough, congestion, rhinorrhea, or increased respiratory secretions when entering a facility.

Components of the respiratory/cough etiquette guidelines include:

  • Education of facility staff, patients, and visitors.
  • Posted signs in languages appropriate to the population served, with instructions to patients, family members, and friends. Signs can be posted at the entrance of the facility or at the reception/registration desk asking that people who have symptoms of a respiratory infection, such as cough, flu-like illness, or increased respiratory secretions, inform the receptionist. You also can add the presence of diarrhea, skin rash, and known or suspected exposure to a transmissible disease such as measles, pertussis, chickenpox, or tuberculosis.
  • Source control measures, such as covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate. The CDC guidelines acknowledge that masking is difficult in some situations, such as in pediatric settings, "in which case, the emphasis by necessity may be on cough etiquette."
  • Spatial separation, ideally more than 3 feet, of people with respiratory infections in common waiting areas, when possible. Immediately placing potentially infectious people in an examination room limits exposure in common waiting areas, the CDC points out.
  • Hand hygiene after contact with respiratory secretions.

Hand hygiene is one of the biggest challenges in health care, Dellinger says. Outside of the operating room, "health care professionals are in a hurry and tend not to follow through," he says.

When examining and caring for patients with signs and symptoms of a respiratory infection, wear a mask and use hand hygiene, the CDC guidelines recommend. "Health care personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients," the guidelines say. "If this is not possible, then a mask should be worn while providing patient care."

Other changes to the Standard Precautions are safe injection practices, including the use of a mask when performing some high-risk, prolonged procedures involving spinal canal punctures, such as myelography and epidural anesthesia. These recommendations grew out of continued outbreaks of hepatitis B and C in ambulatory settings, according to the CDC. The need for a mask was added due to recent evidence of an associated risk for developing meningitis caused by respiratory flora, the CDC says.

Guidelines issued on SARS

Another change to the CDC guidelines is the addition of a section on SARS.

Exposure to aerosol-generating procedures, such as endotracheal intubation and suctioning, has been associated with transmission of infection to large numbers of health care staff outside the United States, the CDC points out. Therefore, aerosolization of small infectious particles generated during such procedures could be a risk factor for transmission to others in a multi-bed room or shared airspace, the CDC says.

The CDC recommends detecting cases early by screening persons with symptoms of respiratory infection for their travel history to areas experiencing community transmission of SARS and for contact with SARS patients. Also, follow respiratory hygiene/cough etiquette by placing a mask over the patient's nose and mouth, and separate those people from other patients in common waiting areas. The CDC also recommends Standard Precautions, with an emphasis on hand hygiene; contact precautions, with an emphasis on environmental cleaning; airborne precautions, including fit-tested N95s or higher-level respirators approved by the National Institute for Occupational Safety and Health; and eye protection.

In another change, the CDC is replacing the term "nosocomial infections" with "health care-associated infections" to reflect the changing patterns in health care delivery and difficulty in determining the geographic site of exposure to an infectious agent and/or acquisition of infection. (The guidelines can be accessed at