Physician offices should take note of revised infection control guidelines

Pediatric IC and isolation precautions released

If you haven't revised your facility's infection control policies and procedures within the past month, then they probably are out of date.

Two major groups have released revised guidelines that had been in the works for several years.

The first was the updated "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007." When published this past summer, the guidelines replaced the 1996 version.

For the first time the new guidelines focus on ambulatory care and other health care settings. The transition of the health care delivery system from acute care hospital settings to ambulatory care and other settings is the primary reason listed for why the guidelines needed a major revision from the 1996 version.1

"It's brand new and exciting because the guidelines not only go into detail about what you should do with patients seen in clinical settings like ambulatory settings, but they discuss what to do with long-term care and home health care," says Vicki L. Brinsko, RN, CIC, infection control coordinator at the Vanderbilt University Medical center in Nashville, TN. Brinsko is on the Healthcare Infection Control Practices Advisory Committee, which has spent three years on revising the isolation precautions guidelines.

"Medical care is changing," says Elise Beltrami, MD, MPH, medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC). The CDC sponsored the isolation precautions guidelines, and staff from the division of healthcare quality promotion was involved in the revision.

"We used to be a hospital infection program, but our work isn't just hospitals, and health care is changing, which is why we became the division of healthcare quality promotion — to emphasize that it's not hospital-specific," Beltrami adds.

Multidrug resistant organisms also are a focus of the revised guidelines, Beltrami says.

The guidelines' executive summary lists the increase in multidrug-resistant organisms in all health care settings and the emergency of new pathogens, including severe acquired respiratory syndrome (SARS) and concern about evolving organisms, such as community-associated methicillin-resistant Staphylococcus aureus (MRSA), and the risk of bioterrorism as fueling a need for addressing a broader scope of issues in the isolation guidelines.1

The new isolation guidelines will have an impact globally, since medical societies and health care departments across the world will follow their recommendations, Brinsko notes. (See sample page of chart from isolation guidelines)

"And as soon as the guidelines are published you look for ways to update them," Brinsko says. "Since the 1996 guidelines, we've had SARS, monkeypox, and the fear of a pandemic flu and bioterrorism."

Likewise, so many patients have moved from the "horizontal plane" to the "vertical plane," she says.

"We see many more outpatient surgeries and same-day surgeries, including things like a 1996 hip replacement that would result in a week or two stay 10 years ago, and now it's just about overnight," Brinsko says.

The second revised guidelines are sponsored by the American Academy of Pediatrics (AAP) and are called, "Infection Prevention and Control in Pediatric Ambulatory Settings." Published in the September 2007 issue of Pediatrics, the guidelines focus primarily on hand hygiene, but also address needle safety and respiratory hygiene.2

"If one summarizes infection control in two words, I think most infection control experts would say, 'hand hygiene,'" says Lorry G. Rubin, MD, chief of pediatric infectious diseases for Schneider Children's Hospital of the North Shore-Long Island Jewish Health System in New Hyde Park, NY. Rubin is on the AAP's Committee on Infectious Diseases, which worked on the revised infection prevention policy statement.

"We used to say hand-washing, but now we say hand hygiene because of the alcohol-based handrubs, which are completely acceptable and preferred over soap and water," he says. "Over multiple uses, it's less damaging to the hands, less drying and irritating than the use of soap and water."

While hand washing and alcohol rubs are routine in most hospitals, where dispensers are located at the room exits, it's less ubiquitous in ambulatory settings, Rubin says.

Nonetheless, hand washing should be standard procedure each time a health care professional has a patient contact, he says.

"Whether the patient is sitting in bed as an inpatient or sitting on an end table when the doctor or nurse walks in the room, the [health care worker] should use hand hygiene before they touch the patient," Rubin says.

Often, this habit and mentality is not routine for physicians and nurses in outpatient settings, he notes.

"It's not on the minds of practitioners, particularly those who are not dealing with acutely ill patients," Rubin explains. "So the orthopedist who examines a patient's knee should do hand hygiene, as well, but it's not viewed as a make and break technique."

What these practitioners fail to realize is that any patient could be colonized with an antibiotic-resistant organism that could be transferred from the patient to the health care practitioner to the next patient, he adds.

Infection control naturally is easier in hospitals where there are the necessary equipment and trained staff to handle an emergency isolation situation, Brinsko says.

"In ambulatory settings, you have patients come in who don't know if they're infectious," she says.

The revised isolation guidelines address this issue, focusing on the commingling of patients in large rooms, such as long-term care community rooms and psychiatric group therapy rooms, Brinsko says.

"You won't have to do the Draconian measures that you'll have in the inpatient acute intensive care unit, but there are guidelines to follow," she says.

Hand hygiene, respiratory and cough etiquette are discussed in the guidelines.

"This is something my mother taught me in the 1950s — cover your mouth when sneezing or coughing, and some people don't do that," says Brinsko.

Also, health care workers in ambulatory settings need to be alert to signs that patients have antibiotic-resistant infections, such as MRSA. Skin lesions could be a sign of a resistance problem, Brinsko says.

"They need to make sure the health care environment is cleaned after patients with suspected infection leave the area," Brinsko says. "I don't know how stringently doctor's offices think about these things, but it should be back to the basics."

In pediatric clinics and offices, the toys should be cleaned in a dishwasher or by other sanitary means, Rubin says.

"Some people advise having a child bring his or her own book or toy to the office rather than having these available in the waiting room," Rubin notes. "Or if a health care worker sees a child put a toy in his or her mouth, then that toy should be separated and cleaned before being returned to the waiting area."

Also, it wouldn't hurt doctors' offices to have an infection control expert on hand to provide staff education, Brinsko adds.

"At Vanderbilt, we go out every six months and do mock inspections of clinic areas," Brinsko says. "We answer questions and look at the physical environment, review charts, and do all sorts of things to help the clinic areas and ambulatory areas to be on their toes like the inpatient areas are."

All health care workers who have patient contact should update their flu vaccine each year, Brinsko advises.

Employees also should be immunized against hepatitis B, Rubin says.

"The additional vaccine preventable diseases that office people, particularly those who have contact with young children, should be immune to or immunized against are measles, mumps, varicella, and pertussis," Rubin says.

"I'm a strong believer in the flu vaccine for all health care providers," Brinsko says.

References

  1. Siegel JD, Rhinehart E, Jackson M, et al. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings 2007. Healthcare Infection Control Practices Advisory Committee; Centers for Disease Control and Prevention. June 2007; 1-219. Available on-line at http://www.cdc.gov.
  2. Committee on Infectious Diseases. Infection prevention and control in pediatric ambulatory settings. Pediatrics 2007; 120(3):660-665.