CDC Paring Down Patient Isolation Guidelines to User-Friendly Format
Concise document will complement CDC’s Project Firstline
The CDC is revising its 2007 patient isolation guidelines,1 going from a ponderous 206-page “textbook” to a simplified “lean” document that healthcare workers can easily access and understand, according to recent discussions at a CDC advisory committee meeting.
With the pandemic as the backdrop, making the patient isolation guidelines more user-friendly complements the CDC’s Project Firstline2 effort to reach healthcare workers (HCWs) directly, using short educational videos and other resources to help them identify risks to protect themselves and their patients from infections.
A major focus will be on delineating the blurred line between droplet and airborne precautions, which has been the subject of some confusion and controversy during the pandemic. The conventional wisdom has been most respiratory infections spread primarily by larger droplets at short-range, while airborne pathogens, like measles, can spread widely through smaller particles that become airborne.
Michael Lin, MD, MPH, co-chairs a work group on the patient isolation revisions as a member of the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC).
“Since the publication of the [2007] isolation guideline, new evidence has emerged regarding the size of pathogen [particle] transmission in the healthcare setting,” said Lin, associate professor of infectious diseases at Rush University Medical Center. “For example — and probably most importantly — the distinction between droplet and airborne routes of respiratory transmission needs to be re-evaluated.”
Generally, under respiratory droplet precautions, masks should be worn by healthcare workers and, if possible, by the patient for source control to prevent spread within a 3 ft to 6 ft range. True airborne pathogens, like measles and tuberculosis, call for N95 respirators and negative air pressure rooms to prevent spread throughout a facility via air currents. Coronavirus does not fit neatly into either category, exposing a flaw in the guidelines that some say are too rigid and dogmatic.
The issue of airborne spread of COVID-19, beyond aerosol-producing procedure, has been somewhat contentious, recalling similar debates when SARS-CoV-1 struck in 2002-2003. Last year, the CDC reported emerging science shows transmission of SARS-CoV-2 airborne viral particles can occur beyond 6 ft, particularly in enclosed, poorly ventilated spaces. This risk increases in “enclosed spaces with inadequate ventilation or air handling within which the concentration of exhaled respiratory fluids, especially very fine droplets and aerosol particles, can build up in the air space,” the CDC emphasized.3
While HICPAC did not delve into any clinical detail in announcing the revision plan, a previous member of the advisory committee addressed the issue at a recent webinar hosted by the Association for Professionals in Infection Control and Epidemiology.
“[For] droplet and airborne, we thought, well, particles are one size. Well, no — they’re not,” said Ruth Carrico, PhD, FSHEA, RN, CIC, a professor of infectious disease at the University of Louisville. “Airborne is not only small [particles], and droplet is not only large. When someone coughs, they project a variety of particle sizes. This really hit home with this coronavirus — that we could have many different sizes of particles.”
As a result, infectious disease experts are moving away from “compartmentalizing” isolation and thinking more broadly about how disease is transmitted.
“Some [larger particles] will fall out of circulation and contaminate the environment. That’s why we need to be thinking about environmental disinfection,” Carrico said. “Some will be smaller in size and may actually follow air current.”
HCWs must use personal protective equipment — including eye protection — to avoid contact with these various particle sizes, along with respiratory protection to avoid inhaling the tiny particles that may be aerosolized, she concluded.
In an interview with Hospital Employee Health, David Kuhar, MD, one of the CDC principals working on the isolation revision with HICPAC, said one expanded focus probably will be source control. Generally, this implies masking infected patients, but could include HCWs in some situations.
“I suspect that the big changes will be in source control for respiratory infections,” Kuhar explains. “I don’t think before this [pandemic] we had a lot of data on source control, but there is no question at this point how important it is. I see us expanding how we use source control in healthcare — it’s both a worker safety and a patient safety issue.”
The CDC’s challenge is to explain that and other revisions in a concise, understandable way. With that in mind, the first part of the revised guidelines — which will include the gamut of isolation precautions — will be a 10- to 15-page document accessible in a PDF on a mobile device.
“This will provide an updated scientific foundation for how pathogens spread in the healthcare setting,” Lin said. The goal is to put the concise “new part one” document in draft form for the HICPAC meeting this November.
Sections of established science and specific issues, like needle reuse, from the 2007 document will not be discarded, but may be repackaged into other documents or included to some degree in the next iteration of the isolation revision process (i.e., “new part two”), said Michael Bell, MD, deputy director of the CDC Division of Healthcare Quality Promotion.
“We will not throw any of that away,” Bell said at the HICPAC meeting. “But we are deliberately trying to make this a much leaner and cleaner document. This is intended to provide the framework for a lot of subsequent products. This first piece of work is a hard intellectual lift to get us to the point as a nation where we can agree on a new framework. Then, we will move forward with how we implement it.”
With the lessons of the pandemic in mind, CDC implementation is getting innovative with Project Firstline, an ambitious effort to teach all HCWs the basics of infection prevention and the “why” behind recommendations. The idea is to protect both HCWs and their patients by using short, specific videos and other cutting-edge tools accessible on computers and mobile devices.
“The good news about Project Firstline content is that if you get it — if you hear the message about where the infectious risk is and how it spreads — it [protects both groups],” Bell tells HEH. “I don’t think there’s a healthcare worker out there who’s trying to create risk for colleagues in the workplace, or put themselves at risk. By the same token, no one is trying to cause infections to spread to patients. They want to do the right thing.”
Currently, the Project Firstline website offers short videos and other resources to train HCWs to recognize infection risks by learning how germs spread in healthcare and how they can establish reservoirs within a facility. This is “the first step in understanding when to take action to protect your patients and yourself from infections,” the CDC stated.
Although facilities use employee health and infection control teams, individual HCWs face daily decisions that could prevent or enable an infection.
“We’ve focused a lot of attention on device-associated infections because they cause severe illness, but infection transmission is something that can happen minute by minute all across healthcare delivery,” Bell says. “For example, things like early detection of Ebola coming into your facility. That [Dallas] incident was a classic example of people needing to be thoughtful and aware and actually act on what they’re seeing in a real-time way.”
Bell was referring to the tragic case of Thomas Eric Duncan, a Liberian man who traveled to the United States in 2014 with Ebola incubating in his system from an ongoing outbreak in Africa. He presented for care at Texas Health Presbyterian Hospital in Dallas on Sept. 26, 2014, but was misdiagnosed with sinusitis and sent home. Two days later, he returned by ambulance with worsening symptoms and was admitted. Before he died on Oct. 8, 2014, Duncan transmitted the Ebola virus to two nurses — both of whom survived.4
The resonating question is how different the entire outcome might have been for the patient and the two nurses had Duncan been admitted when he first presented for care. Could something like Project Firstline — which did not exist at the time — have made a difference by providing timely, easily accessible information for recognizing an Ebola case? This type of system has long been Bell’s vision. Some of the funding allotted to the CDC for pandemic response has finally helped launch the effort.
“The target audience is literally everyone working in healthcare. Everyone,” Bell emphasizes. “That means the delivery needs to reach everyone. Right now, if you look back at what’s been delivered over the past several decades, it’s generally been in the format of 45 minutes to one-hour talks, more recently in the form of PowerPoints. For a generation, we have hit our colleagues with rules.”
Project Firstline is seen somewhat like “crowdsourcing” with a broad reach of short messages.
“We’re really wanting to leverage smartphones,” Bell says. “We’re wanting to deliver information to people in that five or six minutes they have while they’re waiting for a rideshare, or just at the end of shift change when you’ve got a little bit of down time. For example, the idea of reservoirs of infectious material. The fact that a little puddle next to the sink faucet is probably teeming with Serratia and pseudomonas — that’s why you don’t want to prepare medication there.”
In an era of emerging infections, the CDC outreach could help HCWs feel safer in their daily activities.
“I don’t like the idea that anybody in healthcare should walk around feeling uncertain and maybe afraid,” Bell says. “That’s really unfair. We are trying to get this information to people so they know what to do and they know why they’re doing it. They have that level of professional confidence, regardless of their role.”
Project Firstline will move in the direction reflected in feedback from HCWs and organizations partnering with the CDC.
“This is not a unidirectional, one-and-done kind of project,” Bell explains. “It’s a process that I’m hoping will result [in more] communications avenues, giving us more understanding of what information [HCWs] need, what they want, and where the soft spots are that we can help reinforce. Also, we don’t have a static workforce. Now, more than ever, we have such turnover, so much burnout, and people are exhausted. Despite that, we have new, enthusiastic people coming on board, and we have the tried-and-true dedicated staff who are trying to hang in there. We want to make sure that this is a process and a program that will keep supporting them going forward.”
REFERENCES
- Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings.
- Centers for Disease Control and Prevention. Project Firstline. Page last reviewed March 10, 2022.
- Centers for Disease Control and Prevention. Scientific brief: SARS-CoV-2 transmission. Updated May 7, 2021.
- Evans G. Expert report: PPE changes, confusion preceded Dallas nurses’ Ebola infections. Hospital Employee Health. Dec 1, 2015.
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