After reading this article, you will be able to:
Recall revisions to the CDC’s 2007 isolation precautions
Assess your facility’s compliance with the updated guidelines
The highly anticipated CDC isolation precaution guidelines are out, and although the document brings a number of changes, there are few surprises.
“In general, the basic principals are the same,” says Alfred DeMaria, state epidemiologist with the Massa-chusetts Department of Public Health. “The things that are new are not so new anymore,” says DeMaria.
For example, most facilities are already on top of respiratory hygiene and cough etiquette, he says, which are recommended in the report.
“Most of the things that people were expecting and are already incorporating in their practice were validated by the final version [of the guidelines],” he says.
The updated guidelines also call on hospital administrators to make infection control a financial priority, and ask organizations to work on changing their culture to prevent the spread of infectious diseases. Additionally, there are a number of new sections in the guidelines, including cough etiquette and respiratory hygiene. The guidelines also clarify the language in other existing sections, in an effort to remove any ambiguities.
Because of its scope, the 219-page document is not something that people will likely sit down with and read in one sitting, says Michael Bell, MD, associate director for infection control with the CDC division of healthcare quality promotion. “It’s the sort of thing you want to have handy for reference. In the short term, scanning the recommendations quickly to familiarize yourself with them is probably all you need to do,” says Bell. “There is nothing earthshakingly different in the guidelines that needs to be changed as of today.”
Most of the interventions, such as instituting culture change at your organization, are larger projects and will need to be worked on over time.
However, “given the time of year, ICPs should be planning ahead,” says Bell. “Facilities should be ready to implement respiratory hygiene and cough etiquette and ensure the appropriate vaccination of healthcare workers—and not just for flu, but all vaccine-preventable diseases.”
About the precautions
The isolation precautions first came out in 1996 and are based on a concept called “standard precautions,” says Bell. They were intended to be a commonsense strategy to protect healthcare personnel and reduce disease transmission to patients, he says. The guidelines address the use of personal protective equipment such as gowns, face masks, and gloves.
“That hasn’t changed—standard precautions are still the foundation of the updated guidelines,” says Bell.
This is the CDC’s first major revision to the guidelines since they were released. Many of the changes were in response to changes that have taken place in the interim, such as the emergence of new pathogens (e.g., severe acute respiratory syndrome [SARS] and norovirus), new therapies such as gene therapy, and increased concerns about bioterrorism.
The guidelines also include an updated section about multidrug-resistant organisms, which the CDC released last year due to high demand from the industry. The guidelines are noteworthy not only because MDROs are a critical issue, but also because, for the first time, the guidelines tie actions to outcomes. In other words, if a facility is not seeing a decrease in its MDRO numbers, it is required to add interventions, says Bell.
“The goal is to get everyone on a downward curve with regard to MDRO rates,” he says.
Expansion of the guidelines
As healthcare delivery has expanded to other settings, these new guidelines now apply to:
Special environments such as pediatrics, ICUs, and burn units
Further, the new guidelines focus on the administrative support of IC programs, in particular the importance of IC and nurse staffing levels. However, the CDC stopped short of recommending specific numbers related to staffing levels, says Bell, because facilities are so diverse and have a multitude of sizes and populations.
Some other changes are as follows:
Cough etiquette and respiratory hygiene.
These recommendations came about in reaction to SARS and are steps that can reduce transmission in the event of an avian flu pandemic, says Bell.
“The need for a recommendation for respiratory hygiene/cough etiquette grew out of observations during the SARS outbreaks where failure to implement simple source control measures with patients, visitors, and healthcare personnel with respiratory symptoms may have contributed to SARS coronavirus (SARS-CoV) transmission,” states the executive summary of the report.
If a coughing patient arrives in the waiting room, the CDC recommends that healthcare facilities have tissues, wastebaskets, and hand sanitizer in the waiting area to help the patient minimize exposure to others. Healthcare facilities should also post information teaching patients how to properly cover their cough. And personnel should also quickly move these potentially contagious patients to more isolated areas to prevent the spread of disease, says Bell.
Lumbar puncture procedures. Recently there were small outbreaks of meningitis in patients who had received special lumbar puncture procedures such as epidural and anesthesia, says Bell. Oral flora from the healthcare personnel performing the procedures is believed to have been the cause. As a result, in addition to using sterile gloves and equipment, the CDC also recommends that personnel use a surgical mask to reduce the risk of these infections when performing lumbar puncture procedures.
Safe injection strategies. There continues to be a risk—and concrete evidence—of occupational infection with the Hepatitis B and C virus, says Bell. Although the injection guidelines haven’t changed, they are reinforced and reiterated in this updated document in hopes of getting people to take the proper precautions, says Bell.
Transmission-based precautions. These precautions are designed for situations in which a healthcare worker knows or suspects that a certain infection is present.
CDC recommends the use of three key precautions, which are not mutually exclusive. They are as follows:
1. Contact precautions
2. Droplet precautions
3. Airborne precautions
These categories have remained the same. But there are some noteworthy changes to the precautions, says Bell.
Contact precautions: The guideline now specifically states that healthcare workers must put on a gown and gloves before entering the room and take them off before exiting the room, says Bell. This was a gray area before, and the CDC wanted to clarify that this is a requirement.
Droplet precautions: The updated guideline uses a distance of about 6 ft, rather than the previous 3 ft, with regard to droplet-based transmissions because many people are able to generate coughs and sneezes that splash beyond 3 ft, says Bell.
As a result, a surgical mask should be worn if the healthcare worker is going to be within 6 ft of a contagious individual under the revised droplet precaution guidelines, says Bell.
This more conservative guideline was designed to reduce those instances of transmission.
Culture change. One of the more noteworthy items in this document is the focus on encouraging a change in culture to help prevent the spread of infection.
“Culture change is something people have been aware of that they should be embracing, but it’s never been written down so clearly,” says Bell.
It’s important to make infection control everyone’s job, he says.
“In the past it was up to a few hardworking ICPs to prevent transmission of infections. Everyone else just went about their own duties,” says Bell.
Now, he says, the philosophy needs to change—every individual should accept the responsibility for doing their part to ensure infection control. Some of the ways an individual can make a difference include the following:
– Follow cough etiquette and hand hygiene
– Get flu shots on time so patients and healthcare workers aren’t exposed to influenza
– Use antibiotics properly to avoid promoting resistance
These measures and others should be a personal and professional obligation for all staff members, says Bell.
Administrative support. In order to have a successful IC program, facilities need to have adequate staff to ensure that IC measures are carried out.
For example, if an organization is short on nursing staff, it makes it more difficult for those staff members to do a perfect job of hand hygiene, says Bell. The same goes for housekeeping staff or members of the IC department, he says. The CDC declined to give specific staffing numbers, because the size of facilities can vary greatly as can the type of care they provide. But there are numbers that have been generated by academic researchers that many people have referred to and can use as a guide in this area, says Bell.
Whether your organization is already complying with the CDC’s new isolation precautions, or you’re reading it for the first time, it’s a good idea to keep a copy of the guidelines within reach.
For a downloadable copy, go to www.cdc.gov/ncidod/dhqp/gl_isolation.html.
Proper removal of PPE
The following are some helpful tips for properly removing personal protective equipment (PPE). Remember: Remove PPE at the doorway before leaving the patient room or -anteroom.
If outside of gloves is contaminated:
Grasp outside of glove with opposite gloved hand; peel off
Hold removed glove in gloved hand
Slide fingers of ungloved hand under remaining glove at wrist
If outside of goggles or face shield is contaminated:
Handle by the “clean” headband or ear pieces
Place in designated receptacle for reprocessing or in the waste container
If the gown front and sleeves are contaminated:
Unfasten neck, then waist ties
Remove gown using a peeling motion; pull gown from each shoulder toward the same hand
Gown will turn inside out
Hold removed gown away from body, roll into a bundle, and discard into waste or linen receptacle
Mask or respirator
If the front of mask/respirator is contaminated, do not touch.
Grasp only bottom, then top ties/elastics and remove
Discard in waste container
Perform hand hygiene immediately after removing all PPE
Source: CDC, “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007.”