Be immune to respiratory infection season

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Train your staff on respiratory hygiene and cough etiquette

After reading this article, you will be able to:

  • State the four components the Centers for Disease Control and Prevention recommends hospitals include in a respiratory etiquette program
  • Explain why healthcare facilities should encourage workers to stay home when sick
  • List at least two ways to improve training efforts to help staff members and patients follow the guidelines for proper cough technique and hand hygiene

With fall under way, it’s time to start gearing up for respiratory virus season. That means giving staff members a refresher on respiratory etiquette.

“I personally like to see training start in September,” says Joan M. Wideman, MS, MT, (ASCP) SLS, CIC, owner of JMW Consulting, LLC, in Clawson, MI. “Our influenza season seems to have shifted over the past few years. It traditionally peaked over the winter holidays but now seems to peak in later January and into February, depending on locale.”

The Centers for Disease Control and Prevention (CDC) recommends that facilities institute respiratory etiquette practices as a component of standard practices to prevent respiratory infections, including influenza.

According to the CDC, a program should include:

Visual alerts. Signs should be placed at the entrance to outpatient facilities, such as EDs, physician offices, and outpatient clinics. Such postings should instruct patients and individuals accompanying them to report symptoms of a respiratory infection to staff members and give information on how to practice respiratory hygiene and cough etiquette.

Respiratory hygiene/cough etiquette. Staff members should instruct patients and visitors with symptoms of a respiratory infection to take these steps:

  • Cover the nose and mouth when coughing or sneezing
  • Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle
  • Perform hand hygiene

Masking and separation of persons with respiratory symptoms. Train staff members to offer masks to persons who are coughing or sneezing and to encourage them to sit at least 3 ft. away from others in common waiting areas.

Droplet precautions. Remind staff members to follow droplet precautions in addition to standard precautions when examining a patient with symptoms of a respiratory infection, particularly if a fever is present, until you can identify the infection. At that point, you can discontinue precautions if they are not warranted.

Train staff members not only to encourage patients to follow these practices, but to follow the same precautions in the event that they contract a respiratory infection.

Education can include anything from formal training to informal instruction provided by infection control professionals (ICP) walking the floor. Peggy Luebbert, MS, MT (ASCP), CIC, CHSP, owner and consultant at Healthcare Interventions, Inc., in Omaha, NE, and the ICP at Nebraska Orthopaedic Hospital in Omaha, conducts lighthearted and humorous training on this topic.


Putting it all together

In addition to instructing staff members on proper cough etiquette and hand hygiene, you must train them on how to help patients adhere to these guidelines. The following are some tips to help improve your training efforts:

Present training from two angles: protecting the patient and protecting yourself. Staff members need to know that these measures are designed to keep them from getting sick and from transmitting these infections to their family members. “Yes, this is designed to protect patients, but it also protects the employees from each other,” Luebbert says.

Encourage employees to stay home when sick. “What we try to teach people is that when they first show early symptoms, especially with a fever, they are most contagious,” Luebbert says. If they stay home during that time, there is less risk that they will transmit the illness to others.

It’s important to consider factors that might make it more likely for a healthcare worker to show up to work with a contagious respiratory illness. Many facilities group sick time in with vacation or personal days, which might make people reluctant to use the time when they’re actually sick. Ideally, sick time should be separate, says Wideman.

And as always, enforce proper respiratory hygiene and cough etiquette guidelines. Take every opportunity to remind staff members to keep their hands away from their face, eyes, nose, and mouth.

Keep supplies on hand. The CDC specifies that healthcare facilities should have the proper supplies on hand to help reduce the transmission of respiratory infections. These include tissues and wastebaskets for tissue disposal, as well as alcohol-based hand rub or sinks with soap and towels.

Don’t forget your support staff. Although nurses and frontline workers are generally the first to be trained on respiratory etiquette, facilities sometimes forget about other staff members, such as receptionists and security personnel, who may be the first to encounter patients.

Set up respiratory etiquette stations. Some companies sell ready-made cough etiquette stations that contain all the needed supplies and can be placed at the entrance to the facility.

If you’re not sure where to place these stations at your facility, conduct a risk assessment to determine where the greatest risks lie. Consider placing stations outside the hospital.

Luebbert says one of the children’s hospitals in her area put its cough etiquette stations at the hospital’s entrance from the underground parking.

Develop scripts for staff members. It can be difficult to approach a patient and ask him or her to wear a mask, Wideman says. For this reason, it’s wise to develop scripts that staff members can use for this purpose, considering your patient population and being sensitive to any cultural issues that might exist, she says. It’s also a good idea to pilot your script with some patients to make sure it’s effective and not offensive.

Observe compliance. Once you train your staff on respiratory etiquette, be sure to monitor compliance. You can make such an exercise part of a quality improvement initiative. For example, develop a check- list and periodically observe staff member behavior to detect missed opportunities or areas for improvement, Wideman says.

Don’t forget hand hygiene. Hand hygiene is the single most important means of preventing the spread of infectious agents, Wideman says.


Briefings on Infection Control, August 2008, HCPro, Inc.