2 Infection Control

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will be shown simply as (Code: …). If an item is testable only on the ELE, it will be shown as (ELE code: …). If an item is testable only on the WRE, it will be shown as (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item of the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall (R) level questions typically expect the exam taker to recall factual information. Application (Ap) level questions are more difficult because the exam taker may have to apply factual information to a clinical situation. Analysis (An) level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision. For example, [Difficulty: ELE is R, Ap; WRE is An].

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown that an average of four questions (out of 140), or 3% of the exam, will cover infection control issues. A review of the most recent Written Registry Examinations (WRE) has shown that an average of two questions (out of 100), or 2% of the exam, will cover infection control issues. The Clinical Simulation Examination is comprehensive and may include everything that should be known or performed by an advanced level respiratory therapist.

MODULE A

Follow infection control policies and procedures (e.g., Standard Precautions) (Code: IIB5) [Difficulty: ELE: Ap; WRE: An]

1. Hand washing or cleansing

Hand washing or cleansing is probably the single most important procedure for reducing the spread of infection. Washing with plain soap and warm tap water is acceptable in most cases. Antimicrobial soap should be used if called for in the infection control protocol. In many institutions, an isopropyl alcohol and skin softener/cleansing agent is used unless the hands are obviously contaminated. When contaminated with body fluids, the hands should be washed. In any case, respiratory therapists should wash or cleanse their hands before and between each patient contact. The following times are recommended when working in a general patient care area:

• When coming on duty

• When hands are obviously soiled or after contamination by blood or other patient body fluids. Hands should be washed, rather than using a cleansing agent, if a patient has an antibiotic-resistant infection, such as methicillin-resistant Staphylococcus aureus (MRSA).

• Before contact with the face and mouth of a patient, especially if the patient has an artificial airway

• Before setting up equipment or pouring medicines

• When leaving an isolation area or handling contaminated articles from an isolation area

• After handling soiled dressings, sputum containers, urinals, bedpans, catheters, etc.

• After removing patient care gloves. When working in a restricted area, such as the operating room, burn unit, or neonatal intensive care unit, policy may require hand washing before putting on gloves and entering the unit, as well as after removing the gloves.

• After personal use of the toilet

• After using hands to cover a cough and after blowing or wiping the nose

• Before eating or serving food

• On completion of duty

The most common bacterial organisms spread by personal contact are Staphylococcus aureus, Escherichia coli, and Streptococcus species. Suspect personal contact and poor hand cleansing whenever a patient has one of these infections.

Exam Hint 2-1 (ELE, WRE)

Past examinations have asked about the importance of hand washing and the indications for it to prevent the spread of infection.

2. Standard precautions

Standard (formerly called Universal) Precautions are designed for the care of all patients, regardless of their diagnosis or presumed infection status. Barriers such as gloves and masks and other procedures are used to prevent contact with body fluids. This approach to patient care has been adopted because of the concern of health care workers and the public that the human immunodeficiency virus (HIV), hepatitis B, or other deadly pathogens may be spread unknowingly by contact. Box 2-1 includes specific standard precaution guidelines established by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).

BOX 2-1 Precautions to Prevent the Spread of Infection

EXCLUSION FROM PATIENT CONTACT

Any health care worker with exudative skin lesions should not work in the direct care of patients.

BARRIERS

1. Gloves should be worn under these conditions: during direct contact with blood, body fluids, secretions, mucous membranes, and wounds; when handling all items or surfaces contaminated by blood or body fluids; when performing venipuncture; or when handling intravenous catheters or monitoring devices.

2. Gloves must be changed between patients or if the gloves become torn or punctured, as with a needle-stick injury.

3. Hands should be washed immediately after the gloves are removed; the hands and any other body areas must be washed immediately if contaminated by blood or other body fluid.

4. Masks, eye goggles, or face shields, as well as gowns or aprons, should be worn when a procedure is performed that may lead to the splashing or splattering of blood, secretions, or body fluids.

5. Contaminated masks, goggles, face shields, gowns, and aprons should be removed and disposed of properly.

6. Contaminated worker uniforms should be left at the hospital for cleaning.

NEEDLE AND INSTRUMENT PRECAUTIONS

1. Care should be taken when needles and sharp instruments are handled.

2. Used needles and sharp instruments should be placed into puncture-resistant containers for proper disposal; reusable needles should be placed into a puncture-resistant container for transport.

3. No attempt should be made to manually recap arterial blood gas or other needles, remove them from the syringe, or bend or cut them (needle-covering systems or methods of pushing the needle into a rubber cube are used widely; these require the use of only one hand with no touching of the needle).

PATIENT SPECIMENS

1. Blood and body fluids should be placed into leak-proof, sturdy plastic bags for transportation to the laboratory.

2. The laboratory requisition form should be placed on the outside of this bag.

CARDIOPULMONARY RESUSCITATION

1. Mouth-to-mouth breathing should be avoided even though no evidence suggests that saliva transmits human immunodeficiency virus infection.

2. Mouth-to-valve mask resuscitators and manual resuscitators (bag-valve) should be readily available for use in ventilating patients.

3. Respiratory hygiene/cough etiquette

To contain respiratory secretions, anyone with signs and symptoms of a respiratory infection should be told to do the following:

• Cover nose and mouth when coughing or sneezing.

• Use tissues to contain secretions.

• Throw away used tissues in the nearest waste container.

• Cleanse the hands after contact with respiratory secretions. An alcohol-based hand rub should be used when hand washing cannot be done.

• Wear a surgical mask and sit at least 3 feet away from others.

• Droplet Precautions should be used by health care workers when working with a patient who is showing signs and symptoms of a respiratory infection.

4. Respiratory care equipment and procedures

The following guidelines are recommended to minimize the spread of infection by equipment and procedures. Follow the manufacturer’s specific guidelines when applicable:

a. Each patient should have his or her own equipment.

b. Disposable equipment should be discarded after use.

c. Reusable equipment should undergo high-level disinfection or should be sterilized between patients.

d. Equipment such as O₂ masks, large-volume nebulizers, and aerosol tubing should be changed every 24 hours.

e. Ventilator breathing circuits should be changed only when they are visibly soiled with secretions or blood. If a heat-moisture exchanger is used for humidification, it may be kept with the circuit for at least 48 hours unless visibly soiled.

f. Sterile water should be used for procedures, and the unused portion should be discarded after 24 hours.

g. Add water to reservoir systems immediately before use.

h. Discard any unused water in a reservoir system before refilling.

i. Drain and discard any water collected in tubing; do not drain water back into the reservoir.

j. Medications should be stored under the conditions set by the manufacturer, should be discarded if they appear abnormal, and should be discarded on the expiration date.

k. Unused portions of medications should be discarded after 24 hours.

l. Sterile syringes should be used when measuring medications.

m. Sterile suction catheters should be used and sterile gloves worn whenever the patient’s airway is suctioned.

Exam Hint 2-2 (ELE, WRE)

Past examinations have questioned the types of routine procedures that should be performed to con-trol the spread of infection through respiratory care equipment.

5. Implement transmission prevention protocols

Transmission prevention protocols are used for patients known or suspected to be infected or colonized with epidemiologically significant pathogens, which are spread through airborne or droplet transmission or by contact with dry skin or contaminated surfaces. These protocols are used in addition to Standard Precautions. The following are general guidelines and specific diseases or conditions established by the CDC for the three types of patient isolation categories. Hospitals may establish extra standards and post them at the door to the patient’s room.

a. Airborne precautions

Airborne Precautions are used in addition to Standard Precautions for patients with known or suspected illnesses transmitted by airborne droplet nuclei (these include pulmonary tuberculosis [TB], varicella [chickenpox], rubeola [measles], and avian influenza [flu]), and when severe acute respiratory syndrome (SARS) is known or strongly suspected.

1. Room placement

Patients under Airborne Precautions must be placed in an airborne isolation room (AIR). This room must have a negative airflow versus that of the corridor, with 6 to 12 air changes per hour. Room air can be vented outside of the building, or it can be recirculated through a high-efficiency particulate air (HEPA) filter.

2. Gloves and hand washing

Use Standard Precautions.

3. Respiratory protection

a. If a patient is known to have or is suspected of having TB or SARS, a National Institute for Occupational Safety and Health (NIOSH)-approved respirator mask (N-95, N-99, or N-100) must be worn by all caregivers who enter the room. If the caregiver cannot wear an N-95 mask, a powered air protection respirator (PAPR) must be worn.

b. If a patient is known to have or is suspected of having varicella or rubeola, a NIOSH-approved respirator mask (N-95 or higher) must be worn by all susceptible caregivers who enter the room.

4. Eye protection

Health care workers should wear goggles or a face shield when within 3 feet of the patient.

5. Patient transport

a. Transport personnel must wear a NIOSH-approved respirator mask (N-95 or higher).

b. The patient must wear an isolation mask while out of his or her room.

6. Patient equipment

Use Standard Precautions.

b. Droplet precautions

Droplet Precautions are used in addition to Standard Precautions for patients known to have or suspected of having serious illness transmitted by large-particle droplets such as human influenza (flu), invasive Haemophilus influenzae (type b), Neisseria meningitidis disease including meningococcal bacteremia and meningitis, Mycoplasma pneumoniae, and Bordetella pertussis. A patient with possible SARS also is placed into this group until the condition is ruled out. (If SARS is confirmed, the patient is kept under Droplet, Airborne, Contact, and Standard Precautions.)

1. Room placement

A private room is preferred, but patients with the same infection may be placed in the same room.

2. Gloves and hand washing

Use Standard Precautions.

3. Gown

Use Standard Precautions.

4. Respiratory protection

a. Use Standard Precautions.

b. Caregivers must wear an isolation mask if working within 3 feet of the patient.

5. Patient transport

a. Transport personnel must wear an isolation mask if working within 3 feet of the patient.

b. The patient must wear an isolation mask while out of his or her room.

6. Patient equipment

Use Standard Precautions.

c. Contact precautions

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