Case 9: Community and ambulatory care issues in infection control

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The staff of your ambulatory care unit in a community-based hospital have asked you to meet with them regarding some specific issues they have as influenza season approaches.

Their concerns are as follows:
a) lack of separation between potentially infectious patients and non-infectious patients,
b) lack of facilities for adequate handwashing
c) concerns regarding side-effects of influenza vaccination and
d) whether vaccination of staff is compulsory and what will happen if staff choose not to be vaccinated.

You visit the area and note that there is a common waiting room, that rooms are usually used for multiple clinics during the week, and that there is indeed a lack of sinks. Further questioning reveals that approximately 30% of the staff are vaccinated for influenza yearly.

Case Nine Questions:
1. How would you mitigate against the risk of respiratory infections in the ambulatory care setting?

Promote good hand hygiene: Place hand sanitizer stations at the front door, admin/admissions desk and outside every clinic room (lautenbach, p. 397).

Educate:

  • Implement respiratory hygiene and cough etiquette: Post “cough etiquette” signs in the waiting room and washrooms along with hand sanitizer dispensers and tissues within easy reach(CDC, 2016).
  • Screening and triage of symptomatic patients: Ask any sick patient to phone ahead so that they may be re-scheduled and seen at the start or end of appointment days to prevent their sitting in the shared waiting room for extended periods (CDC, 2016). Note: if the patient’s appointment can be postponed until they are no longer sick, do so to avoid sick patients coming into the hospital at all. (CDC, 2016)
  • Instruct patients (and those accompany them) to inform staff upon arrival if they have symptoms of any respiratory infection (cough, runny nose, fever) and to take appropriate preventive actions (wear a facemask), (CDC, 2016).
  • Instruct sick patients (and educate staff triage patients) to report to the front desk upon arrival so that they may be shown into the next available clinic room rather than sitting out in the shared waiting room for long periods where they might infect others.
  • For clinic team leads “strong organizational leadership and an infrastructure for clear and timely communication and education, and for program implementation, have been common elements in successful programs.”(CDC, 2016)

Vaccinate:

  • Promote the flu vaccine and offer vaccination clinics to staff and vulnerable patients prior to the onset of flu season (Lautenbach, 397).
  • Also consider offering vaccination to vulnerable patients against preventable infectious diseases beyond the flu considering the shared environment in which different clinics are run(Lautenbach, p. 397).
  • The infection preventionist’s goal should be to vaccinate everyone who shares the community-based hosptial “unless contraindicated, vaccinate all people aged 6 months and older, including HCP, patients and residents of long-term care facilities” (CDC, 2016).

Use techniques to increase the flu vaccine rate amongst staff (we know currently on 30% are vaccinated).

Strategies such as:

  • providing incentives
  • providing vaccine at no cost to staff or vulnerable patients
  • improving access (e.g., offering vaccination at work and during work hours)
  • require staff and patients to sign a form to acknowledge that they have been educated about the benefits and risks of vaccination to be kept on file
  • mandating influenza vaccination for all healthcare professionals without contraindication is also an option (this seems to be debated every year!) (CDC, 2016).

Sanitization and cleaning:

  • Ensure proper adherence to environmental infection control procedures
  • ensure proper protocols are followed for sterilization and disinfection of all equipment
  • ensure high-touch surfaces in the environment are cleaned frequently throughout the clinic days
  • ensure proper cleaning procedures are followed for cleaning and disinfection of waiting room and clinic rooms as they are at higher risk to transfer infections being used for multiple clinics during a week (Lautenbach, p. 397).

Surveillance: perform surveillance for healthcare-associated infections at this community based hospital

  • Investigate any influenza outbreaks.
  • Ensure a mechanism of investigation and reporting of sentiel healthcare associated infection events is in place (Lautenbach, p. 398).
  • Sick staff: appropriate management of ill health care workers (use influenza screening tool for sick calls) (CDC, 2016).
  • Risk management: adherence to infection control precautions for all patient-care activities and aerosol-generating procedures (CDC, 2016)

Infection control precautions for staff to mitigate against the risk of respiratory infections:

  • wear gloves when in contact with any potentialy infectious material
  • gown for care activities with risk of contact with blood, body fluids, secretions (including respiratory), or excretions (CDC, 2016)
  • Remove gown and perform hand hygiene before leaving the patient’s environment.
  • Upon arrival, and until departure from the community-based hospital place patients on droplet precautions with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer (CDC, 2016).
  • Staff are to follow influenza patient care policy of putting on a mask prior to entering a room containing an influenza infected patient. (CDC, 2016).

Implement engineering controls:

  • Renovate the community-based hospital if possible to a design with control measures to reduce or eliminate exposure to infection
  • Install elements that shield staff and other patients from infected individuals
  • Examples of engineering controls include installing physical barriers such as partitions in triage areas and curtains that are drawn between patients (CDC, 2016).

Limit visitors:

“Visitors who have been in contact with the patient before and during hospitalization are a possible source of influenza for other patients, visitors, and staff”(CDC, 2016).

  • Restrict visitors to those necessary for the patient’s emotional well-being and care
  • Screening visitors for symptoms of acute respiratory illness over the phone before they accompany a patient to the community-based hospital
  • provide instruction (if possible before arrival) or at the front door using posters and signage on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) if needed.
  • Visitors should not be present during aerosol-generating procedures.
  • Visitors should be instructed to limit their movement within the facility (CDC, 2016).

2. Do you have any suggestions on how to involve the patients and family in infection control in this unit and in the community?

According to the public health agency of Canada, there are key elements to effiectively engaging the public. The 5 steps are:

  • Planning
  • Developing products
  • Implementing
  • Reporting
  • Evaluating (HC and PHAC, 2016)

Examples of engagement are:

  • Provide handwashing and cough etiquette material and posters for patients and families to read, share, put up in their community such as at their schools, local libraries, their workplaces and even in their homes.
  • Patients and families can help one another as well as other families and patients they come in contact with in this unit by following good flu prevention strategies.
  • They can get the seasonal vaccine, remind others to do so as well along with reminders to wash hands or cover their cough.
  • Families and patients both can help prevent the spread of the seasonal flu by staying home when sick.
  • Broadcast public education and information on social media, TV and radio (PH and PHAC, 2016).
  • Place flu prevention technique posters on buses, in public washrooms and publc waiting areas around town.

3. What is the current recommendation or directive from your province regarding vaccination of healthcare workers? Explain the rationale for the directive and why you agree or not.

The BCCDC influenza prevention policy states:

“BC’s Influenza Prevention Policy requires all healthcare workers to either be vaccinated against influenza or wear a mask in patient care areas throughout the influenza season. The policy also applies to visitors, volunteers and students who attend a patient care area” (BCCDC, 2017).

The rationale for the directive:

If less than the target of 80% of healthcare workers are immunized herd immunity falls below levels effective at preventing an influenza outbreak in a healthcare setting which places vulnerable patients at risk.

Healthcare workers are exposed to the most vulnerable individuals in a population – those at greatest risk for contracting the flu and suffering potentially life-threatening complications as a result of the flu. “Severe illness can result in hospitalization or death. Certain populations, such as young children and seniors, may be at higher risk for serious influenza complications such as viral pneumonia, secondary bacterial pneumonia and worsening of underlying medical conditions.” (PHAC, 2017).

If healthcare workers become sick with the flu they may spread it to vulnerable patients whom are unable to fight it off due to their underlying conditions.

Some patients may be immunocompromised as a result of their underlying conditions or as a result of treatment. These patients cannot build sufficient immunity against the flu even if a vaccine is given as therefore rely on (herd immunity) those around them being healthy (BCCDC, 2017).

Rationale according to the ministry of health:

  • “Influenza – or the flu – can be a serious contagious disease, which is spread by droplet transmission through close contact with an infected person. Infected individuals are highly contagious and can transmit the virus for 24 hours before they show any symptoms.”
  • Influenza causes by far the most deaths among vaccine- preventable diseases, outpacing all others combined.
  • Hospitalized patients and seniors in residential care are more vulnerable to influenza than healthy adults.
  • The vaccine is also less effective for frail seniors or other hospitalized patients, making it even more important that their caregivers are vaccinated.
  • Infected health care providers can pass the virus on to their patients before they even know they are sick. The most effective way to prevent the flu is by getting vaccinated” (Ministry of health, 2014).

4. What other respiratory illness might cause outbreaks in the community and the hospital setting? What rapid diagnostic methods are used to identify viral respiratory pathogens?

Respiratory illnesses that cause community outbreaks:

  • Severe acute respiratory syndrom (SARS)
  • Measles
  • Tuberculosis (TB) (Lautenbach, p. 357)

Other illnesses spread in outpatient settings:

  • Bordetella pertussis (Lautenbach, p. 361)
  • Varicella- zoster virus
  • parvovirus B19

Rapid diagnostic methods for viral respiratory pathogens:

New methods:

  • rapid respiratory virus culture methods
  • pooled antibody reagents
  • rapid antigen direct tests (RADTs)
  • improved specimen collection devices
  • nucleic acid amplification tests (NAATs).
  • “The introduction of these new systems has created new challenges for laboratory directors, who must decide which of the many tests to offer and what specimen types to accept for diagnostic testing”(Gnocchino and McAdam , 2011).

Old/Traditional methods:

  • RADTs
  • direct fluorescent antibody testing (DFA)
  • virus culture
  • traditional methods are often inferior in assay sensitivity, specificity, time to virus identification, and breadth of pathogen detection compared to NAATs. (Gnocchino and McAdam, 2011)

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(Above table from USCDC, 2016)

5. You decide they might benefit from a more structured infection control approach. What key elements are important to consider in an outpatient infection control program?

  • Patients maybe carrying unrecognized pathogens in and out of the outpatient envirmonment (Lautenbach, p. 357).
  • the appropriate level of infection prevention to prevent ambulatory care-associated pathogen transmission is presently unknown (Lautenbach, p. 357).
  • The CDC has not yet recommended specific infection prevention and control surveillance systems for ambulatory care (Lautenbach, 357).
  • Infection prevention and control programs, planning and resources are lften lacking beyond inpatient hospital settings.

Key elements of infection prevention and control for outpatient settings are:

Pathogen Transmission occurs in 2 ways:

  1. congregation of patients in waiting rooms/areas or common rooms/areas
  2. invasive procedure-associated

Pathogens can be spread via healthcare workers in these amublatory care settings when staff fail to follow proper:

  • aseptic technique
  • hand washing technique
  • environmental sanitation standards(Lautenbach, p. 357)

In structuring infection control in outpatient settins Infection Preventionists must determine:

  • which infections to conduct surveillance on
  • whom to report the data to
  • who will be responsible for implementing the changes (Lautenbach, p. 357).

Methods to reduce respiratory illness spread in outpatient settings:

  • post visual alerts at the entrance to instruct patients to report respiratory symptoms
  • cover nose and mouth when coughing or sneezing
  • use tissues to contain respiratory secretions and dispose of them in nearest garbage
  • perform hand hygiene after contact with respiratory secretions, contaminated objects or materials
  • provide conveniently located handwashing agents
  • offer masks to coughing persons
  • trage coughing persons out of the common areas asap (Lautenbach, 359).

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

2.  Center for disease control and prevention, CDC (2016). Prevention Strategies for Seasonal Influenza in Healthcare Settings Guidelines and Recommendations. https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

3. BCCDC. (2017). Influenza Prevention Policyhttp://www.bccdc.ca/health-professionals/clinical-resources/immunization/influenza-prevention-policy

4. Public Health Agency of Canada. (2017). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2016-2017. http://www.phac-aspc.gc.ca/naci-ccni/flu-2016-grippe-eng.php#i2

5. Ginocchio, C. C., & McAdam, A. J. (2011). Current Best Practices for Respiratory Virus Testing. Journal of Clinical Microbiology, 49(9 Suppl), S44–S48. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185851/

6. Health Canada and the Public Health Agency of Canada. (2016). Guidelines on Public Engagement. Obtained from: http://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/guidelines-public-engagement-publique-lignes-directrice/alt/pub-eng.pdf

7. USCDC. (2016). Rapid Diagnostic Testing for Influenza: Information for Health Care Professionals. https://www.cdc.gov/flu/professionals/diagnosis/rapidclin.htm#Table1

8. ministry of Health. (2014). Influenza Vaccine – Frequently Asked Questions Influenza Control Program. http://www.immunizebc.ca/sites/default/files/graphics/influenzavaccinefaqphsa.pdf

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