Show
Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: . Type 508 Accommodation and the title of the report in the subject line of e-mail. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)Prepared by The material in this report originated in the National Center for Infectious Diseases, James M. Hughes, M.D., Director; and the Division of Healthcare Quality Promotion, Steven L. Solomon, M.D., Acting Director. Summary The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.IntroductionParameters of the ReportThis report, which contains the complete list of recommendations with pertinent references, is Part II of Guidelines for Environmental Infection Control in Health-Care Facilities. The full four-part guidelines will be available on CDC's Division of Healthcare Quality Promotion (DHQP) website. Relative to previous CDC guidelines, this report
In the full guidelines, Part I, Background Information: Environmental Infection Control in Health-Care Facilities, provides a comprehensive review of the relevant scientific literature. Attention is given to engineering and infection-control concerns during construction, demolition, renovation, and repair of health-care facilities. Use of an infection-control risk assessment is strongly supported before the start of these or any other activities expected to generate dust or water aerosols. Also reviewed in Part I are infection-control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss of electricity and ventilation, or disruption of water supply) and the limited effects of environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on disease transmission in health-care facilities. Part III and Part IV of the full guidelines provide references (for the complete guideline) and appendices, respectively. Part II (this report) contains recommendations for environmental infection control in health-care facilities, describing control measures for preventing infections associated with air, water, or other elements of the environment. These recommendations represent the views of different divisions within CDC's National Center for Infectious Diseases and the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 12-member group that advises CDC on concerns related to the surveillance, prevention, and control of health-care--associated infections, primarily in U.S. health-care facilities. In 1999, HICPAC's infection-control focus was expanded from acute-care hospitals to all venues where health care is provided (e.g., outpatient surgical centers, urgent care centers, clinics, outpatient dialysis centers, physicians' offices, and skilled nursing facilities). The topics addressed in this report are applicable to the majority of health-care facilities in the United States. This report is intended for use primarily by infection-control practitioners, epidemiologists, employee health and safety personnel, engineers, facility managers, information systems professionals, administrators, environmental service professionals, and architects. Key recommendations include
Topics outside the scope of this report include 1) noninfectious adverse events (e.g., sick building syndrome), 2) environmental concerns in the home, 3) home health care, 4) terrorism, and 5) health-care--associated foodborne illness. Wherever possible, the recommendations in this report are based on data from well-designed scientific studies. However, certain of these studies were conducted by using narrowly defined patient populations or specific health-care settings (e.g., hospitals versus long-term care facilities), making generalization of findings potentially problematic. Construction standards for hospitals or other health-care facilities may not apply to residential home-care units. Similarly, infection-control measures indicated for immunosuppressed patient care are usually not necessary in those facilities where such patients are not present. Other recommendations were derived from knowledge gained during infectious disease investigations in health-care facilities, where successful termination of the outbreak was often the result of multiple interventions, the majority of which cannot be independently and rigorously evaluated. This is especially true for construction situations involving air or water. Other recommendations were derived from empiric engineering concepts and may reflect industry standards rather than evidence-based conclusions. Where recommendations refer to guidance from the American Institute of Architects (AIA), the statements reflect standards intended for new construction or renovation. Existing structures and engineered systems are expected to be in continued compliance with those standards in effect at the time of construction or renovation. Also, in the absence of scientific confirmation, certain infection-control recommendations that cannot be rigorously evaluated are based on strong theoretic rationale and suggestive evidence. Finally, certain recommendations are derived from existing federal regulations. Performance MeasurementsInfections caused by the microorganisms described in this guideline are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations:
Updates to Previous RecommendationsContributors to this report reviewed primarily English-language manuscripts identified from reference searches using the National Library of Medicine's MEDLINE, bibliographies of published articles, and infection-control textbooks. All the recommendations may not reflect the opinions of all reviewers. This report updates the following published guidelines and recommendations: CDC. Guideline for handwashing and hospital environmental control. MMWR 1998;37(No. 24). Replaces sections on microbiologic sampling, laundry, infective waste, and housekeeping. Tablan OC, Anderson LJ, Arden NH, et al., Hospital Infection Control Practices Advisory Committee. Guideline for prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol 1994;15:587--627. Updates and expands environmental infection-control information for aspergillosis and Legionnaires disease; online version incorporates Appendices B, C, and D addressing environmental control and detection of Legionella spp. CDC. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care facilities. MMWR 1994;43(No. RR13). Provides supplemental information on engineering controls. CDC. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1995;44(No. RR12). Supplements environmental infection-control information from the section, Hospitals with Endemic VRE or Continued VRE Transmission. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53--80. Supplements and updates topics in Part II --- Recommendations for Isolation Precautions in Hospitals (linen and laundry, routine and terminal cleaning, airborne precautions). Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 1999;4:250--78. Updates operating room ventilation and surface cleaning/disinfection recommendations from the section, Intraoperative Issues: Operating Room Environment. U.S. Public Health Service, Infectious Diseases Society of America, Prevention of Opportunistic Infections Working Group. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. Infect Dis Obstet Gynecol 2002; 10:3--64. Supplements information regarding patient interaction with pets and animals in the home. CDC, Infectious Diseases Society of America, American Society of Blood and Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Cytotherapy 2001;3:41--54. Supplements and updates the section, Hospital Infection Control. Key TermsAirborne infection isolation (AII) refers to the isolation of patients infected with organisms spread via airborne droplet nuclei <5 µm in diameter. This isolation area receives numerous air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure, such that the direction of the air flow is from the outside adjacent space (e.g., the corridor) into the room. The air in an AII room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons entering these rooms when caring for TB or smallpox patients and for staff who lack immunity to airborne viral diseases (e.g., measles or varicella zoster virus [VZV] infection). Protective environment (PE) is a specialized patient-care area, usually in a hospital, with a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of HEPA filtration, high numbers of air changes per hour (>12 ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have undergone allogeneic hematopoietic stem cell transplant (HSCT).Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders (e.g., human immunodeficiency virus [HIV] infection or congenital immune deficiency syndrome), chronic diseases (e.g., diabetes, cancer, emphysema, or cardiac failure), or immunosuppressive therapy (e.g., radiation, cytotoxic chemotherapy, anti-rejection medication, or steroids). Immunocompromised patients who are identified as high-risk patients have the greatest risk of infection caused by airborne or waterborne microorganisms. Patients in this subset include persons who are severely neutropenic for prolonged periods of time (i.e., an absolute neutrophil count [ANC] of <500 cells/mL), allogeneic HSCT patients, and those who have received the most intensive chemotherapy (e.g., childhood acute myelogenous leukemia patients).AbbreviationsAAMI Association for the Advancement of Medical Instrumentation ACH air changes per hour AER automated endoscope reprocessor AHJ authority having jurisdiction AIA American Institute of Architects AII airborne infection isolation ANSI American National Standards Institute ASHRAE American Society of Heating, Refrigeration, and Air-Conditioning Engineers BMBL Biosafety in Microbiological and Biomedical Laboratories (CDC/National Institutes of Health) CFR Code of Federal Regulations CJD Creutzfeldt-Jakob disease CPL compliance document (OSHA) DFA direct fluorescence assay DHHS U.S. Department of Health and Human Services DOT U.S. Department of Transportation EC environment of care EPA U. S. Environmental Protection Agency FDA U.S. Food and Drug Administration HBV hepatitis B virus HEPA high efficiency particulate air HIV human immunodeficiency virus HSCT hematopoietic stem cell transplant HVAC heating, ventilation, air conditioning ICRA infection-control risk assessment JCAHO Joint Commission on Accreditation of Healthcare Organizations NaOH sodium hydroxide NTM nontuberculous mycobacteria OSHA Occupational Safety and Health Administration PE protective environment PPE personal protective equipment TB tuberculosis USC United States Code USDA U.S. Department of Agriculture UV ultraviolet UVGI ultraviolet germicidal irradiation VHF viral hemorrhagic fever VRE vancomycin-resistant Enterococcus VRSA vancomycin-resistant Staphylococcus aureus VZV varicella zoster virus Recommendations for Environmental Infection Control in Health-Care FacilitiesRationale for RecommendationsAs in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretic rationale, applicability, and possible economic effect. The recommendations are evidence-based wherever possible. However, certain recommendations are derived from empiric infection-control or engineering principles, theoretic rationale, or from experience gained from events that cannot be readily studied (e.g., floods). The HICPAC system for categorizing recommendations has been modified to include a category for engineering standards and actions required by state or federal regulations. Guidelines and standards published by the AIA, American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the Association for the Advancement of Medical Instrumentation (AAMI) form the basis of certain recommendations. These standards reflect a consensus of expert opinions and extensive consultation with agencies of the U.S. Department of Health and Human Services. Compliance with these standards is usually voluntary. However, state and federal governments often adopt these standards as regulations. For example, the standards from AIA regarding construction and design of new or renovated health-care facilities, have been adopted by reference by >40 states. Certain recommendations have two category ratings (e.g., Categories IA and IC or Categories IB and IC), indicating the recommendation is evidence-based as well as a standard or regulation. Rating CategoriesRecommendations are rated according to the following categories: Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretic rationale.Category IC. Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standards.)Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretic rationale.Unresolved issue. No recommendation is offered. No consensus or insufficient evidence exists regarding efficacy.Recommendations --- AirI. Air-Handling Systems in Health-Care Facilities
II. Construction, Renovation, Remediation, Repair, and Demolition
III. Infection Control and Ventilation Requirements for PE rooms
IV. Infection-Control and Ventilation Requirements for AII Rooms
V. Infection-Control and Ventilation Requirements for Operating Rooms
VI. Other Potential Infectious Aerosol Hazards in Health-Care Facilities
Recommendations --- WaterI. Controlling the Spread of Waterborne Microorganisms
II. Routine Prevention of Waterborne Microbial Contamination Within the Distribution System
III. Remediation Strategies for Distribution System Repair or Emergencies
IV. Additional Engineering Measures as Indicated by Epidemiologic Investigation for Controlling Waterborne, Health-Care--Associated Legionnaires Disease
V. General Infection-Control Strategies for Preventing Legionnaires Disease
VI. Preventing Legionnaires Disease in Protective Environments and Transplant Units
VII. Cooling Towers and Evaporative Condensers
VIII. Dialysis Water Quality and Dialysate
IX. Ice Machines and Ice
X. Hydrotherapy Tanks and Pools
XI. Miscellaneous Medical Equipment Connected to Water Systems
Recommendations ---Environmental ServicesI. Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas
II. Cleaning Spills of Blood and Body Substances
III. Carpeting and Cloth Furnishings
IV. Flowers and Plants in Patient-Care Areas
V. Pest Control
VI. Special Pathogens
Recommendations ---Environmental SamplingI. General Information
II. Air, Water, and Environmental Surface Sampling
Recommendations ---Laundry and BeddingI. Employer Responsibilities
II. Laundry Facilities and Equipment
III. Routine Handling of Contaminated Laundry
IV. Laundry Process
V. Microbiologic Sampling of Textiles
VI. Special Laundry Situations
VII. Mattresses and Pillows
VIII. Air-Fluidized Beds
Recommendations --- Animals in Health-Care FacilitiesI. General Infection-Control Measures for Animal Encounters
II. Animal-Assisted Activities and Resident Animal Programs
III. Protective Measures for Immunocompromised Patients
IV. Service Animals
V. Animals as Patients in Human Health-Care Facilities
VI. Research Animals in Health-Care Facilities
Recommendations --- Regulated Medical WastesI. Categories of Regulated Medical Waste
II. Disposal Plan for Regulated Medical Wastes
III. Handling, Transporting, and Storing Regulated Medical Wastes
IV. Treatment and Disposal of Regulated Medical Wastes
V. Special Precautions for Wastes Generated During Care of Patients with Rare Diseases
References
Table 1
Return to top. Figure 1
Return to top. Box 1
Return to top. Table 2
Return to top. Figure 2
Return to top. Box 2
Return to top. Figure 3
Return to top. Box 3
Return to top. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication. Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to .Page converted: 5/27/2003 What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion?What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? Remove the tubing from the primary line Y-site port, and cap the end.
Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback?Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? Use the most proximal insertion port on the primary tubing.
What precautions need to be taken when administering IV medications?Never use a needle when injecting IV medication. Always use a needleless system. After preparing the medication, always label the medication syringe with the patient name, date, time, medication, and dose. Never leave the syringe unattended.
What is the most important action the nurse can take to to protect the patient when administering a medication by IV bolus?CORRECT. Injecting the medication at the prescribed rate is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus, since injecting the medication faster than recommended may result in injury or death.
|