Infection Control

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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

Contact Precautions are used in addition to Standard Precautions for patients known to have or suspected of having epidemiologically important organisms that can be transmitted by direct contact with environmental surfaces, such as patients with SARS, avian flu, diarrhea, inadequately contained wound infection, or localized herpes zoster (shingles).

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

a. Wear gloves when entering the patient’s room.

b. Change gloves after contact with any contaminated item.

c. Remove gloves and wash hands before leaving the patient’s room.

3. Gown

a. Wear a gown when entering the patient’s room if you anticipate substantial contact with the patient, environmental surfaces, or patient items.

b. Remove the gown and wash hands before leaving the room.

4. Respiratory protection

Use Standard Precautions.

5. Patient transport

a. Limit transportation of the patient from the room. The patient must wear a clean gown.

b. If transportation is required, caregivers must wear a gown and gloves.

6. Patient equipment

a. Each patient should have his or her own dedicated noncritical equipment (thermometer, commode, blood pressure cuff, sphygmomanometer, stethoscope, etc.).

b. Clean and disinfect all patient care equipment after the patient has been discharged.

6. Implement infectious disease protocols (Code: IIB4) [Difficulty: ELE: Ap; WRE: An]

a. Avian flu (avian influenza)

Avian flu (also called “bird flu”) is caused by influenza type A viruses that primarily infect poultry. Although human infections are rare, persons in contact with infected poultry or who inhale infected aerosolized droplets from infected poultry can become infected. A person who presents with a severe febrile respiratory illness and has traveled within the past 10 days from an area with an avian flu outbreak (usually China or a Southeast Asian country) should be suspected of having avian flu. Standard Precautions and Droplet Precautions are implemented for the patient. These precautions are continued for 14 days after the symptoms begin, or until (1) it is proven that the patient does not have avian flu, or (2) a different diagnosis is established.

See the previous discussion on Standard Precautions, respiratory hygiene/cough etiquette, and Droplet Precautions for guidance on how to prevent the spread of this infection. In addition, all health care workers should be immunized against influenza.

b. Severe acute respiratory syndrome (SARS)

Severe acute respiratory syndrome (SARS) is caused by a corona virus (CoV). (Thus, the common abbreviation, SARS-CoV.) This rare but serious pulmonary infection is spread by respiratory droplets through close person-to-person contact. If a person has a serious pneumonia or acute respiratory distress syndrome (ARDS) with an unknown cause and has traveled to China or a Southeast Asian country within the past 10 days, SARS infection should be considered until another cause cannot be found.

See the previous discussion on Standard Precautions, respiratory hygiene/cough etiquette, and Droplet Precautions for guidance on how to prevent the spread of this infection.

MODULE B

Recommend vaccinations (Code: IIIG4k) [Difficulty: ELE: R; WRE: Ap]

1. Pneumovax

The Pneumovax 23 (pneumococcal vaccine polyvalent) vaccine provides protection against the 23 most prevalent or invasive types of Streptococcus pneumoniae bacteria. Patients with serious chronic illness should be immunized to prevent them from developing this very dangerous type of pneumonia. Guidelines for immunization include the following:

In any immunocompetent person 2 years of age or older who fits the following conditions:

• 50 years of age or older

• Chronic cardiovascular disease (congestive heart failure and cardiomyopathies)

• Chronic pulmonary disease (chronic obstructive pulmonary disease, asthma with chronic bronchitis)

• Diabetes mellitus

• Alcoholism or chronic liver disease

• Cerebrospinal fluid leaks

• Sickle cell disease

• Splenectomy

• Persons who live in special environments or social settings (Alaskan Natives and certain American Indian populations)

In any immunoincompetent person 2 years of age or older who has one of the following conditions:

• Human immunodeficiency virus (HIV) infection

• Hodgkin’s disease

• Multiple myeloma

• Generalized malignancy

• Renal failure or nephrotic syndrome

• Receiving immunosuppressive chemotherapy including corticosteroids

• Organ or bone marrow transplant

Revaccination is recommended in the following circumstances as long as at least 5 years have passed since the first vaccination:

1. An immunocompetent person 65 years of age or older

2. An immunoincompetent person who is at highest risk for a serious pneumococcal infection or who has a rapid drop in pneumococcal antibody levels

A third vaccination is not recommended. In general, vaccination should be performed at least 2 weeks before certain medical procedures such as elective splenectomy or immunosuppressive therapy are started. The Pneumovax 23 intramuscular or subcutaneous injection can be given at the same time as the influenza vaccination, as long as a different arm is used for each injection.

2. Influenza

Seasonal influenza (flu) vaccination begins in September or October of each year but can be given later if necessary. Two ways to be immunized are available, and each method provides protection against three strains of flu virus. The intramuscular injection vaccine contains inactivated or killed virus and is given to healthy people and those with medical conditions. The inhaled vaccine is given only to healthy individuals between 5 and 49 years of age; pregnant women are excluded.

The flu vaccine is recommended for the following groups:

• Children 6 to 59 months of age

• A woman who will be pregnant during the flu season

• Those who will be 50 years or older

• Anyone 6 months of age or older with a chronic heart or lung condition, including asthma

• Anyone with difficulty breathing or swallowing caused by brain injury or disease, spinal cord injury, seizure disorder, or neuromuscular disease

• Anyone who has been hospitalized or needed regular doctor visits in the past year because of chronic medical conditions such as diabetes, kidney disease, hemoglobin abnormalities, or a weakened immune system

• Those between 6 months and 18 years of age in need of regular aspirin therapy who might therefore be at risk for Reye’s syndrome if they get the flu

• Residents of nursing homes or similar facilities

• Family members and caregivers of children younger than 6 months of age and anyone at risk for severe complications from influenza

• Any health care worker

The influenza vaccination injection and Pneumovax 23 intramuscular or subcutaneous injection can be given at the same time as long as a different arm is used for each injection.

MODULE C

Decontaminate respiratory care equipment

Decontamination is the process of disassembling, washing (to remove dried secretions or other debris), rinsing, and disinfecting or sterilizing used patient care equipment. The process results in the equipment being free of any pathogens, so that it can be used with another patient. Obviously, once disinfected, the equipment must be reassembled aseptically and stored for future use.

1. Choose the appropriate agent and method for disinfection and sterilization (ELE code: IIB1) [Difficulty: ELE: Ap, An]

a. Disinfection

Disinfection is a procedure that significantly reduces the microbial contamination of the equipment that has been processed. All disinfection processes destroy the vegetative form (the cell) of pathogenic organisms, including the vast majority of respiratory system pathogens. However, a few Bacillus-type bacteria are difficult to kill because they have a particularly tough cell wall or have spores for reproduction. Spores are analogous to seeds in that they grow into bacteria under the right conditions and are resistant to drying, heat, and many chemicals that kill the bacterial cell. Therefore a spore-forming organism may be able to reproduce itself after the cells have been killed. Obviously, disinfection can be used only on equipment that is not contaminated by spore-forming bacteria. Knowing what pathogen has infected the patient, if possible, can help the clinician determine the appropriate disinfection (or sterilization) method to be used on contaminated equipment. Some disinfecting agents kill different kinds of organisms, depending on the length of exposure time.

Another consideration in selecting the appropriate disinfection method is how the equipment will be used in patient care. Equipment or instruments that do not directly touch the patient (e.g., an electrocardiograph machine) are classified as noncritical (low risk of spreading infection) and can undergo low-level disinfection. Low-level disinfectants are agents capable of killing some vegetative bacteria, fungi, and lipophilic viruses. Equipment or instruments that touch surface mucous membranes and the skin but do not penetrate them are listed as semicritical and must undergo high-level disinfection (e.g., laryngoscope blades, a bronchoscope). Agents that kill all microorganisms except bacterial spores are classified as high-level disinfectants.

A third consideration in choosing the best disinfection method is the type of equipment that requires decontamination. Certain processes and agents can be used only on certain types of equipment. Table 2-1 lists the various ways of disinfecting reusable patient care equipment decontaminated in the hospital.

TABLE 2-1 Methods of Disinfection Used in the Hospital Setting for Respiratory Care–Related Equipment

The fourth consideration to take into account is the location of the patient. The previous discussion relates to patients in the hospital or a long-term care facility. Home care patients typically will not use these methods because of the high costs. Instead, the plastics used in home care medication nebulizers, etc., usually are cleansed in the following way:

1. Disassemble as needed.

2. Run hot water from the tap to eliminate as many organisms as possible. Clean the sink.

3. Use hot water to wash the equipment in a detergent solution.

4. Place the equipment into an acetic acid (white vinegar) solution for disinfection. It should soak for 60 minutes. (Grocery store–purchased white vinegar contains 5% acetic acid. However, it may be diluted with three parts of water to produce a 1.25% solution.) After use, the acetic acid must be thrown away because it will no longer be effective.

5. After soaking, the equipment should be rinsed in hot water and placed on a clean towel to air dry.

A 1.25% or higher percentage solution is classified as a low-level disinfectant and will kill most vegetative bacteria (including Pseudomonas aeruginosa) and some fungi and viruses. However, Mycobacterium tuberculosis, nonlipid viruses, and spores will not be killed.

Exam Hint 2-3 (ELE, WRE)

Expect to see one question about using white vinegar or acetic acid to disinfect equipment in the home. The percentage of acetic acid specified in the NBRC question should not matter.

b. Sterilization

Sterilization is a procedure that destroys all living microbial organisms and renders them unable to reproduce. All sterilization procedures destroy the vegetative forms and spores of all microscopic organisms. Examples of spore-forming bacteria include Bacillus anthracis (anthrax), Clostridium botulinum (botulism), C tetani (tetanus), and C perfringens (gas gangrene). Any equipment or instruments that penetrate body tissue (e.g., a surgical scalpel) are listed as “critical” (high risk of spreading infection) and must be sterilized before use on another patient. As was discussed previously, the method of sterilization depends on the type of equipment under consideration. Table 2-2 lists various methods of sterilization for reusable supplies and patient care equipment decontaminated in the hospital.

TABLE 2-2 Methods of Sterilization Used in the Hospital Setting for Respiratory Care–Related Equipment

Method	Conditions	Comments
Steam autoclave	Autoclave chamber with an internal steam pressure of 15 lb per sq in, 121° C (250° F), 15 min	Used with glass, cloth, bandages, unsharpened stainless steel instruments, ventilator bacteria filters.
Steam autoclave		Avoid use with many plastics used in respiratory care, rubber, dextrose solutions, sharpened stainless steel instruments, electrical devices, or machines.
Dry heat	Autoclave chamber at 160° C-180” C (320° F-356°F), 2-hr use	Used with glass or sharpened stainless steel instruments.
Dry heat	Autoclave chamber at 160° C-180” C (320° F-356°F), 2-hr use	Avoid use with many plastics used in respiratory care, rubber, dextrose solutions, electric devices, or machines.
Ethylene oxide gas	Specific guidelines vary depending on the manufacturer of the chamber and the supplies or equipment being sterilized. In general, a gas concentration of 800-1000 mg/L must be kept for 3-4 hr at 50%-100% relative humidity and 49° C-57° C (120° F-135” F). Great care must be taken to pre-dry all items before gassing and to properly aerate them after sterilization.	Used with heat-sensitive and moisture-sensitive items, as are many plastics in respiratory care equipment.
Ethylene oxide gas		Avoid use with supply pouches or plastic films, such as aluminum foil, nylon, thermoplastic resin (Saran), Mylar, cellophane polyamide, polyester, or other films that are not penetrated by the gas, or with PVC that has been sterilized previously by the manufacturer with gamma radiation.
GLUTARALDEHYDE SOLUTIONS
Alkaline glutaraldehyde (Cidex, Cidex 7, Sporicidin)	Complete immersion. Cidex products for 10 hr; Sporicidin for 6 hr and 45 min	Used with rubber and many plastics in respiratory care, especially those that are heat sensitive; care must be taken to thoroughly rinse items after they have been cleansed.
Alkaline glutaraldehyde (Cidex, Cidex 7, Sporicidin)		Avoid use with any item that cannot be immersed or that will absorb the solution.
Acid glutaraldehyde (Sonacide)	Complete immersion for 1 hr at 60° C (140° F)	Use with rubber and many plastics used in respiratory care, especially those that are heat sensitive; care must be taken to thoroughly rinse items after they have been cleansed.
Acid glutaraldehyde (Sonacide)	Complete immersion for 1 hr at 60° C (140° F)	Avoid use with any item that cannot be immersed or that will absorb the solution.

PVC, Polyvinyl chloride

2. Disinfect or sterilize respiratory care equipment (ELE code: IIB1) [Difficulty: ELE: Ap, An]

As was previously discussed, the choice of whether to disinfect or sterilize equipment depends on how it is used clinically, what type of pathogen is involved, and from what material the equipment is made. Most respiratory pathogens are not spore-formers, so low-level or high-level disinfection is acceptable. Either a glutaraldehyde solution or pasteurization is used in most departments for disinfecting plastic masks, hoses, etc.

Any department that processes its own equipment must have adequate facilities for receiving used equipment and for its disassembly, cleansing, packaging, and distribution. First, a “dirty” area must exist where contaminated equipment is brought for disassembly, scrubbing of secretions or blood, and rinsing. Equipment then is placed into the glutaraldehyde solution or a pasteurizing machine. After that, equipment is taken to a “clean” area to be rinsed, dried, reassembled, and placed into plastic bags for storage. Care must be taken not to recontaminate the equipment during this procedure. Items that must be sterilized usually are just processed through the dirty area before being sent to the central supply department, where equipment is sterilized according to the criteria shown in Table 2-2.

3. Monitor the sterilization process to ensure its effectiveness (ELE code: IIB1) [Difficulty: ELE: Ap, An]

The term surveillance describes the monitoring of equipment to ensure that the disinfection or sterilization process was successful and that in-use equipment is not a source of patient contamination. Processing (chemical) indicators are used to ensure that disinfection or sterilization was done correctly. Examples include special tapes used to hold the wrapping around packages of equipment being autoclaved or placed into ethylene oxide. These tapes turn color when the autoclave has reached the proper temperature, or when the correct concentration of ethylene oxide has been reached. The color change shows the user that the package was processed correctly; therefore the package contents are probably sterile.

Another example is a biologic indicator placed into the wrapped package before sterilization. These biologic indicators are bacterial spores that are killed only if the required conditions are met. For example, the spores of Bacillus subtilis are placed onto strips of paper to be killed by ethylene oxide gas. After the equipment and spores have been sent through the sterilization process, the spores are placed into conditions favorable for growth. If no growth occurs, they are dead; therefore no other living organisms survived.

Equipment held in storage or being used in patient care also is randomly sampled for contamination. A sample is taken in three ways for culturing of possible organisms in three ways. The first involves wiping a sterile swab onto an equipment surface, and then rubbing it over a plate of growth medium or placing it into a tube of liquid broth. The second, which is used to check inside lengths of tubing, necessitates pouring a liquid broth through the tube and into a sterile container. The third involves sampling the aerosol that a nebulizer produces. A hose usually is attached to the outlet of the nebulizer. The other end of the hose is connected to a funnel, which is attached to a culture plate, where the droplets impact. In all three examples, the growth of any organism in the growth medium indicates a form of contamination. The laboratory then determines whether the organism is pathogenic. If so, measures must be taken to improve the disinfection or sterilization process.

MODULE D

Biohazardous materials

1. Make sure that biohazardous materials are handled properly (Code: IIB2) [Difficulty: ELE: Ap; WRE: An]

A respiratory therapist is most likely to come into contact with biohazardous materials in the form of infectious waste, body fluids, or needles and syringes. All must be handled and disposed of properly to keep the practitioner and the patient safe. Although hospital policies will vary, infectious waste and body fluids usually are placed into a red bag. The bag is removed from the patient care area and incinerated to ensure that all pathogens are killed.

Needles, syringes, or any sharp objects are placed into a sharps container, which also is red and usually is marked with a biohazard symbol. Every patient room should have a sharps container, so that used needles and syringes can be disposed of easily. If at all possible, the needle should not be recapped after use. Instead, simply drop the used needle and syringe into the slot on the container. Never force anything into the container or put a finger into it. When full, the sharps container should be sealed closed and removed for proper disposal.

American Association for Respiratory Care (AARC). Guidelines for the prevention of nosocomial infections. Dallas: AARTimes, Sept. 1983.

American Respiratory Care Foundation (ARCF). Guidelines for disinfection of respiratory care equipment used in the home. Respir Care. 1988;33:801.

Carter C, Stone MK. Respiratory microbiology, infection, and infection control. In: Hess DR, MacIntyre NR, et al, editors. Respiratory care principles and practice. Philadelphia: WB Saunders, 2002.

Centers for Disease Control (CDC). Interim recommendations for infection control in health-care facilities caring for patients with known or suspected avian influenza. http://www.cdc.gov/flu/avian/professional/infect-control.htm, May 21, 2004.

Chatburn RL, Kallstrom TJ, Bajaksouzian S. A comparison of acetic acid with a quaternary ammonium compound for disinfection of hand-held nebulizers. Respir Care. 1988;33(3):179-187.

Eubanks DH, Bone RC. Comprehensive respiratory care, ed 2. St Louis: Mosby, 1990.

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Gordon SM. Principles of infection control. In Wilkins RL, Stoller JK, Kacmarek RM, editors: Egan’s fundamentals of respiratory care, ed 9, St Louis: Mosby, 2009.

Johnson & Johnson Medical: Cidexplus, 28-day solution, Arlington, TX, 1999.

Merck & Co., Inc: Pneumovax 23 (pneumococcal vaccine polyvalent), Whitehouse Station, NJ, July 2008.

OSF Saint Anthony Medical Center, Infection control precautions, Rockford, IL, 1998.

Pagana KD, Pagana TJ. Mosby’s manual of diagnostic and laboratory tests. St Louis: Mosby, 1998.

U.S. Department of Health and Human Services: Public health guidance for community-level preparedness and response to severe acute respiratory syndrome (SARS), version 2: Supplement I: Infection control in healthcare, home, and community settings, January 8, 2004.

U.S. Food and Drug Administration (FDA). Influenza: Vaccination still the best protection. http://www.fda.gov/fdac/features/2006/506_influenza.html, September-October 2006.

Washington JA. Infectious disease aspects of respiratory therapy. In Burton GG, Hodgkin JE, Ward JJ, editors: Respiratory care, ed 4, Philadelphia: Lippincott-Raven, 1997.

SELF-STUDY QUESTIONS FOR THE ENTRY LEVEL EXAM See page 583 for answers

1. A hospitalized patient who recovered from a Clostridium botulinum infection received several respiratory care services. How should a nondisposable plastic pulmonary function testing mouthpiece be sterilized before being reused?

A. Steam autoclave for 15 minutes.

B. Soak in glutaraldehyde solution for 10 hours.

C. Pasteurize for 20 minutes.

D. Soak in an alcohol solution for 15 minutes.

3. After use of a mechanical ventilator has been discontinued, what is the best method to sterilize the reusable main-flow bacteria filter?

A. Wrapping it and soaking it in acetic acid

B. Pasteurization

C. Glutaraldehyde soak

D. Steam autoclaving

4. A batch of respiratory care equipment has gone through the gas sterilization process with ethylene oxide. Routine surveillance of the equipment shows that spores of Bacillus subtilis have survived the process. What should be done next?

A. Use the equipment because this organism does not cause illness.

B. Aerate the gas as usual, and put into use.

C. Resterilize the equipment, and check for destruction of the spores.

D. Wipe off the equipment with 70% alcohol to remove the spores from the equipment.

5. A retired home care patient living on a fixed income needs to be able to disinfect her respiratory therapy equipment. Which of the following would be best for her?

B. Acid glutaraldehyde

C. Ethylene oxide system

D. Warm, soapy water

6. What is the most cost-effective way for a respiratory care department to disinfect large amounts of reusable plastic tubing and oxygen masks?

A. 70% ethyl alcohol

B. Steam autoclave

C. Pasteurization

7. A contaminated Bird Mark 7 intermittent positive-pressure breathing (IPPB) unit must be sterilized before use with another patient. What is the best method?

A. Pasteurization

B. Ethylene oxide

C. 10-Hour soak in glutaraldehyde

D. Steam autoclave

8. A 58-year-old patient had an exacerbation of his COPD related to spring allergies. As he is being prepared for discharge from the hospital, what should the respiratory therapist recommend?

A. Get an influenza vaccination as soon as possible.

B. Get a tuberculosis skin test as soon as possible.

C. Have a throat swab performed to check on a possible Streptococcus infection.

D. Get an influenza vaccination in the fall.

SELF-STUDY QUESTIONS FOR THE WRITTEN REGISTRY EXAM See page 606 for answers

1. A home care company has found that several of its tracheostomy patients have Escherichia coli tracheal infections. What is the most likely cause of the infections?

A. Poor hand-washing technique by visiting respiratory therapists

B. Contaminated tracheostomy tubes from the manufacturer

C. Contaminated bottles of sterile water from the manufacturer

D. Poor hand-washing technique by patients’ family members

2. A respiratory therapist notices that two people in the Emergency Department waiting room are coughing regularly. All of the following should be done EXCEPT

A. Have the two coughing people sit near each other to minimize their contact with other people in the waiting room.

B. Have each person wear a face mask while waiting.

C. Give facial tissues to the two people.

D. Have both people sit at least 3 feet away from anyone else.

4. A home care respiratory therapist is setting up a continuous home oxygen system for a 52-year-old patient with congestive heart failure. Besides teaching the patient about her condition and how to properly use the oxygen system, which of the following should the therapist recommend?

A. Get the severe acute respiratory syndrome (SARS) vaccination.

B. Get the pneumovax vaccination if it has not been given already.

C. Soak the nasal cannula in a glutaraldehyde solution for 1 hour every day.

D. If the patient has already received the pneumovax vaccination, she should get a booster.

6. An annual influenza vaccination should be given to all of the following groups EXCEPT

A. Health care workers

B. People 50 years of age and older

C. Children and adults with asthma

D. Infants younger than 6 months of age

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The Comprehensive Respiratory Therapist Exam Review