Infection prevention for NIV adults

Recommendations

SectionRecommendationGrade of recommendation

39.

Clinicians are to undertake a risk assessment to identity the risk of contamination and mucosal or conjunctival splash injuries when caring for a patient being treated with NIV. PPE (including goggles/face shield/gloves and gown/apron) as per NSW 2007 Infection Prevention Control Policy should be worn according to the risk assessment (1, 2).

PD2007_036 Australian Guidelines for Prevention & Control of Infection in Healthcare.

40.

Clinicians must adhere to the Five Moments of Hand Hygiene (3).

PD2010_058

41.

To reduce the risk of microbial transmission, equipment utilised for each patient must be cleaned as per the NSW Infection Control Policy and ASA Standard 4187 prior to and following use (1, 4).

PD2007_036

AS 4187 2003

42.

Items labeled single patient use are intended to be used in the care of one patient only and are to be discarded when the patient no longer requires the item (1).

NSW Policy PD 2007_036

43.

Reuse of an NIV circuit/face mask may be possible only if the items are marked as reuse and cleaning instructions are supplied; the manufacturer’s recommendations are to be followed. The NSW Infection Control Policy (PD2007_036) states that the circuit and face mask are classified as a semi-critical item and require cleaning and disinfection before reuse (1).

NSW Policy PD 2007_036

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

Hand hygiene

The NSW Health Hand Hygiene Policy (PD2010_058) states that all staff must perform hand hygiene as per the Five Moments for Hand Hygiene; Hand hygiene must occur before touching the patient; prior to a procedure; after a procedure or body fluid exposure risk; after touching a patient; after touching a patient’s surroundings. Hand hygiene can be performed using appropriate soap solutions and water or ABHR (alcohol-based hand rub). Soap and water must be used when hands are visibly soiled.

Before touching a patient, before a procedure, after procedure, after touching a patient, after touching a patient's surroundings
Based on the 'My 5 moments for Hand Hygiene', © World Health Organization 2009. All rights reserved.

NSW Ministry of Health policies

Prevention of infection is an important aspect of any clinical practice guideline. Users are directed to the following policy directives covering infection control. Local policy must also be consulted.

  1. Infection Control Policy (PD2007_036)
  2. Infection Control Policy: Prevention & Management of Multi-resistant Organisms (MRO) (PD2007_084)
  3. Hand Hygiene Policy (PD2010_058)

Other relevant policies and standards

  1. NHMRC. Australian Guidelines for the Prevention and Control of Infection in Health Care
  2. Cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment, and maintenance of associated environments in healthcare facilities. ASA 4187:2003.

Personal protective equipment

The Australian Guidelines for the Prevention and Control of Infection in Health Care and the NSW Infection Control Policy (PD2007_036) state that all procedures that generate or have the potential to generate secretions or excretions require that either a face shield or a mask with protective goggles be worn. PPE must be discarded appropriately on leaving the patient’s environment.

The clinical manifestation of the disease, the site of infection, the presence and type of a pathogen dictate the probability of spread of infection by either droplet or airborne means.

Pathogen factors and effects

Factors

Effect

Type of respiratory activity

Different activities produce different numbers and sizes of particles. e.g. coughing, sneezing,suctioning, chest physiotherapy, non-invasive positive pressure ventilation.

Frequency of respiratory activity

Frequent activities associated with clinical disease are more likely to spread pathogens.

Number of particles generated

Activities that atomise more particles are more likely to spread pathogens e.g. non-invasive ventilation, suction and chest physiotherapy.

Site of infection

Activities that generate aerosols from the infected region of the respiratory tract are more likely to propagate disease.

Pathogen load

Sufficient pathogen load must be present in expelled particles to establish infection in a susceptible individual.

Pathogen type

The size of the pathogen may determine the size and infectivity of expelled particles.

Droplets

Particles are generated by natural human activities including breathing, talking, sneezing and coughing (5). Airborne sized particles are considered to be ≤ 5µm in size and droplet-sized particles are considered to be ≥5µm in size (5). Simonds (2010) found that the particle size predominately produced by non-invasive positive pressure ventilation and chest physiotherapy was >10µm (6). Particle sizes of infectious organisms vary. The NSW Infection Control Policy (PD 2007_036) classifies the additional transmission based precautions required for respiratory infections based on the particle size. Droplets larger than 100µm often fall to the floor within 1m of the source patient or evaporate on surfaces forming fomites and may later become re-suspended in the air (7).

Two studies (8, 9) identified that during NIV droplets were found up to 1m from the patient during therapy such as chest physiotherapy and non-invasive mask positive pressure ventilation. However, the 2007 Centers for Disease Control guideline states that “it may be prudent to don a mask when within 6 to 10 feet of the patient” (1.8 to 3m) (10).

Infectivity of the patient

Patients requiring NIV are critically ill and frequently do not have a microbiological diagnosis of their respiratory failure. Each patient requires a careful risk assessment of their probable diagnosis to guide the appropriate placement of the patient (i.e. isolation) and to inform staff on the need for transmission based precautions. Transmission-based precautions may need to be implemented based on clinical presentation as opposed to confirmed microbiological status.

Selection of PPE

Selection of PPE must be based on assessment of the risk of disease transmission to other patients and staff. Local policies and current health and safety legislation must also be taken into account. The NSW Infection Control Policy (PD2007_036) lists the additional precautions required for a number of diseases transmitted via the droplet or airborne route.

Cleaning of equipment

The manufacturer’s instructions regarding single use or reuse of the mask interface and circuit are to be followed. Single patient use items are to be discarded when no longer required by the patient. If the manufacturer’s instructions permit mask and circuit reuse then the NSW Infection Control Policy (PD2007_036) is to be followed. The mask and circuit used for NIV are classified as semi-critical items and must be cleaned and disinfected prior to its reuse. Cleaning is to precede disinfection. Items must not be stored soaking in disinfectants as they may become contaminated or the disinfectant may degrade over time. The manufacturer’s instructions must be checked for compatibility of the instrument or equipment with the method of disinfection to be used. Disinfection is to be achieved by either thermal or chemical methods. Thermal disinfection must be used in preference to chemical disinfection. Chemical disinfection may only be used for items for which thermal disinfection methods are unsuitable (NSW Health PD2007_036).

Respiratory infectious diseases that require additional precautions

Disease

Airborne

Droplet

Contact

Avian influenza

X

X

X

Adenovirus pneumonia

 

X

X

Haemorrhagic fevers

(Marburg, Lassa, Ebola)

X

X

X

Haemophilus influenzae

 

X

 

Influenza (seasonal)

 

X

X

Measles

X

  

Neisseria meningitides

(Meningococcal disease)

 

X

 

Norovirus

X

 

X

Pandemic influenza

X

X

X

Parovirus B19

 

X

 

Pertussis (Whooping Cough)

 

X

 

Respiratory syncytial virus (RSV)

 

X

X

Rubella

 

X

X

SARS

X

X

X

Shigella (incontinent adults)

 

X

 

Streptococcal pneumonia or Scarlett Fever

 

X

X

Tuberculosis

X

  

Varicella

X

 

X

Adapted from: Australian Guidelines for the Prevention and Control of Infection in Health Care (2).

Precautions definitions

Airborne precautions

Droplet precautions

Negative pressure room (if available) single room if not available

P2 mask

Single room

Goggles/face shield

Surgical mask

Combined airborne and droplet precautions

Contact

Negative pressure room (if available) single room if not available

P2 mask

Goggles/face shield

Gown

Gloves

Grading of recommendations

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (2)

References

  1. Clinical Safety QaG. Infection Control Policy. In: Health Do, editor. Sydney: NSW Health 2007.
  2. NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: Commonwealth of Australia; 2010.
  3. Clinical Safety QaG. Hand Hygiene Policy. In: Health Do, editor. Sydney: NSW Department of Health; 2010.
  4. Association AS. Cleaning, disinfection and sterilizing resusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities. Australian Standards Association; 2003.
  5. Gralton J, Tovey E, McLaws M-L, Rawlinson WD. The role of particle size in aerosolised pathogen transmission: A review. Journal of Infection. 2011;62(1):1-13.
  6. Simonds A. AK Simonds,* A Hanak, M Chatwin, MJ Morrell, A Hall, 2 KH Parker, 3 JH Siggers3 and RJ Dickinson3. Health Technology Assessment. 2010;14(46):131-72.
  7. Li Y, Leung G, Tang J, Yang X, Chao C, Lin J, et al. Role of ventilation in airborne transmission of infectious agents in the built environment–a multidisciplinary systematic review. Indoor air. 2007;17(1):2-18.
  8. Hui DS, Chow BK, Ng SS, Chu LCY, Hall SD, Gin T, et al. Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks. Chest Journal. 2009;136(4):998-1005.
  9. Simonds AK, Hanak A, Chatwin M, Morrell M, Hall A, Parker KH, et al. Evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections. Health Technol Assess. 2010 Oct;14(46):131-72. PubMed PMID: 20923611. Epub 2010/10/07. eng.
  10. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. American journal of infection control. 2007;35(10):S65-S164.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.