Infection control practitioners (ICPs) and their colleagues need every possible tool at their disposal to prevent and beat infections. Guidelines are one such tool and since germs and technology keep changing, guidelines must follow suit.
One important set of guidelines by the Healthcare Infection Control Practices Advisory Committee (HICPAC) was recently updated. The latest version of the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, was released in June 2007, and contains significant changes. The document had not been changed since 1996.
The guidelines are intended for infection control staff, epidemiologists, administrators, nurses and other healthcare providers. For specialized infection control situations, the guidelines refer users to more applicable resources.¹
HICPAC is a federal advisory committee that includes 14 infection control experts. The group provides healthcare infection control advice to the Centers for Disease Control and Prevention (CDC) and the secretary of the Department of Health and Human Services. HICPAC also provides strategies for surveillance and prevention in American healthcare facilities.
A vital function of the committee is to issue recommendations, guidelines, resolutions and informal communication on the topic of healthcare acquired infection (HAI) reduction.
The guidelines provide advice for hospitals, long-term care facilities, ambulatory care, home care and hospice, and reaffirm standard precautions and transmission-based precautions as a foundation of safe care.
The document is 219 pages and includes the following sections:
- A review of scientific data about the transmission of infectious agents in healthcare settings
- A summary of what is needed to prevent transmission of infectious agents
- Type and duration of precautions that are recommended for specific infections and conditions
- History of isolation precaution guidelines in hospitals
- Clinical syndromes or conditions that warrant empiric transmission-based precautions in addition to standard precautions
- Infection control considerations for highpriority (CDC category A) diseases that may result from bioterrorist attacks
- Standard precautions for the care of patients in all healthcare facilities
- Components of a protective environment
- Examples of safe donning and removal of personal protective equipment
The guidelines are an evolution of isolation and infection prevention documents that started in 1970. Changes were necessary, says Michael Bell, MD, associate director for infection control at the Division of Healthcare Quality Promotion, part of the CDC.
“The healthcare world is vastly different now than it was 10 years ago in several ways, and these guidelines acknowledge that and start addressing some of the newer issues that we have,” Bell says.
“A great example is the multi-drug resistant organism (MDRO) part of the guideline which looks very critically at how best to prevent transmission of MDRO,” he adds. “That’s based on a great deal of evidence and experience that was accumulated over the last ten years. In that way I think it’s a very important update.”
According to HICPAC members, the guidelines were revised from their 1996 status for many other reasons as well, the most important of which are:
1. The fact that healthcare has transitioned from a sole reliance on acute care hospitals, and has branched out to home care and untraditional settings such as ambulatory care, free-standing specialty care and long-term care facilities.
HICPAC authorities thought these varied settings called for standards that could be used across the board, and that can also be modified to meet specific needs. The new copy includes more information about untraditional healthcare methods than the last copy contained.
2. The emergence of pathogens such as severe acute respiratory syndrome and a continued concern for evolving pathogens such as C. difficile, noroviruses, and methicillin- resistant Staphylococcus aureus (MRSA). Other new considerations include gene therapy and increasing concern for the threat of bio-weapons attacks.
3. The standard precautions that debuted in the 1996 guideline proved helpful, so HICPAC authorities decided to expound on them. These precautions against infectious agents are usable in any healthcare setting. Additions include more information on respiratory hygiene and cough etiquette, safe injection practices, including the use of a mask when performing certain highrisk, prolonged procedures involving spinal canal punctures.
Respiratory hygiene and cough etiquette recommendations needed to be revised because of SARS outbreaks wherein failure to implement certain simple control measures among healthcare workers, patients and visitors may have contributed to greater SARS transmission.¹
Furthermore, the guidelines read, “the recommended practices have a strong evidence base. The continued occurrence of outbreaks of hepatitis B and hepatitis C viruses in ambulatory settings indicated a need to reiterate safe injection practice recommendations as part of standard precautions. The addition of a mask for certain spinal injections grew from recent evidence of an associated risk for developing meningitis caused by respiratory flora.”
4. The accumulated evidence that environmental controls decrease the risk of life-threatening fungal infections in the most severely immunocompromised patients (allogeneic hematopoietic stem-cell transplant patients) led to the update on the components of the protective environment (PE).
5. Another reason for the update was emerging evidence that organizational systems and idiosyncrasies such as staffing levels and degrees of safety culture influence adherence to infection control practices. HICPAC guideline authors thus decided to emphasize administrative involvement in infection control programs.
6. The continued prevalence of HAIs was perhaps the biggest reason the guidelines were re-worked. The new guidelines include detailed information about transmission, such as bio-aerosols and airborne pathogens, which became a serious concern during the SARS outbreaks of 2003.¹
The guidelines also use a new definition, “epidemiologically important organisms” that identifies clusters of infections that need to be investigated such as MDRO and C. difficile. There is also a focus on norovirus, prions, monkeypox, and hemorrhagic fever viruses.
Other additions, the guidelines state in an opening summary, are: “the need for appropriate infection control staffing to meet the ever-expanding role of infection control professionals in the modern, complex healthcare system. Evidence presented also demonstrates another administrative concern, the importance of nurse staffing levels, including numbers of appropriately trained nurses in ICUs for preventing HAIs. The role of the clinical microbiology laboratory in supporting infection control is described to emphasize the need for this service in healthcare facilities.”
The 2007 guidelines for the first time discuss surveillance of healthcare-associated infections, which, authors say, will be especially useful to new infection control professionals, and to ICPs who are responsible for dealing with state programs that require HAI public reporting.
One part that is unchanged from 1996 is the category of transmissionbased precautions, which still include contact, droplet, and airborne. There, is, however, an addition to this information that recommends that healthcare workers don proper personal protective equipment such as gowns, gloves and masks when they enter patients’ rooms if the nature of the patient interaction can’t be predicted.
Lastly, the protective environment for allogeneic hematopoietic stem cell transplant patients has been updated. The guidelines so far have been well received, says Bell.
“Everything from the original publication in the Federal Register a couple years ago, all of those comments were assessed and incorporated where possible,” Bell says. “More recently with the official release we’ve had mostly very supportive comments.”
A few suggestions that the HICPAC staff found pertinent may be included in an updated re-release of the 2007 isolation document, Bell says. It could happen in early fall, or may not happen at all. It has yet to be determined. In addition to alterations in systems and approaches, the guidelines contain some terminology changes.
“Healthcare-associated infection” (HAI), for instance, is used to refer to infections associated with any healthcare setting, ranging from acute care facilities to home care. The term “nosocomial infection” on the other hand, is used in the document only in reference to infections that are acquired in hospitals. This change was made because it is often difficult to determine where a pathogen was acquired. Plus, patients may be exposed to pathogens before they even enter a healthcare setting. Furthermore, patients sometimes move between various healthcare settings, which makes it even more difficult to track down the point of transmission.¹
“Airborne precautions” are now referred to as “airborne infection isolation room (AIIR)” for consistency with the Guidelines for Environmental Infection Control in Healthcare Facilities 11, the Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings 200512 and the American Institute of Architects (AIA) Guidelines for Design and Construction of Hospitals, 2006.
A set of prevention measures termed “protective environment” has been added to the precautions used to prevent HAIs. These measures contain engineering and design interventions that aim to decrease the risk of exposure “to environmental fungi for severely immunocompromised allogeneic hematiopoietic stem cell transplant (HSCT) patients during their highest risk phase, usually the first 100 days post transplant, or longer in the presence of graft-versus-host disease,” the document states. These recommendations only apply to acute care hospitals that provide care to HSCT patients.
The guideline-writing process at the CDC is evolving, Bell says, and will be apparent in several future guidelines.
“We’ve been looking very carefully at how we can make a useful product with a more efficient timeline,” he says. “There is something to be said for the major document with 1,100 or more references and a vast expanse of subject matter like you have with the isolation guidelines, but on the other hand, just as with making a textbook, it takes several years.”
That is not always practical for ICPs and their colleagues who need information that is as research-based and up-to-date as possible. A product that is more streamlined is also easier to use, absorb and access.
“One of the ways we’re hoping to refine the process is to have future guidelines focused down on smaller portions of the subject area so that the investment in time is more limited and the users will have a more focused document to work with,” Bell says. “It gives us the freedom to update more easily. Without reviewing or redoing an entire large document we’ll be able to update and review a smaller section when it’s appropriate.”
Technology makes this all far more possible. “One of the nice things about moving toward a much more electronic Web-based system is that we’re not as bound as we used to be by the hard-copy version being the final product,” Bell says. “We have much more flexibility in incorporating late-arriving advice when it’s appropriate.”
Members of HICPAC are recommended by the CDC and experts in nursing, epidemiology, public health, infection control, etc. They are appointed by the secretary of HHS.
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007.