By Rachel Clevenger, RRT, ECG, CTP
Whatever the details of your assignment for the upcoming shift, respiratory care is always “hand in glove” with ongoing infection control practices of an individual hospital facility or clinic. On the adult or pediatric floors, labor and delivery, neonatal ICU, cardiovascular or neurological ICU, PFT labs, emergency departments, or home care rotations; hand sanitizer and personal protective equipment are so ingrained in our mantra of training to the point of almost being inseparable from anything else we do.
Hand sanitizer pumps are outside every hospital room and hallway, and signs for contact and droplet protection are plastered anywhere and everywhere. Through this maze of hygiene prevention, respiratory therapists must walk the proverbial line of infection control practices seamlessly every day and night between rooms and floors for over twelve hours. But even in our utmost desire for proper hand hygiene, many in our profession fail to safeguard our respiratory equipment and accessories from infection with the same sense of urgency as we do our hands. Our nebulizers, ventilators, oxygen equipment, and multiple circuits and accessories are often neglected from appropriate scrutiny and sanitation as we work tirelessly and in vain to fight the pathogens.
Respiratory therapists by trade are some of the most dedicated employees to the healthcare profession; excelling in both in their desire to care for others and also the vigilance that they not harm others in that desire to care. Fall and the season of influenza always bring infection control into the forefront with the department, and the pressure to lower percentages on HAI and VAP (hospital-acquired infections/ ventilator-associated pneumonia) can seem overwhelming for RTs; many who are constantly fighting illnesses themselves just to make it to work.
It is important to use a common-sense approach to contact, droplet, and airborne infection control as we live in a world surrounded by pathogens at all times; both ON our bodies and WITHIN them as well. Keeping this truth in mind, what extra steps can the respiratory therapist take to comply with rigorous infection control practices effectively without becoming neurotic in the process? For this, remember these four terms: eyes, nebs, phones, and vents.
Step one: Don’t forget your eyes. In the quest for hand hygiene complete with mask and gloves, many seasoned employees forget about the viscous and mucous membranes of our eyes. While we remember to cover our cough, and not to scratch our noses; our peepers are forgotten entirely. Any little rub or scratch of your eye can transmit a nasty little pathogen either to you….or from you to the patient! Employees with contact lenses, glasses, and allergy/dry eyes are especially vulnerable because of the repeated attempt of touching; often even without the person’s notice. Keep this in mind when you are inside a patient’s room, or in a common crowded area like a waiting room. Your hands may be clean, but by rubbing the corner of your eye with a contaminated gloved finger; all those routine repeated attempts with hand sanitizer were all for nothing!
Step two: Switch out those nebulizers and respiratory bags. Either on the floor, ICU, home care, or other units; nebulizers are vital for keeping both chronic and acute respiratory patients in the normal range for oxygen saturation. Unfortunately, many hospitals do not have a set policy for the duration of nebulizers. For any respiratory therapist, back to back nebulizer treatments can make this problem even more complicated due to time management needs; and the fear of getting behind on your assignment.
Respiratory therapists are taught to clean as they treat but often have enormous patient loads. However, we must never forget that an aerosolized treatment is a direct route of transmission into the airways; which should be treated with caution and with the utmost care in regards to infection control. An uncleaned nebulizer medication cup is an easy method of passing pathogens to the patient, as is the O2 tubing, mouthpiece or mask. The patient’s oral cavity, trach, or vent circuit is always humidified and warm; a perfect nursery for bacteria and virus to colonize.
Here is a list of the most common bacteria and pathogens found on nebulizers and added components (tubing, aerosol masks, vent circuits, tracheotomy, and endotracheal tubes), not including the multidrug-resistant strains:
- Fusarium oxysporum
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Escherichia coli
- Serrratia marcesans
- Klebsiella pneumonia
Keep in mind that the plastic respiratory bag used to store the nebulizer and supplies should be replaced as needed. Even if the nebulizer is clean, an already contaminated bag from spilled Albuterol will be just as dirty. Most nebulizers are considered disposable, and their mechanisms begin to get plugged by medication after only two to three days of use. Switch them out and obtain a new one when you find one this way. And if your fear is about cost, consider for a moment which is more expensive: a ten-dollar disposable nebulizer and aerosol mask, or the total bill for a patient that develops hospital-acquired Klebsiella pneumonia that insurance will refuse to cover? Just a hint: it’s not the nebulizer!
Step three: Where is your phone? Most respiratory therapists carry an assigned hospital phone or pager, in addition to their personal cell phone in a scrub or jacket pocket for the duration of the shift. While most try their best to remain compliant, how many times has there been a rapid response call in the middle of a patient procedure; and you answer the phone with a gloved hand? Our phones then are placed on our face or touched with the other hand before being slid back in the scrub pocket. This route of infection is a simple but dangerous one, as we could potentially carry these pathogens home to our families as well as our vehicles and other stops along the commute. Invest in a case for your phone that can be cleaned with anti-microbial wipes as needed, and take steps to protect yourself from touching a patient and then your phone. The same goes for pagers, electronic devices, smartwatches, laptops, and anything else that could be a mode of transmission. Many hospitals are transitioning to stationary work computers inside patient rooms, eliminating the need for bringing external devices into patient care areas. This is a common sense approach of which we may need a little reminding, due to our phones being so integrated into our daily lives.
Step four: Wiping down ventilators, Bipap, and CPAP devices. Ventilator support is our true forte, and respiratory therapists are taught to take extreme care when managing ventilator circuits, suction tubing, and airway care. Prevention protocols and pathways are usually very strict about breaking the circuits, as well as sterile techniques for endotracheal and nasal tracheal suctioning. But despite all of our training, many therapists fail to remember that the outside of the ventilator is little more than a large computer with massive amounts of surface area.
From the vent screen (patient interface) to the inhalation and exhalation ports and O2/air hoses, the freestanding device is constantly being touched and adjusted by the care team; and is rarely wiped down on a constant basis. This is another source of potential infection for both the employee and the patient, and one that must be kept in mind. Many respiratory therapists place cuff measurement devices, yankers (suction equipment), and extra circuit parts on the top of the vent, without verifying that the surface is even clean. Everyone on the care team must keep in mind that the ventilator has many surfaces for pathogens to be transmitted, and illness can easily be spread even under the care of the most vent savvy RT.
So take the additional step to wipe down that ventilator inside the patient’s room, because bacteria does not discriminate between the seasoned ICU RT and the new hire. The same practice goes for your patients on BiPAP and CPAP devices or IVP/Metanebs in the room. Wipe them all down, and don’t give those suckers a chance multiply and disperse. We think about this when removing a ventilator from the room, but hardly ever when it is still IN the room.
Respiratory therapists should strive to use their common sense in infection control areas such as these, not only the ones that have been ground into them by routine. Being aware of surfaces on your eyes, nebs, phones, and vents will help to decrease cross-contamination of devices; and might assist to prevent infection rates for staff as well as patients. Let us not be so fearful of contracting every pathogen, but rather thinking in a more constructive way to avoid taking these illnesses home to your loved ones.
Rachel Clevenger, RRT, ECG, CTP is a respiratory therapist at Houston Methodist Hospital. She is a frequent blogger and passionate about lung health. Visit her website lunghelp.net to learn more about her efforts to create a Vaping Lung Injury Specialist (RRT/VLI-S) certification. The views and opinions expressed in this article are those of the author and do not necessarily reflect the views of Houston Methodist Hospital.