Report of the Month
REPORT OF THE MONTH, Number 6 - November-December
1997
- - - - -
from the NC Statewide Infection Control
Program
CONTENTS:
- TUBERCULOSIS PROPOSED RULE
- VENTILATOR TUBING CHANGES EXTENDED TO 14 DAYS
- NEW HEAD OF FEDERAL OSHA IS CHARLES JEFFRESS OF NORTH
CAROLINA
- QUESTION OF THE MONTH
- COURSES FOR THE INFECTION CONTROL PROFESSIONAL
- NEWS AND ANNOUNCEMENTS
TUBERCULOSIS PROPOSED RULE
Fit checking/Fit Testing: How often will it have to be done?
According to Gina Pugliese (infection control consultant to the
American Hospital Association) the proposed tuberculosis (TB)
standard states annual fit testing is not required unless the
annual medical evaluation determines that it is necessary. The
implementation of this rule for healthcare facilities would mean
a checklist could be used to determine if there are any changes
such as significant weight loss, changes in facial structure from
accident or surgery, dental changes or facial hair that might
require fit testing of a different respirator. If there are no
significant changes, then annual repeat fit testing is not
required. A more difficult problem may be the requirement for
fit checking each time a TB N95 respirator is used. The fit
check device described by OSHA fits entirely over the N95
respirator. Currently, only one manufacturer has a device that
can fit check respirators. OSHA believes that more manufacturers
will come forward in light of the standard. With the extended
comment period (See News and Announcements) infection control
practitioners should share their comments with OSHA on these
issues.
VENTILATOR TUBING CHANGES EXTENDED TO 14 DAYS
At the Society for Healthcare Epidemiology of America (SHEA)
meeting in St. Louis an abstract presentation by Sally Padilla,
Charles Salemi, Teresa Canola, and Dave Reynolds of the Kaiser
Permanente Medical Center, in Fontana, California suggested
nosocomial ventilator-associated pneumonia (VAP) rates were
reduced at their institution while extending the use of tubing.
They began in 1989 with a Ventilator Pneumonia Prevention Task
Force that substantially reduced the VAP rates from 18.6 in 1989
to 2.2 cases per 1000 ventilator in 1991. The reduction equated
to going from the 75th percentile to the 10th-25th percentile of
NNIS. Then in 1991, heat moisture exchanges (HME's) were
introduced which prevent moisture accumulation in the tubing
because a water cascade is no longer required. The authors
theorize the dry tubing prevents colonization with opportunistic
bacteria. The facility then decreased ventilator tubing changes
from every 48 hours to every 14 days with no observed adverse
effects for the ventilated patient. In fact, the VAP rates
reported have remained within the 10th-25th percentile of NNIS.
The facility with an average of 16 ventilators in-use per day has
estimated an annual savings of $157,011 per year since 1992 in
respiratory therapy costs.
Other studies have also examined the benefits and problems
associated with HMEs. One major advantage is the HME eliminates
the need to ever drain the ventilation tubing. A problem has
been where to pour the tubing drainage and how frequently the
collection device should be cleaned. Gallagher et. al. observed
that the tubing stayed free of microorganisms for 22 days in 28
patients using a HME. However, at least one study has
demonstrated increased airway resistance and another a lack of
humidification in critical ICU patients. Newer models of HMEs
seem to have eliminated these problems. Also, HMEs have been
shown to have a low potential for generating bacterial aerosols.
The CDC Pneumonia Guidelines state the use of HMEs rather than a
heated humidifier is an unresolved issue. HMEs have shown
promise to be cost effective and efficacious in keeping VAP rates
low. However, institutions need to consider the specific needs
of their individual patient population, potential cost savings,
and infection control issues.
References. 1) Gallagher J, Strangeways JEM, Allt-Graham J.
Contamination control in long-term ventilation. Anaesthesia
1987;42:276-481. 2) Padilla S, Salemi C, Canola T, Reynolds D.
Ventilator Circuit Tubing Changes Every 14 Days - Significant
Cost Savings Without Adverse Outcomes. Abstract. Infect Control
Hosp Epidemiol 1997;18:p20. A list of additional references is
available by email upon request and on-line at http://www.unc.edu/depts/spice/report-6-ref.html.
NEW HEAD OF FEDERAL OSHA IS CHARLES JEFFRESS OF NORTH
CAROLINA
Charles N. Jeffress took office as Assistant Secretary of Labor
for Occupational Safety and Health on November 12, 1997. As head
of OSHA, Jeffress will be responsible for administering a broad
program to reduce injuries and illnesses on the job that includes
development of workplace safety and health standards to abate
hazards, enforcement of those standards, and consultation and
education for both employers and workers. Jeffress pledged to
"continue the North Carolina tradition of cooperation and
communication among business, labor and OSHA."
Prior to his nomination by President Clinton, Jeffress was Deputy
Commissioner and Director of OSHA at the North Carolina (NC)
Department of Labor. US Secretary of Labor Alexis M. Herman
praised Jeffress for the leadership he demonstrated as director
of NC's state OSHA program. Jeffress has 20 years of experience
working on labor and workplace issues including serving as
Assistant Commissioner of the NC Department of Labor from 1977-
1992.
QUESTION OF THE MONTH
Q:Can transmission of pathogens occur via the space above a false
ceiling?
A: In order for transmission to occur, certain conditions have to
exist, e.g., a very strong positive pressure so that the air
would be seeking a way out of the room; the pathogens would have
to have an airborne route of transmission; a physical disturbance
of the ceiling tiles shake up dust and aerosolize the pathogens;
and an opening would have to exist in the ceiling. It is
unlikely that transmission of pathogens via the space above the
ceiling would occur.
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control Part I: Surveillance of Nosocomial Infections"
will be held April 27-May 1, 1998 at the Holiday Inn in Chapel
Hill.
"Infection Control in Long-Term Care Facilities" will be held
May 18-19, 1998 at the Friday Center in Chapel Hill.
NEWS AND ANNOUNCEMENTS
"Occupational Exposure to Tuberculosis" (proposed standard) was
published in the Federal Register October 17, 1997. The deadline
for written comments and notices of intention to appear at the
informal rulemaking hearings has been extended to February 17,
1998. Informal public hearings will begin April 7, 1998 in
Washington DC and continue in other cites. The document is
available on the internet at the Statewide Infection Control
Program home page http://www.unc.edu/depts/spice/ (Choose "What's
New") or http://www.osha.gov or http://www.access.gpo.gov
A PRACTICAL HANDBOOK FOR HOSPITAL EPIDEMIOLOGISTS, edited by
Loreen A. Herwaldt and Michael D. Decker is available from SLACK
Inc for $39.95. http://slackinc.com
To subscribe to the Report of the Month, send email to
spice@unc.edu
Report of the Month is also available on the home page of the
Statewide Infection Control Program at http://www.unc.edu/depts/spice/
The Statewide Infection Control Program (SICP) is funded by the
General Assembly of North Carolina to serve the State. The SICP
is not a regulatory agency but provides education and
consultation to North Carolina healthcare facilities.
Copyright 1997 Statewide Infection Control Program
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