Re: query re on management of neutropenic patients – your thoughts and practices appreciated for their safer management & pt. flow issues

[Julie Hunt]

Hi Lindy,

We have a similar protocol to that mentioned by Glenys, including building, flowers, vaccinations this is relatively easy to achieve in a large metro facility with a haematology ward with mostly single rooms (standard, negative & positive pressure) however we still need to prioritise who gets what room.

As it is a stand alone ward we dont allow visitors or staff into the ward with respiratory, gastro etc infection, no children under 12yrs. We have a specific a cleaning and disinfection protocol for the haematology ward due to previous issues with environmental organisms.

Basically the hierarchy is:

Protective Isolation (Type P room)
(i) High-risk allogeneic stem cell transplant patients or
(ii) Acute leukaemic patients undergoing induction chemotherapy
In order of priority
o MUD (including cords)
o Haploidentical
o Sibling Related, T depleted
o Standard matched sibling transplants
o Acute leukaemic undergoing induction chemotherapy

Negative pressure (Type N) rooms – prioritised for patients as above with organisms transmitted by airborne or droplet routes

Single rooms (Type S) – used for standard-risk haematology patients with MROs or Clostridium difficile etc

Shared rooms and Standard Precautions – all other haematology patients not requiring contact, droplet or airborne precautions

Regards

Julie Hunt

Clinical Nurse Consultant
Infection Prevention & Control
Royal North Shore Hospital
Reserve Rd St Leonards 2065
Tel 02 99264339 or 99264490
Email: Julie.Hunt1@health.nsw.gov.au

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Glenys Harrington
Sent: Wednesday, 25 February 2015 11:17 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: query re on mangament of neutropenic patients – your thoughts and practices appreciated for their safer management & pt flow issues

Hi Lindy,

Last year I reviewed the evidence for placing all neutropenic patients in a single room (any single room) at a healthcare facility where it had been a long standing practice over many years.

Using the following headings and questions here are my summary notes and answers to some of the questions you raise.

Subject – Protective environment rooms and placement of immunocompromised/neutropenic patients

Immunocompromised patient groups

As a general group, immunocompromised patients can be cared for in the same environment as other patients.

As with other patient groups exposure to persons with transmissible infections (i.e. influenza, respiratory viruses) should be managed by staff following Standard and Transmission based precautions

What is a protective environment room?

The specific ventilation criteria/requirements for a protective environment single room are as follows.
A room with:

>12 air exchanges per hour

Point of use Hepa filters that are capable of removing 0.3m

A pressure differential between the patient room and the anteroom or corridor to maintain positive pressure and

A room that is well sealed (i.e. around the windows, electrical outlets)

Which immunocompromised patient groups require placement in a protective environment room (as per above room ventilation criteria)?

In addition to standard precautions those patients for whom there is evidence that placing them in a single room with specific ventilation requirements (i.e. protective environment room) are those who have received an allogeneic stem cell transplant.

The need for patients receiving an autologous stem cell transplant to be placed in a single room with specific ventilation requirements (i.e. protective environment room) has not been established.

Which immunocompromised patients may require placement in a single room with negative ventilation?

In addition to standard precautions stem cell transplant recipients and other immunocompromised patients may from time to time require airborne precautions and will requiring a single room with negative ventilation (i.e. those with disseminated VZV, Mycobacterium Tuberculosis)

Which immunocompromised patients may require placement in a single room with normal ventilation?

In addition to standard precautions stem cell transplant recipients and other immunocompromised patients may from time to time require contact or droplet precautions and will require a single room with normal hospital ventilation (i.e. Pertussis, influenza, MRSA, VRE).

What other hospital infection control strategies can be used to reduce the risk of infection in severely immunocompromised patients?

Other strategies include the following:

Construction, Renovation and Building

Hospital construction and renovation has been associated with an increased risk of fungal infection, particularly aspergillosis, among severely immunocompromised patients

Persons responsible for construction and renovation should consult published recommendations regarding environmental controls during construction

Severely immunosuppressed patients, healthcare workers and visitors should avoid construction and renovation areas

Equipment and supplies used by severely immunocompromised patients and their healthcare workers should not be exposed to construction or renovation areas (i.e. areas contaminated with dust).

Cleaning

Wards caring for severely immunocompromised patients should be cleaned 1 time/day with special attention to dust control

Exhaust vents, window sills and all horizontal surfaces and high touch areas and equipment should be cleaned and disinfected daily

Water leaks should be cleaned up and repaired within 72 hours to prevent mould proliferation in floor and wall coverings, ceiling tiles and cabinetry.

Personal protective equipment

Personal protective equipment should be worn in accordance with Standard and Transmission based precautions.

Plants and dried or fresh flowers

Plants and dried or fresh flowers should not be allowed in rooms of severely immunocompromised patients as Aspergillus species have been isolated from soil of potted ornamental plants (e.g. Cati), the surfaces of dried flower arrangement (dust contamination)and fresh flowers

Addition strategies include the following:

Healthcare worker immunisations and vaccinations

Screening visitors, particularly children for potentially infectious conditions

Preventing bacterial intravascular catheter-related infections.

Reference:

CDC. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR – Morbidity & Mortality Weekly Report 2000; 49(RR-10):1-125.
Following this review the practice of placing all neutropenic patients in a single room (any single room) was ceased.

Regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
PO Box 5202
Middle Park
Victoria, 3206
Australia
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Ryan, Lindy
Sent: Wednesday, 25 February 2015 4:42 PM
To: AICALIST@AICALIST.ORG.AU
Subject: [ACIPC_Infexion_Connexion] query re on mangament of neutropenic patients – your thoughts and practices appreciated for their safer management & pt flow issues

Hello

Hope you are all well

Just a query & hope you can send me back your thoughts so make it simple

As we have a lot of pressure for our beds like all of you in health I was wondering what many of your facilities are doing with their neutropenia pts given the recent publication in our Journal HI 2014,19 135 140 Mitchell et al prior room occupancy increases the risk of MRSA acquisition .

I am left wondering where the risk/logic / evidence lies to insist on neutropenia pts being placed in a single room as we all used to dobut do we still now? (& often these pts remain for long time in ED whilst a single room is located anywhere in the facility to take them & ED is not always a low risk environment for this pt group ) given this information in the publication and as we know we cannot always guarantee our environmental cleaning is always at the highest standard each time ..when the push for bed and rapid bed movement occurs (no offences to our hard working cleaning team who are always under the pump intended) I was seeking your learned and expert advice with some quick questions below

1. Can I ask if your facility is currently placing all patients admitted with no neutrophils (neutropenia) in single rooms protective isolation Yes/ No

2. Can I ask if your facility is currently only placing some types of patients with no neutrophils (neutropenia) in single rooms protective isolation yes / No
If yes what is your criteria for making this call?

3. If you place a pt in protective isolation is PPE worn Yes/No/NA

4. If you place a pt in protective isolation is a sign notifying protective isolation requirement placed on the door Yes/ No/NA

5. If you do place them in a single room are these same rooms you use to accommodate MRO or pts with a communicable disease in at other times for other admissions Yes/No
If No how do you manage the use of these room from pt flow perspective (ie leave the room empty, screen all non known MRO pts admitted in these rooms to ensure they dont have an MRO, trust they are cleaned well enough etc?)

6. If you do not place neutropenia patients in single rooms then what strategies does you facility employ to reduce the risk of cross infection if not in a single room ? (do you have a dedicated ward, location or risk group they can be cohort with ,exclusion group they cant be admitted with etc)

Thank you and I look forward to any responses with eagerness and any other thoughtful advice with much appreciation . Thank you Brett et al for you interesting and thought provoking articleI am trying to think forward to the best way to advise our staff here and what folks may already have in place around this and neutropenia pts

Kind regards

Lindy

Lindy Ryan

Infection prevention & Control Clinical Nurse Consultant (CNC) | Coffs Harbour Health Campus
Pacific Hwy Coffs Harbour NSW 2450
Tel (02) 6656 7770 | lindy.ryan@ncahs.health.nsw.gov.au
http://www.health.nsw.gov.au

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Wise and human management of the patient is the best safeguard against infection
(Florence Nightingale Circa 1860)

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This message is intended for the addressee named and may contain confidential information. If you are not the intended recipient, please delete it and notify the sender.

Views expressed in this message are those of the individual sender, and are not necessarily the views of NSW Health or any of its entities.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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