The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
Influenza is like the hands of a clock— it comes around every year and every year ambulatory infection prevention professionals struggle to put together meaningful training for healthcare personnel. The challenge is figuring out what will work to encourage staff to get vaccinated and how to put together a program that helps prevent or minimize transmission of influenza in the ambulatory setting. With countless patients coming though an ambulatory surgical center or ambulatory care clinic at any given time, the risk for transmission of influenza is very high. The Centers for Disease Control and Prevention (CDC) document titled "Prevention Strategies for Seasonal Influenza in Healthcare Settings" is a great resource for developing a plan. Access it here: www.cdc.gov/flu/pdf/infectioncontrol_seasonalflu_ICU2010.pdf.
Infection preventionists (IPs) know that getting the influenza vaccine is an important strategy in preventing transmission and lost work days. The influenza vaccine has been shown to be very effective in protecting against the flu, as well as the symptoms and complications if the virus is contracted.
Influenza viruses are spread from person to person primarily through respiratory droplets through close talking, coughing, sneezing and touching contaminated surfaces. Hands pick up the virus from contaminated environmental surfaces (where the influenza virus can live for one to two days) and carry it to the mucous membranes of the eyes, nose, or mouth. A person can incubate and spread the virus at least one day before developing symptoms. So what can be done to minimize influenza transmission in the ambulatory care setting?
Protecting patients and healthcare workers is one of our prime directives. Support from administrative leadership is strongly recommended to help drive the influenza prevention program, vaccination compliance and necessary resources. The IP or employee health nurse can't do this alone. Having an effective influenza immunization program is a multidisciplinary effort; it is critical to develop a written plan. Collaborators on the plan should include administration, materials management, nursing, providers, pharmacy, purchasing, employee health and infection prevention. This group should collaborate regularly several months in advance of the start of the influenza season to work out the operational aspects.
Three critical elements of the flu season plan are vital to the success of the program. These elements include communication and training of healthcare workers, vaccine and vaccine supply and availability, and respiratory etiquette and hygiene supplies.
Communication and Training:
Developing a systematic plan for communication should entail describing what the healthcare worker needs to know about the vaccine, vaccine administration, disease process, prevention, respiratory protection, supplies and available training. Influenza training for healthcare workers may involve the use of web-based modules, PowerPoint presentations, "Jeopardy" style games, posters and handouts.
It's also important to have a dependable notification system in place (email, memo, website, newsletter) to keep staff informed of changes (which may occur daily) and a designated person or team to answer healthcare workers' questions. Group Health Cooperative in Seattle, Washington, has an internal website titled "All Things Flu." The site includes links to CDC and local health jurisdiction influenza information websites; it also offers a "question and answer" section.
Part of the influenza prevention program can also include incentives for staff vaccination. This can be done by organizing friendly competitions between departments with prizes, providing declination forms and group education. Providing free vaccinations for healthcare workers and conveniently administering the vaccine at work also incentivizes healthcare workers to obtain their vaccines.
Another critical aspect of the influenza prevention program is to supply educational information to ambulatory patients about influenza, the vaccine, how to prevent infection, how to recognize the symptoms, and when they should obtain medical help.
Vaccine Supply and Availability:
The second vital element of any influenza prevention program is the operational planning required to procure, store and distribute the vaccine and supplies for administration. Part of this activity is assuring refrigerator monitoring (vaccine-containing refrigerators require temperature monitoring twice a day) and assuring the documentation of the administration in the employee's medical record. Clearly written guidelines help everyone know and understand their role.
An ambulatory facility's influenza vaccination program may include the following aspects:
- Organize facility-specific healthcare worker vaccination clinics.
- Provide influenza vaccine to healthcare workers by using a roving cart.
- Encourage managers to provide influenza vaccine at staff meetings. Employee Health can prepare a vaccination kit to assist managers with standing orders, consent forms, Vaccine Information Statements, fact sheets on proper injection practices and infection control for vaccine injections.
- Display posters that strongly encourage all healthcare workers to get the influenza vaccine. Reinforce in the messaging that the vaccination helps protect them, their families and their patients.
- Use the organization's internal website to broadcast influenza updates and messages to staff.
- Send e-mail reminder messages the day before and day of scheduled Employee Health influenza vaccine clinics.
- Award "wellness points" to staff who receive a seasonal influenza vaccine, if your organization participates in an employee Wellness Program.
Respiratory Etiquette and Hygiene Supplies:
Promoting respiratory hygiene is the third essential element of the influenza prevention program. Use the following questions to assess your current respiratory etiquette program:
- What does your respiratory hygiene program consist of?
- Is it year-round?
- Are there procedures that describe respiratory hygiene and what is expected of staff when they become ill, or when they have a mild cold or cough?
- Are there procedures that describe respiratory etiquette when a coughing patient comes into the ambulatory facility for a visit or procedure?
Respiratory hygiene should be followed year-round, not just for influenza season to reduce transmission of droplet/airborne illnesses. The ambulatory facility should supply enough masks for patients who have coughs or respiratory illnesses, and masks with eye protection for healthcare workers who have direct face-to-face contact with unmasked coughing patients.
Hygiene stations with masks, tissues, and trash receptacles for soiled tissues must be available throughout a facility, especially at the entrances. Group Health Cooperative reduced influenza exposures when they implemented masking of coughing patients and required staff to wear masks with eye protection in the presence of an unmasked coughing patient, especially during a respiratory exam. Ambulatory facilities must also remember to assign dedicated personnel to restock the tissues, hand sanitizers, masks and environmental disinfectants.
Staff members who have mild coughs or colds may come to work, as long as they don't have a fever and must wear masks to prevent droplet transmission and hand contact with the mucous membranes of their face.
Hand hygiene is still an effective way to reduce transmission of influenza and other infections; this should not be overlooked. In the comprehensive document titled "Prevention Strategies for Seasonal Influenza in Healthcare Settings," (also previously referenced) the CDC recommends that healthcare personnel perform hand hygiene "before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves." Hand sanitizers can be used when hands are not visibly soiled. If hands are visibly soiled, the CDC recommends washing hands with soap and water.
Ambulatory facilities must not forget about the importance of environmental disinfection of high-touch surfaces. All items and surfaces that staff or patients touch in the exam room should be cleaned between patients. Most of Group Health Cooperative's facilities have only evening environmental services. Therefore, it's important to know what surfaces environmental services are responsible for cleaning and what the staff are responsible for cleaning throughout the day.
Group Health Cooperative encourages its clinic staff to clean their phones, keyboards, mice and desks. If staff share their stations, they should clean them after another person uses them. Remind staff that they need to wear disposable exam gloves when using disinfectants to prevent skin irritation.
Remember that early planning, teamwork, creativity, and collaboration with your organization's CEO and managers make influenza prevention program efforts much more effective, efficient and fun.
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