Infection Prevention and Control: Frequently Asked Questions

General Infection Prevention Guidance

Q: How can I evaluate my practice’s infection prevention and control processes? How can I train myself and my staff on infection prevention and control practices?

A: Proper and consistent IPC training across team members is important not only to mitigate the spread of infectious diseases found in the practice setting but to assure all members of the team understand the “why” behind infection prevention and control policies in place. Project Firstline has created a suite of infection prevention and control related quality improvement resources from the AAP IPC Quality Improvement ECHO (Extension for Community Health Care Outcomes) program.

Pediatric practices can repurpose this change package for their own quality improvement projects to help improve IPC practices. Resources include a project checklist, sample curriculum and timeline, QI measures, data collection spreadsheet, and more.

AAP Project Firstline has developed an Infection Prevention and Control for Pediatric Clinics PediaLink course. The purpose of this on-line course is to train pediatric practice managers on infection prevention and control (IPC) basics, and how to create safer environments for pediatric care teams, patients, and their families. This course will provide the tools and resources needed to develop and implement IPC practices in your office setting.

Additionally, self-assessment of IPC practices can be done by utilizing the Infection Control Assessment and Response (ICAR) tool. Practices can conduct a gap analysis of their practice’s infection prevention and control polices and identify the changes that the practice team can make to improve infection control practices. For further information, watch the AAP Infection Prevention and Control Ambassador ECHO Session, “Identifying Needs and Training Others on Pediatric-specific Infection Control.”

Q: Is there a centralized set of recommendations available for applying current infection prevention and control guidance for COVID-19 at our facility?

A: The AAP Infection Prevention and Control in Pediatric Ambulatory Settings statement provides practical information regarding infection prevention and control procedures as applied to ambulatory medical settings. The guidance provides specific steps outpatient pediatric providers can take to ensure their staff are educated, prepared to care for patients with communicable infections, as well as to have safe practices related to prevent blood or body fluid exposures.

The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel website hosts guidance for specific facility types (ambulatory care settings, alternate care settings, etc. The CDC has developed Infection Control Assessment Tools that provide a systematic method for evaluating infection prevention and control processes and identifying gaps that can be adapted for pediatric facilities. By identifying problems in your risk assessment you can identify areas for improvement. Your State Health Department’s Infection Control Assessment and Response (ICAR) program is funded by CDC and can help you conduct a review of your facility’s infection prevention practices and assist with intervention.

Q: What procedures are considered aerosol-generating procedures (AGPs) in health care settings?

A: According to CDC, aerosol-generating procedures are those that could produce smaller respiratory droplets and droplet particles at higher concentrations, thereby potentially increasing the risk for transmission to people in proximity to the patient. The CDC does not provide a comprehensive list of AGPs because of the limited data on which procedures may generate potentially infectious aerosols and the challenges in determining if reported transmissions during AGPs are due to aerosols or other exposures. However, AGPs may include procedures that instrument the larynx or trachea (bronchoscopy, laryngoscopy, endotracheal intubation, insertion of a laryngeal mask airway) and those that assist ventilation (high-frequency oscillatory ventilation, noninvasive ventilation including bag-mask, bilevel positive airway pressure [BIPAP] and continuous positive airway pressure [CPAP], airway suctioning, chest physiotherapy with cough induction, and cardiopulmonary resuscitation [CPR]). The World Health Organization also includes sputum induction and tracheotomy.

Q: Are nebulizer treatments considered aerosol-generating?

A: While use of a nebulizer for medication administration and use of high-flow oxygen are aerosol-generating procedures, it is still uncertain whether aerosols generated with these procedures are infectious. Higher levels of PPE (gloves, gowns, goggles or face shields, and masks/respirators) are necessary for the protection of those treating patients more likely to aerosolize respiratory secretions and/or when performing an aerosol-generating procedure. Strong consideration should be given to using N95 respirators and negative pressure rooms, if available.

Metered dose inhalers (and spacers if necessary) should be considered as an alternative to nebulizers in the practice setting.

Source Control and Personal Protective Equipment (PPE)

Q: Should kids be masking in response to COVID-19 or during respiratory infection surges?

A: A well-fitting high-quality face mask can block virus particles from reaching the nose and mouth of the wearer and help block virus particles coming out of a ill person’s nose and mouth from reaching others. Individuals can continue to wear a mask based on personal preference, informed by their perceived level of risk for infection, and their potential for developing severe disease if they exposed. Face masks should not be worn by children if they are under 2 years old. Look for a well-fitting comfortable face mask that fits your child's face. The mask should fit securely under the chin but not impair vision and cover the mouth and nose. It should fit snugly along the sides of the face without any gaps. Remember to wash hands before and after wearing it and avoid touching it once it's on. When back home, avoid touching the front of the face mask by taking it off from behind.

Please note that there are many misconceptions relating to kids and face masks. Check out the Mask Mythbusters here.

For more information about masking for children, visit AAP.org Face Masks and Other Prevention Strategies or HealthyChildren.org.

Q: Does the CDC recommend masking in health care settings?

A: The overall benefit of broader masking is likely the greatest for patients at higher risk for severe outcomes from respiratory virus infection and during periods of high respiratory virus transmission in the community. Facilities should consider several factors when determining how and when to implement broader mask use:

• The types of patients care for in the facility
• Input from stakeholders
• Plans from other facilities in the jurisdiction with whom you share patients
•  Local data/metrics that could reflect increasing community respiratory viral activity

All health care personnel should be following Standard and Transmission-based Precautions in the health care setting. To learn about what to do or what to wear in different scenarios, visit our Infection Prevention and Control Precaution Tools.

Q: What type of PPE should health care providers wear for patient visits, including when administering vaccinations?

A: Standard precautions should be used at all times and in all situations in health care. Additionally, transmission-based precautions should be utilized based on anticipated exposures and suspected or confirmed diagnoses.

Cleaning and Disinfection of Devices and Environmental Surfaces

Q: What is the difference between cleaning and disinfecting? When should I be cleaning and disinfecting a patient room or other areas of the practice?

A: Cleaning removes the visible dirt, dust, spills, smears, and grime, as well as some germs, from surfaces. This is accomplished by washing the surface using a cleaning product and water. Cleaning products include liquid soap, enzymatic cleaners, and detergents. High-touch surfaces should be cleaned regularly. Some examples of high-touch surfaces include tables, door handles, and keyboards.

Disinfecting kills germs on surfaces or objects. This is accomplished by cleaning an area with soap, water, or any additional detergent; then using an EPA-registered household disinfectant. Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning unless they are a combined detergent-disinfectant product. For effective use of the disinfecting product, follow the instructions on the label.

PPE should be worn while cleaning or disinfecting, such as wearing disposable gloves. Additional personal protective equipment might be required based on the cleaning/disinfectant products being used and whether there is a risk of splash.

Visit the Project Firstline Cleaning and Disinfecting Checklist to learn when certain areas/items should be cleaned and disinfected throughout your practice.

Additional information can be found in the CDC Cleaning and Disinfecting Your Facility page.

Q: What is “contact time” and why is it important?

A: Contact time is the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, in order to do its job of killing germs. It can be challenging in a busy health care setting, but it is important to wait for the full contact time to be sure the germs are killed. This time can vary depending on the product and can be found on the label. Combination cleaning and disinfecting products also have a minimum contact time.

Instructions about how to read a disinfectant label are available here.

Q: Can waiting room toys and activities be used in the waiting room?

A: Waiting room toys and activities can be returned to waiting rooms. However, it is recommended that toys and any other waiting room items should be cleaned and disinfected after each use and at least daily, or when a toy or equipment becomes soiled with dirt or bodily fluids, including saliva. Any waiting room toys or items that have porous surfaces such as books, stuffed animals, wood toys, etc should be removed.

Q: How do you clean a room after seeing a patient with a high probability of having an infectious disease?

A: Facility management and cleaning and disinfection should be aligned with evolving safe work practices. The Environmental Protection Agency’s (EPA’s) List “N” provides a list of disinfecting products shown to be effective against common pathogens. In addition, considerations should include waiting room management/elimination and alternate waiting and care delivery sites. Please also see additional room-related guidance in the “Ventilation” section.

Q: What PPE should be worn by practice personnel when they clean and disinfect rooms of patients with an infectious disease?

A: After patient departure, room entry for practice personnel should be delayed until sufficient time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, practice personnel can enter the room and should wear a face mask (for source control) along with a gown and gloves when performing terminal cleaning. Eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time.

Ventilation

Q: Do you have any advice on specifications for medical offices or any particular recommendations for air cleaners and HVAC filters for medical office space?

A: The Environmental Protection Agency (EPA)recommends upgrading air filters to the highest efficiency possible that is compatible with the system and checking the filter fit to minimize filter air bypass.

To assess your practice’s appropriate ventilation requirements, The American Society for Health Care Engineering (ASHE) developed a Ventilation Assessment Tool. Using the tool, clinicians can select the type of work area (e.g., urgent care) and the room’s function (e.g., trauma room) and receive the appropriate ventilation requirements. The tool then provides recommendations based on CDC Environmental Infection Control Guidelines and the 2001 AIA Guidelines for Design and Construction of Hospital and Health Care Facilities. The tool is available here.

To learn more about the ASHE Ventilation Assessment Tool and hear answers to frequently asked questions surrounding ventilation, watch the AAP’s Ventilation Webinar in collaboration with ASHE and CDC.

Q: How long does an examination room need to remain vacant after being occupied by a patient with confirmed or suspected airborne infection (e.g. measles, COVID-19)??

A: The amount of time that the air inside an examination room remains potentially infectious depends on a number of factors, including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an aerosol-generating procedure was performed. Facilities will need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing PPE. General guidance on clearance rates under differing ventilation conditions is available.

Triage and Workflow

Q: How do I adjust patient scheduling and triage in my practice?

A: Consider how to efficiently triage calls and determine those patients that can be managed remotely as opposed to in-person. Practices that offer self-scheduling or same-day walk-in visits for acute illnesses might consider workflow redesign during times of surge. Practices should consider replacing self-scheduling for acute visits with nurse triage conversations (via phone or secure chat). Walk-in hours for acute visits might be replaced with walk-in virtual visits. Balancing a practice’s physical limitations with the need to provide access for in-person acute care when appropriate will be an ongoing process and can be supported by communication with the full practice team.

Accommodating all patients who want to be seen in-person may not be possible, especially if there are limitations in the number of patient rooms, the ability to follow cleaning protocols or the ability to provide safe areas to separate sick and well patients. This might involve providing advice on home care, telemedicine, being seen for an in-person visit or providing a referral. As always, caution should be used against delaying necessary care for acute illnesses. In smaller-sized practices, it may not be possible to assign separate providers to sick and well care, and appropriate PPE can and should be used to safely provide in-person care for both well and sick visits throughout the day.

Additional information on adjusting practice workflow and triage can be found here.