recommendations for reducing risks of infection associated with suction collection procedures

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Recommendations for reducing risks of infection associated with suction collection procedures Gina Pugliese, R.N., M.S.N. Don C. Mackel, M.S., M.P.H. G. F. Mallison, M.P.H. Chicago, III., and Atlanta, Ga. It is recognized that risks are incurred when health care workers contact various body fluids. The handling of suction collection equipment poses a risk because it is one way workers may come in contact with these fluids. Minimizing the risks associated with suction procedures can be accomplished if appropriate policies and procedures can be developed in health care facilities. (AM J INFECT CONTROL 8:72, 1980.) Procedures for aspiration and suction have been discussed in scientific and technical liter- ature for decades.v " The purpose of this article is to discuss the risks to patients and staff as- sociated with the suctioning of body fluids, in- cluding those containing blood and mucus. Recommendations are made regarding appro- priate techniques to reduce risks. RISKS OF INFECTION Several investigations have suggested that health care workers, especially those having di- rect contact with material aspirated from the respiratory tract, have a risk of acquiring herpes virus from patients with occult infec- tions. ll - 14 One investigator determined that one third of attending nurses who were antibody negative developed skin lesions at some point during the study period.!' Operating room personnel, including sur- geons, have been shown to have an increased From the Augustana Hospital and Health Care Center and the Epidemiologic Investigations Laboratory Branch, Bacterial Diseases Division, and Bureau of Epidemiology Center For Disease Control, Public Health Service, Department of Health, Education and Welfare, Atlanta. Reprint requests: Gina Pugliese, RH, M.SN., Nurse Epidemi- ologist, Augustana Hospital and Health Care Center, 411 West Dickens. Chicago, IL 60614. 72 risk of acquiring hepatitis B by virtue of their close contact with blood of HBsAg-positive pa- tients." Contact with the blood of such patients is likely associated with blood suctioning and handling of aspirated blood during cleaning procedures. Because a small percentage of per- sons with acute cases of hepatitis B will remain serologically positive indefinitely. there may be a continually rising number of patients with HBsAg-positive blood being operated on with- out hospital personnel being aware of the po- tential risk." In one study, the seropositivity for hepatitis B was statistically associated with histories of getting blood on skin and clothes at work, but not with histories of accidental nee- dle sticks or cuts on the hands or with failing to wash hands or wear gloves." Surgical procedures most often associated with infections include those where implants or high-flow suction is used." Suction fluid is dis- carded after most surgical procedures. How- ever, in coronary bypass procedures, there are additional suction lines to return aspirated blood from the wound to a preoperative oxy- genator and recirculate it to the patient. When this line is not aspirating blood, it is aspirating room air (approximately 1.5 to 2.0 cubic feet! minute), which mixes with the blood in the machine and eventually is recirculated to the

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Recommendations for reducing risks ofinfection associated with suctioncollection procedures

Gina Pugliese, R.N., M.S.N.Don C. Mackel, M.S., M.P.H.G. F. Mallison, M.P.H.Chicago, III., and Atlanta, Ga.

It is recognized that risks are incurred when health care workers contact variousbody fluids. The handling of suction collection equipment poses a risk because it isone way workers may come in contact with these fluids. Minimizing the risksassociated with suction procedures can be accomplished if appropriate policies andprocedures can be developed in health care facilities. (AM J INFECT CONTROL 8:72,1980.)

Procedures for aspiration and suction havebeen discussed in scientific and technical liter­ature for decades.v " The purpose of this articleis to discuss the risks to patients and staff as­sociated with the suctioning of body fluids, in­cluding those containing blood and mucus.Recommendations are made regarding appro­priate techniques to reduce risks.

RISKS OF INFECTION

Several investigations have suggested thathealth care workers, especially those having di­rect contact with material aspirated from therespiratory tract, have a risk of acquiringherpes virus from patients with occult infec­tions.ll-

14 One investigator determined that onethird of attending nurses who were antibodynegative developed skin lesions at some pointduring the study period.!'

Operating room personnel, including sur­geons, have been shown to have an increased

From the Augustana Hospital and Health Care Center and theEpidemiologic Investigations Laboratory Branch, BacterialDiseases Division, and Bureau of Epidemiology Center ForDisease Control, Public Health Service, Department of Health,Education and Welfare, Atlanta.

Reprint requests: Gina Pugliese, RH, M.SN., Nurse Epidemi­ologist, Augustana Hospital and Health Care Center, 411 WestDickens. Chicago, IL 60614.

72

risk of acquiring hepatitis B by virtue of theirclose contact with blood of HBsAg-positive pa­tients." Contact with the blood of such patientsis likely associated with blood suctioning andhandling of aspirated blood during cleaningprocedures. Because a small percentage of per­sons with acute cases of hepatitis B will remainserologically positive indefinitely. there may bea continually rising number of patients withHBsAg-positive blood being operated on with­out hospital personnel being aware of the po­tential risk." In one study, the seropositivity forhepatitis B was statistically associated withhistories of getting blood on skin and clothes atwork, but not with histories of accidental nee­dle sticks or cuts on the hands or with failing towash hands or wear gloves."

Surgical procedures most often associatedwith infections include those where implants orhigh-flow suction is used." Suction fluid is dis­carded after most surgical procedures. How­ever, in coronary bypass procedures, there areadditional suction lines to return aspiratedblood from the wound to a preoperative oxy­genator and recirculate it to the patient. Whenthis line is not aspirating blood, it is aspiratingroom air (approximately 1.5 to 2.0 cubic feet!minute), which mixes with the blood in themachine and eventually is recirculated to the

Volume 8 Number 3

August. 1980 Reducing infections [rom suc tion collection procedures 73

patient, possibly increasing risk of patientinfection.

Historically, onl y direct contact with the as­pirated liquids has been a matter of concern,but investigators ha ve a lso shown that suctionpumps, traps , and coll ection vessels can createae rosols. ' : 18. 19 In on e s tudy, equipment-dis­persed mists in a hospi tal were shown to travelup to 130 feet in 30 minutes." If such aerosols orsprays of potentially hazardous material are notcontained, the environment can become con­taminated and may be a source of infection forpersonnel who directly contact surfaces con­taminated with aerosols , and airborne spread ofinfection may also be po ssible.

PREVENTION OF INFECTION

An effective, comprehensive program of con­trolling potential risks associated with suction­ing procedures , both to patients and patientcare personnel, involves consistent and realis­tic use of aseptic technique throughout anysuction-related procedure .

Aspirated material sho uld never be allowedto come in contact with patient ca re workers ,either before it is suctioned (i .e., when the pa­tient is disconnected from a respiratory sup­port mechanism) , during suctioning, or whilebeing transported through patient care areas ."

Hands should always, be washed before andafter each patient contact and after handlingpotentially contaminated suctioned body fluidsand suction equipment.

Endotracheal suctioning should be performedaseptically ." Personnel should wear sterilegloves and use sterile catheters, and sterile sa­line so lu tion or water shou ld be used for flush­ing ca theters . A new, sterile ca theter should beused for each entry into the trachea." The samecatheter, however, can be reused to suction th eoropharynx after endotracheal suctioning iscompleted. When a new ca the ter cannot beused for each suctioning, catheters should bedisinfected between use as follows: soak thecatheter in 90% hydrogen peroxide and rinse itin a 70% solution of isopropy l or ethyl alcohol."Dry the catheter with a sterile cloth, and wrapit in a dry sterile towel. Before using the cathe­ter again, rinse it in sterile water. If this les s­than-optimal procedure is employed, never

reuse catheters for mo re th an one 8-hour workshift.

Suction catheters and lin es used for endotra­cheal suct ioning sho uld be tran sp arent to allowpersonnel to observe resid ua l sec re tions .

If tenacious mucou s secretions a re a prob­lem, suc tion ca the te rs ca n be flush ed withst erile solution before and during oropharyn­geal suctioning . If mul tiple-use bottles of sterilesolution are used, they must remain cappedand be changed at least every 12 hours." A newsterile basin or container should be used tohold the sterile solution for each suctioningprocedure.

The collect ion vessel sho u ld re tain all mate­ri al s suc tioned . Therefore the re shou ld be ef­fecti ve anti-overflow devices incorporated inth e sys te m, i.e., sh uto ff va lves th at respond tolevel s of both foam and liquid ." Su ction co n­tainers not having anti-overflow device s kn ownto be effective sho uld be changed before theyare three-fourths full , and in no event shouldth ey con tinue to be used whe n surg ing or fro th­ing wets the exhaus t port (or an exhaus t filter, ifpresent).

Reusable or disposable suc tion bottles andtubin g in use contain potentiall y hazardous se­cretions . To minimize th e associa ted risk, suc­tion collection units and associa ted suctiontubing should be changed at least every 8 to 12hours, ideally between each hospital shift andin all circumstances between use on patients.When not in use, tubing should be suspended soas to prevent any environ me ntal contamina­tion from the remaining fluid material.

All con taminated su ct ion supplies sh ould beplaced immediatel y in an impervious (plast ic)bag for transport from pat ient ca re areas .Reusable supplies shou ld be taken for rep ro­cessing to central se rv ice departments; di sp os­a bles should be disca rded appropria tely .

After use , nondisp osable suction bottlesshould be handled away from patient ca reareas . (i .e., opened. emptied carefully to pre­vent conta mina tion on the outside of the bottleas well as the hands, and sealed in an imperv i­ous bag). Bottles should be thoroughly was hedand then either di sinfected or ster ilized beforebeing reused. High-temperature (180 0 C orhigher), high-pressure washers clean and disin-

74 Pugliese, Mackel, and Mallison

fect satisfactorily in the same process; or bot­tles can be steam sterilized after thoroughwashing. All personnel responsible for empty­ing, cleaning, and/or sterilizing suction equip­ment should be trained in proper methods ofhandling, including good personal hygiene.

If possible, disposable collection bottlesshould be used for patients with known infec­tious secretions, e.g., such as those associatedwith bacterial pneumonia. When disposablesuction bottles and tubing are used, handling inpatient care areas should be kept to a mini­mum; under no circumstances should theseunits be opened or emptied in patient careareas. Disposable collection pouches or vesselsshould not be reused.

Since there is a potential for aerosol produc­tion during suctioning, which contaminatestubing, vacuum fittings, regulators, and pumpsof portable suction machines, containment ofthese aerosols is essential. Therefore it is rec­ommended that high-efficiency bacterial filtersbe used on suction collection systems to mini­mize the transmission of aerosolized microor­ganisms or particulate matter." Ideally, such afilter should be situated between the collectionbottle and vacuum source."

All personnel involved in suctioning proce­dures or handling contaminated equipmentshould be properly trained to minimize con­tamination of the environment and prevent in­fection risks not only to the patient undergoingsuction procedures and other patients, but tothemselves as well.

References

1. Ranger I, O'Grady F: Dissemination of micro-organ­isms by a surgical pump. Lancet 2:299,1958

2. Safar P: Management of the patient with tracheal tubeor tracheostomy. Mod Treat 6:47-60, 1969

3. Skaggs JA, Cogbill CL: Tracheostomy managementmortality complications. Am Surg 35:393-396, 1969

4. Lowbury EJ, Thorn BJ, Lilly HA, et al: Sources of in­fection with Pseudomonas aeruginosa in patients withtracheostomy. J Med Microbiol 3:39,1970

5. Crocker D: The critically ill child management of tra­cheostomy. Pediatrics 46:286-396,1970

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6. Conner GH, Huges D, Mills MJ, Rittmanic B, Sigg LV:Tracheostomy when it is needed. Am J Nurs 72:70-77,1972

7. Anonymous: Tracheostomy. Am J Nurs 72:70-77, 19728. Haberman PB, Green JP, Archibald C, et al: Determi­

nants of successful selective tracheobronchial suction­ing. Crit Care Med 2:29, 1974

9. Center for Disease Control: The control of pulmonaryinfections associated with tracheostomy. National No­socomial Infections Study Quarterly Report, Atlanta,Second Quarter 1971, issued April 1972, DHEW Publi­cation No (HSM) 72 8127

10. Beechum HJ, Cohen ML, Parkin WE: Salmonella typhi­murium transmission by fiberoptic upper gastrointes­tinal endoscopy. JAMA 241: 10 13, 1979

11. Stern H: Herpetic whitlow: A form of cross infection inhospitals. Lancet 2:871, 1959

12. Rosato FE, Rosato EF, Plotkin SA: Herpetic paron­chia-an occupational hazard of medical personnel. NEngl J Med 283:804, 1970

13. Dunbar C: Herpetic whitlow-occupational hazard fornursing personnel. Heart Lung 7:645,1978

14. Orkin F: Herpetic whitlow-occupational hazard toanesthesiologists. Anesthesiology 33:671, 1970

15. Denes AE, et al.: Hepatitis B infection in physicians.JAMA 239:395-400, 1978

16. Levy BS, Harris JC, Smith JL, et al: Hepatitis B inward and clinical laboratory employees of a generalhospital. Am J Epidemiol 106:330, 1977

17. Burke JP: Infection of cardiac and vascular prostheses.In Bennett JV, Brachman PS, eds: Hospital infections.Boston, 1979, Little Brown & Co

18. Rubbo SD, Gardner JF, Franklin JC: Sources of Pseu­domonas aeruginosa infections in premature infants. JHyg 64:121,1966

19. Kresky B: Control of gram-negative bacilli in a hospitalnursery. Am J Dis Child 107:363, 1964

20. Schools GS: Proceedings of the First Conference onClinical Application of the Ultrasonic Nebulizers.Somerset, Pa., 1966. DeVilbiss Co

21. Joint Commision on Accreditation of Hospitals: Func­tional safety and sanitation. Accreditation manual forhospitals [1980 ed]. Chicago, 1979, The Commission,p 45

22. Belinkoff S: Introduction to inhalation therapy. Bos­ton, 1969, Little, Brown & Co, pp 90-92

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24. Sutter VL, et al: Source and significance of Pseu­domonas aeruginosa in sputum of patients requiringtracheal suction. JAMA 197:132-136, 1966

25. Jorgensen, B: Maintenance of suction equipment. HospTop 46:81-82, 1968

26. Rees TA: Bacteria in suction machines. Lancet 1:240,1970