Good Practice: What the Pandemic Taught us about Infection Prevention and Control

Infection Prevention and Control (IPC) has always been top of mind for health-care providers. Over the last few years the pandemic has shined a spotlight on IPC procedures and policies. So, after living with COVID-19 as a large part of our lives, what have we learnt?

I think it is fair to say that all practice settings put their IPC policies and procedures under a microscope throughout the pandemic. As we have seen the end of public health measures several months ago, and statements from government officials indicating that they do not intend to return to vaccine or mask mandates, that leaves us with the question; what does that really mean for daily practice and bigger system wide changes regarding IPC?

The College of Physiotherapists of Alberta has recently revised the IPC guide in order to help guide physiotherapists in their decision making. The goal for IPC is to keep patients and staff healthy during the delivery of physiotherapy services. The goal remains unchanged before and after the pandemic. As you will see in the IPC guide there is a breakdown in IPC measures to four categories and each of the lessons will relate back to one or more of these categories.

1. Administrative Measures: Using policies and procedures to help mitigate the spread of infectious disease. This includes sick time, education and resources, hybrid work conditions, etc.
2. Engineered Measures: Redesigning the physical space using barriers to reduce contact, furniture that is easy to disinfect, cleaning agents, etc.
3. Elimination Measures: Removing risk from the practice environment by using things such as virtual care or safety-engineered sharps.
4. Personal Measures: Using good hand hygiene, personal protective equipment, Point of Care Risk Assessment (POCRA), etc.

LESSON #1: Work within your “sphere of influence” to keep people healthy

One of my new favourite terms is “sphere of influence”. It gives me a sense of what I can actually change and helps frame our IPC guide nicely. Physiotherapists occupy various positions in clinical practice from Clinicians to Professional Practice Leads to Clinic Directors or Clinic Owners, etc. Each of these roles comes with its own “sphere of influence” which may dictate the ability that person possesses to implement change in their practice setting.

Some have the capability to drive Administrative Measures such as changes to policies and procedures that are system wide and can influence a large portion of the work environment. Personal Measures are more focused on the clinician who carries out the changes at the patient level. Hopefully there exists the ability within organizations to have discussions on IPC that travel up and down the organizational structure.

Regardless of the amount of influence you have within your clinic or organization the IPC guide can assist you in creating a safe environment to treat your patients. The IPC guide takes you through the following:

• The Chain of Transmission
• Protective Measures
• Medical Device Reprocessing
• Clinical Resources

LESSON #2: Using Point of Care Risk Assessments

One of the messages that was continually amplified during COVID was the use of POCRA to assess and manage risk during patient interactions. POCRA is a Personal Measure about weighing the risks inherent to your environment, your patient and the physiotherapy services you provide. After evaluating the relevant risks, you use your clinical judgement to decide the protective equipment to implement in the care of that patient.

The first step of utilizing a POCRA is to identity the risks that exist for both you and the patient during the patient care interaction.

1. Patient Risk: The patient’s cognition, willingness or ability to perform hand hygiene, wear PPE or perform other measures of IPC will change the patient’s inherent risk. You or your patient’s current health status or risk of carrying an infectious agent would also alter the assessment of risk at the patient level.
2. Environmental Risk: A lack of environmental measures in the workplace such as poor patient flow through the environment or the type of furniture used in the common areas can elevate the environmental risk. Increased infectious rates within the community can also alter your POCRA.
3. Treatment Risk: What is the inherent risk to the assessment or treatment being performed? Are you performing a suctioning technique that has a higher Blood and Body Fluids Exposure (BBFE) risk than another available option? Are you choosing to wear gloves while performing dry needling techniques? Are you coming into contact with mucous membranes as part of treating a patient’s TMJ? Some assessment procedures and treatment techniques pose additional IPC risks due to their nature.

Once the risks have been identified you can determine the appropriate precautions to take. This may mean using PPE, adjusting the treatments you plan to offer, or rescheduling the appointment. The most important part is that you are using POCRA to make decisions that keep patients, colleagues, and yourself healthy and safe. Physiotherapists have a duty of care to our patients. We need to provide care that is safe and a safe practice environment for patients. Doing so also helps to keep others in the practice setting, including physiotherapists, safe. Sometimes a POCRA may indicate that risks can’t be managed while providing in-person services and in those instances, alternate methods of service delivery (e.g., virtual care) may be appropriate.

LESSON #3: Basics Matter

Wash your hands properly with the appropriate products. This has been taught from the time we were starting at grade school and is still taught regularly to those who have been working in healthcare for 30 plus years. There is substantial evidence to indicate that health-care workers have poor compliance to hand hygiene¹, but there is no excuse at this stage not to employ appropriate hand hygiene. This is an example of a Personal Measure as it relies on the clinician to implement. However, you can also include Administrative Measures such as large-scale policies and educational initiatives to increase compliance. There are also Engineered Measures such as the redesigning of physical spaces to include hand washing or hand sanitization stations that are more readily available in the clinical environment.

Whether it is you or someone else that is responsible, cleaning and disinfecting the work environment is an example of an Engineered Measure and one of the best ways to break the chain of transmission. Some infectious agents can live on surfaces for long periods of time so keep your practice space clean with the right type of cleaning agent following the directions for product use provided by the manufacturer. Cleaning products should have a Drug Identification Number (DIN) that would lead you to Health Canada’s database. You can identify if your cleaning product has the appropriate virucide or bactericide for the health-care setting that you work in. The appropriate level of disinfectant is very important, so double check your DIN and don’t waste your time using vinegar and tea tree oil as they do not provide the level of protection needed to keep you and your patients safe.

We are vectors of disease and health-care workers are considerably more likely to contract the flu or be asymptomatic carriers of the flu virus than members of the public.² Also, physiotherapists deal with patients who are very ill and, therefore, a susceptible host. Vaccinations are a Personal Measure that an individual can take. Vaccinations have been one of the most significant advances in public health, resulting in the control and eradication of many infectious diseases over the past 50 years.3 So if there are no medical reasons not to get vaccinated, then the College strongly encourages you to keep up with your immunizations.

Lesson #4: Masking

I know we touched on PPE previously as a Personal Measure of protection, but it is important to highlight that the appropriate use of masking is still a significant strategy to limit transmission of respiratory diseases. We have learned a significant amount about masking in clinical practice during the pandemic, and its important to review their use now. You may take community infection rates into consideration during your POCRA as you consider the use of masks.

Medical-Surgical Masks are fluid resistant and provide the wearer with protection against large droplets, splashes, or sprays of bodily or other hazardous fluids. They also protect the patient from the wearer’s respiratory emissions.4 They do not provide the wearer with reliable level of protection from inhaling smaller airborne particles as they have gaps that allow airborne particles into the wearer’s respiratory tract. However, they do filter 95% of particles through the mask and are considered appropriate PPE for may infectious diseases.

Appropriately fitting N95 or KN95 Masks provide filtration of at least 95% of airborne particles including large and small particles. They reduce the wearer’s exposure to particles including small particle aerosols and large droplets and also protect the patient from the wearer’s respiratory emissions.⁴

LESSON #5: Let's Talk Device Reprocessing

There are three categories of medical devices:

1. Reusable: These can be used by multiple patients, multiple times
2. Single-patient Use: Used by only one patient but can be used multiple times
3. Single use/Disposable: Must be discarded after one use

The Spaulding Classification of Medical Devices⁵ is a system you can use when making decisions on how to clean and disinfect or sterilize reusable medical equipment. The Spaulding Classification is broken down into:

1. Non-Critical items like gym equipment and treatment tables that need to be cleaned and then disinfected between patients.
2. Semi-Critical items like vaginal probes and peak flow meters. These need to be cleaned and then followed by high level disinfection and/or sterilization. You must follow manufacturer’s guidelines if they are suggesting a higher level of reprocessing
3. Critical items like IMS plungers and wound care instruments require cleaning followed by sterilization.

Device reprocessing falls into Engineered Measures as it involves changing the physical environment to eliminate reservoirs of infectious agents, reduce the source of the hazard, or limit the risk of exposure to the hazard. The facility-level decision making on how to comply with the appropriate process for a piece of equipment is an Administrative Measure as policies are put into place. It is important to remember that you can outsource your medical device reprocessing if you are unable to reprocess equipment properly in your practice setting.

As a reminder the IPC guide can be found on our webpage under guides and guidelines or via the link above. Any questions you may have can be directed to Practice Advice at (780)702-5390 or to professionalpractice@cpta.ab.ca

Sean FitzGerald, PT, Practice Advisor

Page updated: 09/12/2022