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Cover Story: A Prescription for Safety Putting Infection Control into Practice

FitzGerald, Susan

doi: 10.1097/01.HJ.0000429411.00550.10
Cover Story
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Alison Burco, AuD, was getting her doctorate in audiology when she became curious about infection control. In a lecture at Washington University in St. Louis, she heard about the microorganisms that could unknowingly be passed around an audiology practice. Yet in her own experience, she had not witnessed much attention at all being paid to infection control.

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“I never went to a practicum location where we were sat down and told, ‘This is what we do for infection control,’” said Dr. Burco, who is now an audiologist at the Missouri School for the Deaf in Fulton, MO. “I was at practicum locations where staff ate at the same desk where they had just been working on hearing aids.” She also saw workers handling hearing aids and earmolds with their bare hands, even though the devices could be contaminated with all sorts of infectious organisms.

For her doctoral project, Dr. Burco decided to seek out the real numbers behind what she was observing (see FastLinks on page 22). Did audiologists adhere to basic infection control practices?

Working with her advisor, Dr. Burco invited 300 members of the American Academy of Audiology to answer a questionnaire, with the goal of comparing results to a similar survey done seven years earlier. While the repeat survey found that audiologists seemed more aware of infection control issues and had made some strides in their practices, there was still much room for improvement.

“I thought it would be a whole new world, but it wasn't,” Dr. Burco said. While glove use had increased over time, it remained suboptimal, according to the responses on the 71 surveys returned and analyzed. Most respondents did not use masks when modifying hearing aids or earmolds, despite the high risk of cross contamination during these procedures, and although about half said they disinfected touch surfaces, the procedure tended to be done at the discretion of the audiologist, not as a matter of routine.

Even though practitioners by and large said they had a written exposure control plan, as required by the Occupational Safety and Health Administration (OSHA), the survey found that those plans were sometimes lacking, such as in the area of infection control training for staff members. Many practitioners also reported that they had not sought out such educational training themselves.

Dr. Burco said the findings of her doctoral research stuck with her as she headed into practice.

“The more you practice good infection control procedures, the more routine they get,” she added. “I work under the assumption that everyone's got something, including the audiologist. I work on protecting my patients and protecting myself and staff.”

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EAR CANAL AS ENTRY PORTAL

Audiologist A.U. Bankaitis, PhD, who advised Dr. Burco on her doctoral capstone project and is a leading authority on infection control in audiology, defines infection control as “the conscious management of the clinical environment for the specific purposes of minimizing or eliminating the potential spread of disease, regardless of how remote that possibility seems.”

Health practitioners have often wrongly assumed, particularly in the early days of the AIDS/HIV epidemic, that infection control is about “preventing the spread of HIV,” which does in fact seem like a remote possibility in an audiology practice, she said.

Audiologists appear to be coming around to the understanding that infection control is “about preventing the spread of infection in general,” she added.

There is little data to say to what extent infections are transmitted in an audiology setting, Dr. Bankaitis said. But just consider who's coming in the door. Audiology practices tend to have patients with weakened immune systems —people who are older, have diabetes, are undergoing radiation or chemotherapy, or are taking certain medications. Individuals with HIV/AIDS who have compromised immunity and can be prone to hearing problems because of opportunistic infections also may be audiology patients.

In general, good infection control practices prevent inadvertent transmission of disease from patient to patient, from patient to staff member, and from staff member to patient. Like in any healthcare setting, there are all sorts of potentially troubling microbes throughout the audiology environment, particularly on patients’ hearing aids, which many providers handle casually.

Dr. Bankaitis, who is Vice President at Oaktree Products in Chesterfield, MO, published a study in The Hearing Journal in which she analyzed what organisms were growing on hearing aids from 10 patients (see FastLinks on page 22). The results were cringe worthy. What was surprising was that each hearing aid had its own unique contamination profile. The predominant organism identified was a common strain of staphylococcus, but nine other bacteria and three fungi also were identified. The report outlined a scenario of how germs could get passed from patient to patient via their hearing aids if the clinician did not practice proper infection control procedures.

“The ear canal serves as a portal of entry for microbes in the human body,” Dr. Bankaitis said. “Under the right conditions, ubiquitous bacteria and fungi may lead to opportunistic and/or systemic infections.”

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MAKING A PLAN

Historically, the topic of infection control has received little attention in audiology curricula, perhaps quickly covered in a one-hour lecture wrapped into another course.

“It's something that students need to be taught so that it starts to become second nature,” said Dr. Bankaitis, who coauthored the textbook Infection Control in the Audiology Clinic with Robert J. Kemp, MBA. She lectures and conducts online courses on infection control.

Putting in place a good infection control plan may feel overwhelming at first, but it will be more manageable if broken down into steps (see the infection control checklist to the left). At the most basic level, audiology practices are required by OSHA to have a blood-borne pathogens exposure control plan, including details on training and implementation protocols (see FastLinks on page 22). Dr. Bankaitis urges audiologists to start compiling a list of every service they provide in their offices, from earmold impressions to cerumen removal to diagnostic audiometry. Providers might be surprised how much is going in a single space.

Once that list is put together, protocols can be written for what infection control measures must be involved in each scenario, such as sterilizing instruments that are reused, handling the transfer of a hearing aid that is dropped off at the front desk (see the sample written protocol on page 22), and cleaning surfaces after fitting a patient for a hearing aid. An infection control plan won't do much good if it isn't followed because it is overkill or interferes with office flow. Training of staff is essential, and retraining from time to time will help the staff tweak protocols and smooth out how things are done.

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A NEW NORMAL

Joan D'Alessandro, AuD, who has a practice in Paoli, PA, said she takes a common-sense approach to infection control and tries to reinforce good habits by having hand sanitizers, wipes, and disinfectant supplies in designated spots so no one has to go looking for them. “You try to do as much as you can,” she said.

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Audiologists who work as part of a bigger practice, such as an ENT or speech–language–hearing clinic, need to make sure that following broader office policies does not come at the expense of paying attention to the particular features of infection control in audiology. Likewise, audiologists working in a hospital setting or hospital-related clinic usually work under the umbrella of a hospital-wide infection control plan, but they still need to make sure that protocols are in place to address the services going on in their practices.

Kathy Brewer, MS, has been an audiologist for 31 years, and she's seen how far infection control has come. She works for an otolaryngology clinic in Madison, WI, that is part of the University of Wisconsin Hospital and Clinics and thus follows hospital-wide protocols, but she and her colleagues still have to consider infection control in terms of their specific practices in the clinic. Whenever possible, they use one-time disposable items, including otoscope specula, immittance tips, and headphone covers, to prevent cross-contamination between patients, she said.

“Even though this costs a little more, it's about patient safety,” she said. Hearing aid repairs are done in a separate area from where patients are seen, and when patients drop off a hearing aid at the front desk, they are asked to place it in an envelope.

MRSA is on the staff's radar, she added. If a patient who is MRSA positive comes in for an appointment, he or she is taken to a designated room, which afterward is disinfected, air-dried, and kept empty for an hour before another patient can use it.

Mindy Brudereck, AuD, who practices in Birdsboro, PA, said that while she had always considered herself to be fairly smart about infection control, she began to focus intently on her practice habits when she became pregnant eight years ago and started to think even more about the importance of staying healthy.

“We are dealing with a population that can be very vulnerable, both older people and young children,” she said. “You don't want to put yourself at risk, and you don't want to put your patients at risk. Think of what you expect when you go to the physician's office or hospital. You hope everything is clean.”

Her office's protocols — from disinfecting surfaces, equipment, and even the handle of the audiology testing booth to wearing gloves when examining patients — have helped to make what might seem at first like added steps soon become routine. Dr. Brudereck has gotten so used to wearing gloves now “that it's hard to think of what we did before.”

Since patients today are accustomed to seeing infection control practices everywhere they go—even supermarkets offer shoppers wipes to clean off the handles of carts—they will appreciate any stepped-up attention to preventing the spread of disease, Dr. Bankaitis said.

If a patient asks why you're now wearing gloves, tell them that new information emerges all the time on how to prevent the spread of disease, she added. Tell them, “Our clinic is committed to following best practices.”

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INFECTION CONTROL CHECKLIST

To comply with OSHA requirements:

  1. Develop a written exposure control plan.
  2. Provide infection control training for staff.
  3. Have employees fill out necessary forms related to the infection control plan.
  4. Make sure that work-practice controls are executed consistently.

Required components of a written exposure control plan:

  1. Employee exposure classification.
  2. Hepatitis B vaccination plan.
  3. Training plan.
  4. Implementation protocols.
  5. Emergency procedures.
  6. Postexposure evaluation and follow-up.

Universal precautions to implement:

  1. Use appropriate barriers—gloves, mask, eye protection, etc.
  2. Perform hand hygiene.
  3. Clean and disinfect touch and splash surfaces.
  4. Sterilize reusable critical instruments.
  5. Dispose of waste appropriately.

Source: A.U. Bankaitis, PhD

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SAMPLE WRITTEN PROTOCOL FOR HANDLING HEARING AID DROP-OFFS

It is the policy of this clinic that front office personnel will not accept or receive hearing aids, earmolds, or similar devices directly from the patient. In the event that a patient is dropping off a hearing aid for later servicing, the following procedures will be observed:

  • The front office staff member will retrieve a designated hearing aid drop-off envelope and hold the envelope in an open position.
  • The staff person will instruct the patient to place the hearing aid or earmold in the envelope.
  • The employee will close the envelope and staple it shut at the top.
  • In the event the hearing aid or earmold was inadvertently placed on the counter or other surface, the staff person will clean and disinfect the surface using fresh disinfectant towelettes.
  • During this time, the patient will complete any necessary paperwork.
  • The staff person will attach the paperwork to the envelope and place the envelope in the designated location for the audiologist to process later.
  • Prior to returning to the front desk, the staff person will use hand hygiene procedures.

Source: Adapted from Infection Control in the Audiology Clinic (2nd Edition), by A.U. Bankaitis, PhD, and Robert J. Kemp, MBA

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