Inpatient respiratory care

[shay]

Hi All,
I am working to improve infection control procedures at my daughters hospital and I would love your input. At home, after every treatment, we clean the respiratory equipment with dish soap and hot water, rinse, then use the AVENT sterilizer to sterilize the nebs, and air dry them on a dry paper towel. When we are in the hospital, where the threat of infection is so very much higher, the procedure scares me. The respiratory therapist will rinse a neb with sterile water and leave it out to dry. It does not get washed or sterilized. The other issue is that in the inpatient room, there is not good place to let nebs dry. It is either on the nightstand that everyone that enters the room walks by or by the sink...just yuck... These nebs are used for at least 24 hours and cannot dry between treatments.

I am lobbying to move to single use nebs. One treatment and done. It seems like a no brainer to me. I'm interested in what your experience has been and especially if anyone's hospitals use single use nebs. Your input will really help me

Thanks!!!
Shay
Mom to a beautiful 18 year old with CF & CFRD

 

[Aboveallislove]

Gammaw just posted the CFF info.
http://forum.cysticfibrosis.com/threads/131687-To-NUK-or-not-to-NUK

Our hospital uses single use disposable once and done. That's what I prefer.

 

[believingjesus]

Shay - I fully support what you are doing! When my son was in the hospital they would not sterilize his nebs between use either and would always put it in an enclosed bag! next to his bed! Unbelievable knowing what is supposed to be done. I always insisted they give him a disposable but they could not. I also asked if we could bring clean nebs into the hospital setting which was also not allowed. So he ended up hurting his lungs more than helping his lungs by doing his treatments with dirty nebs. Amazing that hospitals do not understand this for CF patients. I fully support whatever you want me to do.

 

[jaimers]

My first hospital used to do what Believing described and we got one neb cup for each med and used it for the day (multiple treatments). After morning neb they would just pop it in this bag and hang it by the bed to be used for the next treatment. Then it was thrown away after each day. My current hospital (Massachusetts General) gives a new neb cup for each treatment. A one-and-done kind of thing that I much prefer for sterilization reasons. I get two new neb cups--one for saline and one for pulmozyme--for each treatment, then i throw them away.

 

[ethan508]

At the very least, you could get a mesh bag to hang them in to dry. Then you could hang it somewhere out of the way, like hanging from the TV stand or the curtain rod. A little rope or shoe lace and a review of knots might be needed. A camping store generally carries mesh bags used for hanging dishes that might be the right size. A mesh bag is a nice way to dry neb cups in other similar situations (camping, hotels, anywhere that the drying surfaces are a little suspect).

If you want boiling water to rinse them in, there are plug-in pots that will boil 4-5 cups of water in just a few minutes. This appliance is handy if you get stuck in places without a microwave or stove to boil water (like a dorm room).

 

[The Dot]

Shay,

I am an RT and have been working to establish the policies for our hospital for CF care, which is why I am on this forum - to get feed-back from people like you. We are using a specialty neb for Pulmozyme and inhaled antibiotics because these medications are very expensive and the CF Clinic we serve requested we use high-quality nebs for the expensive medications so that there is no waste. These nebs cost 10 - 25 times more than your average neb, so in order to be good stewards of our hospital's resources, we do clean and cold sterilize them between treatments. In some rooms, there is like a book shelf behind the door where we can put them out to air dry. In other rooms, we have to leave them on the window sill. You are right, this is not ideal. I liked the idea of a mesh bag that ethan mentioned - I may look into that.

We do use disposable nebs for other meds like albuterol, hypersal and pulmicort. These nebs are thrown away after one use. Someone recommended that you bring in something to boil your nebs. Please, beware that the disposable nebs are not meant to be boiled and will most likely melt! Also, please do not burn down your hospital !!!

 

[windex125]

My hospital as well used one neb a day, and I am lucky that my insurance covers the 30 I get each month. I wld go with Ethan's advice abt washing and hanging in a netted bag. you can also find these netted bags in any market in the dergentent area as woman wash their bras that hv under wires in them so we can place them in the washing machine. Good luck.

 

[shay]

Thanks for everybody's responses. Keep them coming! Dot, I think that the problem you stated is the reason my hospital reuses nebs--to save waste on the expensive meds. But to a parent or patient, I think we would rather waste a little medication rather than risk a dangerous and possibly life shortening hospital acquired infection. Presently, our family does bring our NUK in to the hospital and we do all of the cleaning and disinfecting ourselves as the respiratory staff is not trained to do this. But we still have the issue of having nowhere to lay nebs out to dry away from traffic or other contaminants. Another problem is that not every CF patient has a parent there to do all this work. It doesn't sound like much but if you are a little child or a sick adult you can't do it all. Ethan, I love your practical approach to problems. But I think a mesh bag would stay wet much of the time (with treatments 4x/day) and become it's own breeding ground for bugs. And at our institution, there isn't a good place to hang anyway. Can you all tell I've become quite the germaphobe... Hospitals scare me. I think the best (and really the only safe) answer is to use single use nebs. I'm just having trouble selling the idea to the powers that be at the hospital.

 

[Aboveallislove]

shay,
I'm totally with you re wasting a little medicine versus getting a hospital acquired infection, as I am with the phobias of hospitals. I once, though, heard a federal judge say what I thought nailed it in a case involving a hospital acquired infection: Fear of infections in hospitals isn't irrational! I too am with you re handling the sterilization etc, or alternatively just buying the disposable ones out of pocket, rather than risk it, but not everyone can do or afford. That is so great re you trying to get a solution for others who can't do what you do. I think the best we can do is get them to comply with CF guidance. Good luck.

 

[believingjesus]

Shay - I agree again. You would think that all hospitals would follow the guidelines of the Cystic Fibrosis Foundation and that there would be no question about it. I have become OCD over this stuff too but I honestly think you have to. If you don't watch what happens in a hospital MAJOR mistakes happen. I have a friend who was in the hospital and they almost gave him the wrong bag of antibiotics but he noticed it wasn't his name! It doesn't do any good to use unsterile nebs as you are damaging your lungs rather than helping them. I know that the disposable nebs are cheaper-made and when nebulizing some of the medicine is not dispersed into the lungs but just into the air vs. a Pari neb which will do a better job but if the hospital has no way to sterilize a more expensive neb then a disposable HAS to be used. I will be sneaking in nebs the next time for my son if they do not change the policy but for those who do not have anyone to help them it is unthinkable that this happens. And as far as the fact that these nebs cost 20 times the cost of a disposable, the hospital charges $50 for a box of Kleenex and it only costs $3.00 at the store so I'm sure the hospital will be sure not to lose the money themselves.

 

[ethan508]

Agreed Shay, if the mesh bag(s) didn't dry or you couldn't find a few anchor points to tie a dry line then it just doesn't work. The humidity in my area is low, so I'm used to everything drying rather quick. Drying is definitely an important part of any disinfectant scheme.

 

[wcherri]

I toss my nebs after each use.

Shay, I'm so glad you are another advocate for this! I'm amazed that neb cup sterilization is not always a priority in the hospital setting.

A couple of years ago, I insisted on having my neb cups switched out daily after they were rinsed out with tap water (in a hospital setting...ugh!) and only switched out every 2-3 days. My doctor supported my "request" and it was changed...for me. It was a step in the right direction. They changed nebs once a day AND nebs had to be rinsed out after each use with sterile water.
I also insisted that these changes be made for all CF patients at the hospital
After following up with my CF friend, it appeared that that step one was successful. I provided documentation that I retrieved on a laptop (while I was in the hospital). I am no longer at that hospital, but I have to say that I really did like the hospital and like the fact that they were receptive to change in the right direction. It's still a work in progress.

At my new hospital, I am getting more resistance with this same situation. I am not allowed to bring my own nebs. I can't bring my electric tea kettle either (for sterilizing). A CF friend suggested that I toss my nebs after each use. This passive/aggressive approach "forces" them to always have to retrieve a new neb. It's all I have a the moment.

I really hope the CFF will find a way to get hospitals to cooperate without the patients (and caregivers) having to make a big stink over it every time they are admitted.

 

[wcherri]

Links: Care of Nebulizers in the Hospital

Link to CFF.org page: http://www.cff.org/aboutCFFoundatio...F-Infection-Prevention-Control-Guidelines.cfm

Direct Link to August 2014 PDF: http://www.jstor.org/stable/10.1086/676882

Care of Nebulizers in the Hospital
47. The CF Foundation recommends the following:

• a. Nebulizers are for single-patient use only
• b. Aseptic technique is always followed when handling the nebulizer and dispensing medications
• c. Single-dose vials of medication used in nebulizers are always preferred
• d. Handheld disposable nebulizers are managed as follows:
  • i. After each use, rinse out residual volume with sterile water and wipe mask/mouthpiece with an alcohol pad
  • ii. Discard the nebulizer every 24 hours
• e. Handheld reusable nebulizers (eg, home equipment) are managed as follows:
  • i. After each use, clean, disinfect, rinse with sterile water (if applicable, following cold disinfection method), and air dry away from sink
  • ii. After each use, the nebulizer can be reprocessed (eg, by steam sterilization) if the reprocessing is performed according to the manufacturer’s instructions and the CF Foundation recommendations for home care (rec. 59) and if the nebulizer can be returned to the patient in time for the next treatment

Source of supporting evidence: 2003 CF IP&C guideline, Category II; 2003 pneumonia guidelines, Category IB; 2008 sterilization and disinfection guidelines, Category IB
2013 CF IP&C guideline consensus: 100%
Sections in the text: III.D.2; IV.E.2


**Questions about the guidelines should be addressed to infectioncontrol@cff.org.

 

[shay]

Thanks Wcherri for posting the CFF guidelines for everyone. I am well aware of these and feel that the guidelines for the disposable nebs hurts our cause. Even reusing a neb for 24 hours is not ideal. I wish the CFF would have come out stronger and stated to throw disposables out after a single use. The way it is stated means that these nebs are still sitting around the hospital for 24 hours and are probably being used wet since most CF patients are doing albuterol at least 4x/day. It also gives the hospitals the opening to fight you on what is "disposable" and what is "reusable". Anyone have any thoughts?

 

[believingjesus]

Yes, I do. The CFF guidelines need to be changed. The reason the hospitals are doing it this way is because they ARE following the CFF guidelines. The trouble is the Cystic Fibrosis Foundation must not recognize what is needed for a person with CF and that is that the nebulizers need to be either boiled for 10 minutes in between uses or placed in a tub of Isopropyl Alcohol for 5 minutes and rinsed with sterile water. My sons doctor said to do his nebs this way. I do not understand when a person would be admitted into the hospital to try to get better then they are forced to use the nebulizers the hospital gives them and reuse them for 24 hours but the truth is that the hospitals are following the CFF guidelines.??? This needed to be changed years and years ago. It is not safe for people with CF to reuse a neb even if it is within 24 hours. Maybe some on this forum do not understand these guidelines because they or their children have not been in the hospital for a stay yet but hospitals are reusing disposable nebs for 24 hours for many treatments and are following the CFF guidelines. You are also not allowed to bring any of your meds or nebulizers into the hospital and I am positive the hospitals my son has been in (one very prestigious hospital) would not allow a device that you would plug in to boil the nebs either because of fire hazards and they are the one who reused nebs when my son was hospitalized. The CFF guidelines are Ridiculous and have to be changed.

 

[believingjesus]

I forgot to mention that I really love the suggestion from wcherri to toss the nebs "accidentally" after each use! That seems like the only way around this. I know the hospital would not do anything on purpose but I did not realize they were following CFF guidelines. They also gave my son a more expensive preferred neb over a disposable but they still kept it in a bag by his bed and saved it for the next time. They may have changed it out after 24 hours, I just don't remember when it was changed out, I do remember that he had to reuse it several times though. Dangerous for a person with CF and it is all because of these guidelines. It makes me upset knowing the foundation that is supposed to protect a person with CF could actually be hurting them with their guidelines.

 

[Aboveallislove]

Thanks Wcherri for posting the CFF guidelines for everyone. I am well aware of these and feel that the guidelines for the disposable nebs hurts our cause. Even reusing a neb for 24 hours is not ideal. I wish the CFF would have come out stronger and stated to throw disposables out after a single use. The way it is stated means that these nebs are still sitting around the hospital for 24 hours and are probably being used wet since most CF patients are doing albuterol at least 4x/day. It also gives the hospitals the opening to fight you on what is "disposable" and what is "reusable". Anyone have any thoughts?

Hey Shay,


I agree re the guidelines. That’s what I meant above by the best we can do is get them to comply with CF guidelines. I am absolutely with you on using disposable nebs. The problem is that hospitals only get reimbursed by insurance for a set # and even if it is cheeper to use a new disposable neb than "pay" for the cleaning, the insurance likely has a code in place that allow for billing for the later, but not the former. However, hopefully you can get enough input that others use disposable to convince the hospital to do. If not, I wonder if a good way to push that way is to stress the Guidelines requirement that nebs be handled aseptically which if there is no good place to dry or if in practice the Rts aren’t doing (or if cleaning staff or others touch, etc.), that that might be a way to push for dispoable since they aren’t complying with aseptically. PM me if this interests you and I can help you look for research that might support issues with aseptic handling in the setting.


Also, while I wish the CF Guideline required disposable one-use, those guidelines are based on conclusive scientific guidance and the research shows that no bacteria in 24 hours of re-use. (That is somewhat reassuring–again I’m more concerned with the aseptic cleaning and handling). A hospital and clinic don’t have to follow the CF guidelines and if the CFF pushes for too much and without scientific support, the hospitals are less likely to follow other ones where the support is there. If you read the really dense backup there is lots of "insufficient evidence to support" for various recommendation, meaning there is some evidence of some but not conclusive and thus no recommendation. I hate that, but I understand why. Without the CFF there would be no support to push for things, such as the new recommendation for HEPA filtration in the rooms where they do spirometer and which our "new" clinic (i.e., new building new everything), only instituted after the recommendation.


Finally, I must admit I lol at the "accidently tossed" suggestion. I would caution though that once might be an accident but more than that and the hospital might well bar a parent from the hospital for destroying hospital property. Plus, you will get charged for it anyway and the insurance won’t cover. I’ve talked with Rts re buying the dispoable in bulk at cost when I was having a family crisis and needed a break from the sterlization etc. They are very kind folks. Just a thought.

PS Disposable means you can't sterilize by boiling; it doesn't mean you can't reuse. The instruction on the "disposable" kind we got explain how to clean for multiple (but only 4-5 total) uses. But I'm with you on once-and-done is what I want for disposable.

 

[believingjesus]

Oh! I understood in your first post AboveAll that your hospital uses once and done? Not what you "want"? Besides that what you are saying is that NO bacteria can stay in a neb within 24 hours and it is safe to use the same neb within 24 hours? You said that if we push the hospitals too much they will be less likely to follow the other guidelines the CFF recommends? Does that mean that all the requirements the CFF makes are in the best interest of ALL people with CF that culture all bacteria? My sons doctor recommends boiling for 10 minutes after EVERY use or placing in a bowl of Isopropyl Alcohol for 5 minutes and then using sterile water before he would use the neb again. I agree we need the CFF but we also need them to be sure to support every person with CF with every bacteria as far as guidelines and also research to kill certain bacterias, etc.

And as far as your advice that you are informing a parent who throws a neb away that they may be "barred" - I already knew that but I love the idea! Next time my son may have to go in the hospital I will be sure to order his nebs way ahead of time and take them to the hospital for his use whether they allow it or not. I can keep them in the bag or box they come in so they will know they are new. I am not afraid to pay the whole price for his nebs ever and as a matter of fact I already do. Our insurance only covers one neb every 6 months and I pay full price for all the other 14 nebs he has besides the one the insurance covers and I do that every 6 months. No worries! Thank you for your "advice".

 

[wcherri]

Looking at the bigger picture

There’s some interesting feedback here.

I realize we have repercussions with the way we handlesituations like this. We definitely haveto pick our battles and keep in mind that what we do may have a good short-termoutcome…but the long-term outcome may create more of a challenge. I also try to keep in mind that my actionsaffect my peers. So, for instance, if I’mtossing my nebs for a week while I’m in…if may be good for me at that time. Next month, the hospital may respond bycreating stricter policies or challenging other important requests from CFfamilies. We don’t want this to happen.

My preference is to work with the RTs, Nurses, andDoctors. Feel them out as far as howreceptive they are. Some RTs may becontrol freaks with the nebs , some may rinse with nebs and not realize how badit is to use tap water, and others may secretly bring in a stash of extra nebs. Communicate more with the ones who are willingto work with you. However, if an RTtries to make me use a neb that they dropped on the floor, I will report them.
So with that being said. I know I posted about tossing the nebs. It’s so passive/aggressive and I really don’t like to go in that direction. BUT, sometimes certain situations drive me tobe that way. I need to be for cautiouswith how my actions affect others. Sure,I insisted that when something is changed for the better, I want it to help allCF patients…not just me. That’s notenough though…and I will work on balancing what and how I fight for things thatare important to me with my health. This is definitely an important one to me…especiallybecause it is neglected by many hospitals.

Thank you all for helping me take a step back and try to consider all that is involved.

 

[believingjesus]

Wcherri: No Problem!!! I am not that stupid that I would throw away neb after neb and know that there would be no repercussions! Did you notice that you were not the target of that reply? I was. Aren't you a person with CF? I am a parent. It was directed at me, just like always from a particular person. I do not mind. I have worse troubles in this life than arguing and letting yet another person "control" me. I also know that disposables can be bought in bulk and I have already done this too for my son who was on long trips and had no way to clean his nebs, MANY times. So I knew that "tip" too. I guess when you have dealt with CF for 25 years you really do know a lot more than someone say 5 years, at least as far as experience. I have been through all the trauma of my son being diagnosed, etc., etc., and the fun never ends as there is a continual battle always. So no offense! I actually thought the idea was very funny and I giggled when I read it. And I WILL sneak in nebs or do whatever I have to for my son before I would let a RT have my son reuse his nebs again. You learn a lot of things through experience. I know I may not be as highly educated as another person on this forum but I am a mother who has tried my very best to do all I can for my sons always and to spend time with them. I have spent their whole childhood and teenage years and even young adult years trying to spend every time that was made available to me to enjoy them doing things with them continually such as going to the pool, the lake, golfing with my boys when I hate golfing but they like it, hunting, fishing, going on extreme roller coasters just so they have someone to ride with, vacations year after year, etc. I do not spend my whole day on this forum waiting to give my advice. I know what is important.