Registed Nurses' Association of Ontario

Clinical Practice Guideline for the Cleaning and Disinfection of Reusable Nebulizers

Rebecca Wengle BSc, BScN, RN
Hospital for Sick Children

Patients with Cystic Fibrosis (CF) are immunocompromised and experience chronic lung infections due to excessive airway secretions and inflammation. Patients with CF seen at SickKids are typically prescribed multiple inhaled medications administered through reusable nebulizers. Evidence has found that bacterial contamination may occur on nebulizers that are not cleaned and disinfected routinely. A survey addressing home cleaning practices revealed that only 10% of patients and families were compliant with CF Canada guidelines, which states to clean and disinfect after every use. A selfadministered anonymous survey revealed that only 35% of nurses were using current SickKids policy to clean the nebulizers in hospital and therefore 65% of nebulizers weren’t being cleaned at all. Regardless of these findings, it is important to note that the SickKids’ Nebulizer Aerosol Policy is not applicable to reusable nebulizers. A Clinical Practice Guideline (CPG) was developed to implement and standardize cleaning and disinfection procedures for reusable nebulizers. Staff were trained, educated and resources were available to implement the CPG in their practice. Patients and families were also given educational resources outlining CF Canada cleaning and disinfection guidelines including the various methods that can be used in the home setting. The next phases of the project will include auditing for compliance, address knowledge gaps and challenges, and to review the guideline for best practice updates in the near future.

The overall objective was to create a Clinical Practice Guideline. Although I had an idea of what the guideline would entail, it required a tremendous amount of background work and liaising with even more stakeholders than I originally planned. By leading this initiative, I developed confidence and skill in conducting a comprehensive literature review and analysis structured upon research, clinical practice and current policy. There was expertise to be gained in internal and external benchmarking by liaising with a variety of external stakeholders. I learned quickly to make direct contact with individuals and value the opportunity to meet in person or speak over the phone. This was something I had taken for granted while working as a bedside nurse and having the opportunity to speak directly with individuals every day. Learning how to develop and disseminate pre and post implementation surveys and analyze the data collected was a new skill for me as well. I found it integral to help survey participants find value in the project in order to receive genuine results. I worked closely with SickKids’ Quality Analysts, Infection Control and Risk Management specialists to develop the physical practice guideline and ensure it aligned with SickKids’ standard. I developed implementation and sustainability initiatives to ensure the practice guideline is utilized and updated with best practices. In turn, my work in such capacity has prepared me for abstract submission for conference or workshop use. I have ensured sustainable education and regular guideline revisions to set an example for other Canadian paediatric facilities to adhere to CF Canada Guidelines.

Paediatric patients with Cystic Fibrosis were positively affected by this fellowship. These patients are typically admitted for two weeks at a time for pulmonary treatments. A component of the disease process makes them susceptible to pseudomonas colonization and infection which fills their lungs with sticky mucous. The use of evidence based strategies for the prevention of pathogen transmission is essential to optimizing the clinical outcomes for this population. Prior to implementation, only 10% of patients were compliant with CF Canada guidelines instructing to clean and disinfect after every use. While inpatient, only 35% of nurses were rinsing the reusable nebulizers with sterile water at most, indicating that 65% of nebulizers weren’t being cleaned at all. Post implementation, health care providers had a cleaning and disinfection guideline to incorporate into their practice. Patients and families were also provided with education and resources for home use. The goal is to improve compliance rates both in hospital and at home, and in turn improve infection control and clinical outcomes.

From a staff and organizational perspective, this quality improvement initiative involved understanding current nursing knowledge and practices by collecting pre intervention data, developing and delivering targeted education, assess the effectiveness of the education and re-visit methods to make practice changes more sustainable. From anonymous self administered survey results, education sessions (62%) and informative posters (72%) were the top two choices to support learning and optimize nursing practice. Bedside nurses received easily accessible visual resources, staff meeting presentations, one-onone education blitzes, and were given daily reminders during morning huddles. The next phase of auditing and ensuring sustainability is beyond the timeframe of the fellowship however the goal is to improve compliance with new practices implemented and to help frontline staff find value in this practice change.

Overall, the fellowship has provided me with an enriching opportunity. With allocated time away from the bedside, I was able to lead an important practice change for the Cystic Fibrosis population that may not have been addressed otherwise. I was able to step into a temporary role of guideline development, which is usually occupied by nurses with continuing education, and am now intrinsically motivated to seek continuing education for myself. My favourite aspect of fellowship was connecting with an array of key stakeholders and facilitating meetings that I wouldn’t get to participate in otherwise as a bedside nurse. I felt like a valuable team member and loved the conversations and ideas that arose.