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Precautions for Immunocompromised Patients (Protective Precautions) (4.1.19)

Precautions for Immunocompromised Patients (Protective Precautions) (4.1.19) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.19


UW HEALTH CLINICAL POLICY 1
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19
Category: UW Health
Type: Inpatient
Effective Date: October 23, 2017

I. PURPOSE

To reduce the risk of highly immunosuppressed patients, particularly neutropenic patients and patients with
organ transplants, developing life threatening healthcare-associated infections, especially those caused by
airborne filamentous fungi. For more comprehensive consideration of infectious risks to highly vulnerable
patients, the reader is referred to the Guidelines for Preventing Infectious Complications among
Hematopoietic Cell Transplantation Recipients: A Global Perspective, and The American Society of
Transplantation Infectious Diseases Guidelines, referenced in section VIII.

II. POLICY ELEMENTS
A. The patient's staff physician is responsible for ordering Protective Precautions, and for subsequently
discontinuing precautions when they are no longer deemed necessary.
B. UW Health will provide protective environments for patient populations deemed at high risk of filamentous
fungal infections.
C. Precautions designed to minimize the exposure of vulnerable patients to fungal spores will be taken during
patient care, as well as during activities performed by Environmental Services and Facilities and Engineering
Services.
D. Compliance with department-specific responsibilities designed to protect vulnerable patients will be
expected.
III. RATIONALE

The infectious spores of Aspergillus species and other pathogenic airborne fungi are generated by mycelial
forms present in decaying vegetative material. In outdoor air, spore counts can be very high - depending on,
and fluctuating with, changing environmental conditions. Ordinary air filtration in the hospital does not
reliably remove small fungal spores.

In the hospital environment, aspergilli and other fungal species can grow to high numbers, particularly in
areas which are wet or humid, and typically on substrates of organic origin such as wood, particle board,
paper, cardboard, accumulated dust and debris, flowers, potted plants and soil, etc. Fungal spores which
have become airborne will settle out in dust and may remain viable for months. Any activity which elaborates
dust into the air has the potential of very widely disseminating significant numbers of these infectious
particles on air currents. Outdoor excavation, as well as indoor construction and building maintenance have
been associated with outbreaks of invasive aspergillosis in immunosuppressed patients, with significant
mortality. Aspergillus species are the most common agents of airborne invasive fungal infections and have
high mortality in compromised hosts.

High Efficiency Particulate Air (HEPA) filters can remove 99.9% of fungal spores from ambient air, and
studies have demonstrated that routine use of such filters in the care of vulnerable patients greatly reduces
the risk of invasive aspergillosis. HEPA-filtered supply air is provided to selected UW Health patient care
units housing patients at high risk of invasive filamentous fungal infection.

IV. PROCEDURE
A. Ordering Protective Precautions
i. The patient's physician must order Protective Precautions, based upon an overall assessment of
the degree of immunosuppression. Protective Precautions are needed only for highly
immunosuppressed patients. Such patients may include, but may not be limited to:
a. Patients with severe granulocytopenia (absolute neutrophil count [ANC] less than 500
neutrophils/mm3), especially if prolonged.
b. Patients with Severe Combined Immune Deficiency Syndrome (SCIDS).
c. Solid organ and hematopoietic stem cell transplant recipients:



UW HEALTH CLINICAL POLICY 2
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19

1. in the week following organ transplantation
2. those receiving high doses of immunosuppressive drugs, typically for treatment
of rejection
d. Patients receiving high doses of corticosteroids or other immunosuppressive drugs.
ii. Patients under Protective Precautions will be housed in a Protective Environment (PE) room with
HEPA-filtered source air which is positive in pressure in relation to the corridor.
iii. When there are more candidate patients than available PE rooms, the physician(s) caring for
candidate patients should determine priority of use. In general, priority is assigned in decreasing
order of risk:
a. Recent bone marrow transplants, especially if engraftment is delayed and the period of
neutropenia will be prolonged.
b. Patients having received induction chemotherapy for acute leukemia.
c. Patients receiving intensive anti-rejection therapy.
iv. If no PE rooms are available, a portable HEPA filter will be placed in the room and the door closed
to minimize airborne contaminants as much as possible. For maximum benefit, portable HEPA
units with variable speed fans should be set to the highest setting.
a. For high risk patients, particularly those with ANC <500 and especially if neutropenia may
be prolonged, use of a portable HEPA filter in a regular patient room should be used only
as a temporary measure until a PE room is available.
v. The Infection Control Department is available to advise when conflicts arise regarding priority and
can be reached via the paging operator at 262-2122 or directly on pager #2570.
vi. Nursing staff are responsible for placing a "Protective Precautions” sign on the patient's door.
B. Inpatient units serving patient populations which are especially vulnerable to airborne fungal infection will be
provided with HEPA filtered source air.
i. Currently, B4/3, B4/5, B4/6, B6/3 (TLC), B6/6, D6/5, D6/6, and F4/5 have HEPA-filtered source air.
All patient care areas of the American Family Children’s Hospital building have HEPA-filtered
source air.
a. At the time of installation Facilities and Engineering Services (FES) will test, or contract to
have tested, the filtration efficacy of the bank of HEPA filters. The efficacy of air filtration
provided by the newly installed filter bank will not be considered acceptable until the filter
bank passes particle challenge testing to the 99.97% HEPA standard.
b. After original installation and successful testing, FES will test, or contract to have tested,
the filtration efficacy of banks of HEPA filters at least annually in order to ensure continued
efficacy.
c. Filtration efficacy test results will be forwarded to the Unit Manager and also to the
Infection Control Department for review.
d. The doors leading into HEPA filtered inpatient units should remain closed at all times
when not in use to obtain maximum benefit from the provision of filtered air.
e. HEPA filtered patient care units, and wings housing particularly vulnerable patients (e.g.,
BMT wing of B6/6, Transplant hallway of P4) should be maintained at positive pressure in
relation to surrounding areas to avoid influx of unfiltered air onto the unit or wing.
f. FES staff will verify, by use of a smoke stick or anemometer, that HEPA-filtered patient
care units routinely housing immunosuppressed patients (B6/6, P4 BMT Hallway) are
positive in pressure to surrounding areas. Such testing will be performed monthly.
ii. Rooms with special ventilation for protecting vulnerable patients will be designated by signage near
the entry.
a. Protective Environment (PE) rooms within UW Health are maintained at constant positive
pressure in relation to the corridor and are delineated by a sign near the entry stating
“Positive-pressure ventilation room; suitable for Protective Precautions.”
b. Rooms with local interstitial-mounted HEPA filtration units for dilution ventilation are
labeled, “Room equipped with supplemental HEPA filtration.”
iii. Rooms should be kept as airtight as possible to prevent influx of unfiltered outside air.
a. Windows should NEVER be opened, except for emergent situations or under controlled
conditions when it is necessary to vent worksite air to the outside in order to maintain
control within renovation areas, as detailed in Hospital Administrative Policy #13.16,
Infection Control Precautions During Construction and Renovation.
b. Bathroom exhausts should not allow for reflux of outside air.



UW HEALTH CLINICAL POLICY 3
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19

iv. Maintenance, repair and construction activities involving PE environments will be completed as
follows:
a. Facilities and Engineering Services personnel who must perform repair or maintenance
work which may generate dust within an occupied patient room will coordinate this activity
with the nurse in charge of the patient. If medically possible, the patient should always
leave the room, during all maintenance work and not return for at least 30 minutes after
completion of the work to allow time for any fungal spores disrupted during the work to be
removed by the ventilation system.
b. Routine checking by use of a smoke stick or anemometer to verify that PE rooms remain
consistently at positive pressure in relation to the corridor will be performed
monthly. Deficits in ventilation will be remediated immediately, and if a delay in such
remediation of more than one hour is anticipated, the unit manager will be notified that the
room is unavailable for housing patients under protective precautions.
1. When Protective Precautions is ordered for a patient, a notification is sent to both
the FES Control Room and to the Infection Control email inbox. FES personnel
will go to the room and verify that it is a PE room and that it is at positive
pressure. FES will continue to verify positive room pressure daily until the order
is discontinued through the use of a list of patients in Protective Precautions
which is emailed to FES daily. If FES personnel find that the room is not a PE
room, they will notify unit staff that a portable HEPA filter unit is needed for
temporary use and also notify Infection Control of the discrepancy.
2. If FES personnel find that the room is a PE room, but is not at positive pressure,
they will page Infection Control on pager #2570 to notify them of the discrepancy
and investigate and remediate the loss of positive pressure. Infection Control will
contact the unit to recommend moving the patient to another PE room or
recommend obtaining a portable HEPA filtration unit for temporary use.
3. Portable HEPA filter units are available from the Bed Movers weekdays 5:30am-
11:30pm and from FES at other times.
c. Facilities and Engineering Services personnel will verify the number of air changes per
hour in PE rooms when commissioned and at reasonable intervals thereafter, whenever
alterations to the ventilation system may have affected this parameter and whenever
monthly airflow checks indicate that the room is not at positive pressure as designed.
d. Central and Local HEPA filters will be maintained by FES quarterly, and will include
documentation of pressure differential across central filter banks, inspection of the pre
filter and changing it if necessary, and assuring positive airflow of PE rooms with respect
to the hallway. The scheduling will be coordinated with the nurse manager of the unit.
e. Facilities and Engineering Services will clean the interior of supply and return air ducts
and vents as needed.
f. Facilities and Engineering Services will coordinate maintenance and remodeling activities
with nursing staff and Infection Control personnel as stipulated in Hospital Administrative
Policy #13.16, to minimize the risk of construction associated patient exposure to fungal
spores.
g. Facilities and Engineering Services will provide reports of current and upcoming
remodeling activities, as well as recent ventilation test results, as a standing agenda item
of the Infection Control Committee.
h. Infection Control personnel will test the ambient air in HEPA filtered units for viable molds
if there is reason to believe that biological air quality has potentially been affected by
compromised unit ventilation or compromised construction site containment, or there is
evidence of increased incidence of healthcare-associated fungal infections.
C. Patient Care Procedures
i. While the patient remains under Protective Precautions, the room door should remain closed at all
times.
ii. Nursing staff will educate patients and family about the essential concepts of Protective
Precautions, including sources of airborne fungi and the very serious implications of deep fungal
infection. It should be noted that:
a. Outdoor air in particular, but also air in areas of the hospital without HEPA-filtration, may
contain high levels of airborne spores which can cause infection, necessitating use of a
filtration mask when the patient leaves the protective HEPA-filtered environment.



UW HEALTH CLINICAL POLICY 4
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19

b. Corners of rooms and other areas that accumulate dust must be cleaned well.
c. Large amounts of personal belongings in the patient's room promote dust accumulation
that could pose a hazard. Storage of supplies and patient belongings on horizontal
surfaces should be minimized due to difficulty in keeping surfaces free of dust which may
accumulate around the items.
d. Plants, fresh cut and dried flowers, and moss bases for silk flower arrangements, which
can contain very high counts of Aspergillus spores, are NOT allowed in rooms housing
highly immunosuppressed patients, nor in the corridors adjacent to these rooms.
iii. A neutropenic diet should be initiated in patients with an ANC < 500 per mm3 or prior to bone
marrow transplant.
a. The Physician or Advanced Practice Provider is responsible for ordering diets or this may
be delegated to the Registered Dietitian Nutritionist (RDN) using Delegation Protocol #54,
Clinical Nutrition Authority to Write Diet & Nourishment Orders.
b. Culinary and Clinical Nutrition Services staff will ensure that food items served on the
neutropenic diet trays comply with food safety guidelines.
c. Uneaten foods shall not be kept in the patient's room.
d. Water and ice from the unit dispensing machine may be used.
e. Choose bottled water that has one of these statements on the label: reverse osmosis,
distillation/distilled or filtered through an absolute 1 micron or smaller filter.
f. Food brought to patients from outside the hospital is discouraged. If family/friends choose
to bring foods, hospital staff should encourage compliance to food safety guidelines.
g. The RDN is responsible for the nutritional care of patients in accordance with this policy.
The RDN and/or Clinical Nutrition Services staff will instruct the patient and family
regarding food and water safety guidelines. Cancer patients and patients that have had a
bone marrow transplant will be provided education using Health Facts For You (HFFY)
#476, Food Safety for the Immunocompromised Patient. Patients that have had an organ
transplant will be provided education using HFFY #494: Nutrition Guidelines after Solid
Organ Transplant.
iv. All healthcare workers and visitors must thoroughly wash their hands with soap and water or apply
a waterless alcohol gel before entering the room, or immediately upon entry into the room.
v. Healthcare personnel who are symptomatically ill, especially with a febrile illness, should refrain
from coming to work.
a. If a healthcare worker is afebrile and has symptoms of a simple common cold, they may
render care to patients under Protective Precautions if no other staff are available,
provided that prior to each patient contact:
1. hands are washed with 2% chlorhexidine soap, or a waterless alcohol hand gel is
applied
2. gloves are donned
3. yellow mask is donned
b. A healthcare worker presumed to have a common cold whose symptoms worsen,
particularly if fever or cough develop, must be immediately excluded from work.
vi. Prospective visitors who are symptomatically ill, especially with a febrile illness, are excluded from
entering the room of the patient under Protective Precautions and will be asked to leave the
protective patient care unit as well.
vii. Any neutropenic patient who develops cutaneous mycosis caused by filamentous fungi such as
Aspergillus must be moved to a designated negative pressure ventilation room as described in IV.
C. x., below.
viii. Immunosuppressed patients, as generally described in IV. A. 1., must wear a submicron filtration
mask (blue duckbill PCM 2000; Central Supply #1213037) during the following circumstances:
a. Whenever they leave the protective environment of the HEPA-filtered unit,
b. During housekeeping procedures where the patient is unable to leave their room, and
c. During repairs or maintenance work that must be performed while they are in their room.
1. Nursing staff must educate the patient regarding the importance of wearing a
properly fitting filtration mask when leaving the protective environment of the
HEPA-filtered unit. If the patient is unable to leave the room during dust-
generating housekeeping or maintenance work, the nurse will ensure that the
patient wears a filtration mask for the duration of the procedure and for at least
30 minutes after.



UW HEALTH CLINICAL POLICY 5
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19

2. Filtration masks must be readily available on HEPA-filtered units which provide
care to vulnerable patients so that these patients can access them whenever
they leave the protective unit.
3. If the PCM 2000 filtration mask does not adequately fit the patient’s face because
the mask is too large, a small sized N-95 respirator (3M brand [CS # 4000142],
Kimberly Clark brand [CS #2200447]), or the adjustable AlphaProTech N-95
respirator [CS# 4005452] may be used.
4. Filtration masks used by the patient may be stored in a drawer in the bedside
stand when not in use, and must be replaced if soiled, torn or wet.
5. Respiratory Care staff who walk patients in order to assess pulmonary function
will refrain from having the patient leave their HEPA filtered unit, even when
wearing a filtration mask, because the increased respiratory exertion of the
patient may increase the probability and magnitude of inhaled air bypassing the
filter material.
ix. Most commercially available filtration masks do not adequately fit young pediatric patients. For
highly vulnerable pediatric patients who must leave the protective environment of the HEPA filtered
unit, viable options for respiratory protection may be limited to use of the AlphaProTech N-95
respirator [CS# 4005452], which can be adjusted by pinching the lower edge of the mask into a
point and then twisting to snug the mask under the patient’s chin. Follow instructions provided by
the manufacturer on the product box.
x. Occasionally, a patient requiring a positive pressure ventilation PE room may develop an infection
which requires isolation in a negative pressure ventilation airborne infection isolation (AII) room
(e.g., disseminated herpes zoster or chickenpox, pulmonary tuberculosis, cutaneous filamentous
fungal mycosis). In such a circumstance, the patient must be moved to an AII room in order to
prevent transmission to other patients or healthcare workers.
a. The patient must be moved into an AII room which is labeled as “Suitable for Airborne
Precautions,” and the appropriate isolation signs must be posted at the entry.
b. If the negative pressure ventilation room does not have supplemental HEPA filtration, a
portable HEPA unit should be placed in the room in order to increase protection for the
vulnerable, but infectious, patient.
D. Environmental Services
i. The housekeeper will coordinate room cleaning with the nurse in charge of the patient. If medically
possible, the patient should always leave the room, during all cleaning procedures and not return
for at least 30 minutes after completion of all procedures to allow time for any fungal spores
disrupted during cleaning to be removed by the ventilation system.
ii. Daily patient room cleaning will be performed in a deliberate manner, using procedures which
minimize generation of airborne dust.
a. All surface cleaning will be performed with hospital disinfecting detergent using a damp
cloth.
b. Floors will be damp mopped daily (dust mopping is not permissible).
c. No vacuuming (except with an approved HEPA filtered vacuum cleaner), floor buffing, or
other activities which disturb dust will be performed in rooms while being used for patients
requiring Protective Precautions.
d. The Housekeeper will open and damp wipe all exposed surfaces of both the top and the
bottom of the Nurse Server.
iii. In addition to routine daily cleaning, the following will be done weekly:
a. Toilet swab and caddy changed
b. Windows and blinds cleaned
c. Surfaces of room air vents cleaned
iv. In addition to routine daily cleaning, window valences which are present in Protective Environment
rooms will be removed and washed monthly.
E. Discontinuation of Precautions
i. The patient's physician is responsible for discontinuing Protective Precautions, based upon overall
assessment of the patient's immune status. With hematology and oncology patients, once the
patient's absolute granulocyte count exceeds 500 per mm3, precautions may no longer be
necessary. With transplant patients, precautions are desirable as long as the patient is receiving
doses of immunosuppressant drugs higher than maintenance levels.



UW HEALTH CLINICAL POLICY 6
Policy Title: Precautions for Immunocompromised Patients (Protective Precautions)
Policy Number: 4.1.19

ii. Patients with granulocytopenia (ANC less than 500 per mm3), especially severe granulocytopenia
(<100 per mm3), generally should not be discharged to an uncontrolled environment, such as home
or hotel accommodations which could contain large numbers of fungal spores unless they are
educated on means of reducing their infection risk.
V. FORMS

Protective Precautions Sign

VI. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Hospital Epidemiologist Infection Control Committee
Approval committees: Infection Control Committee, UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 16, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

Administrative Policy #13.16, Infection Control Precautions During Construction and Renovation.
Environmental Services Departmental Policy, “Neutropenic Rooms, Cleaning.”
Registered Dietitian Nutritionist (RDN) using Delegation Protocol #54, Clinical Nutrition Authority to Write
Diet & Nourishment Orders.
Health Facts For You #4577, Neutropenia (Adult) Information for You.
Health Facts For You #476, Food Safety for the Immunocompromised Patient.
Health Facts For You #494, Nutrition Guidelines after Solid Organ Transplant.
Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A
Global Perspective, 2009. Biol Blood Marrow Transplant 15:1143-1238.
Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care
Facilities, 2003. http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.
Academy of Nutrition and Dietetics. Adult Nutrition Care Manual:
https://uconnect.wisc.edu/depts/uwhc/clinical-nutrition-services/.
Leser, M., Ledesma, N., Bergerson, S., Trujillo, E. (2013). Oncology Nutrition for Clinical Practice. Oncology
Dietetics Group of the Academy of Nutrition and Dietetics.
Food Safety for People with Cancer. U.S. Department of Agriculture Food Safety and Inspection Service.
https://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/UCM312761.pdf.
Food Safety for Transplant Recipients. U.S. Department of Agriculture Food Safety and Inspection Service
https://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/UCM312793.pdf.

IX. REVIEW DETAILS
Version: Revision
Last Full Review: October 23, 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #13.06