20Q: Infection Control Guidelines for SLPs

From the Desk of Ann Kummer

According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), handwashing is the single most important means of preventing the spread of infection in a healthcare setting.  As such, all healthcare providers are trained to wash their hands before and after each patient contact and to wear personal protective equipment during high-risk procedures. This advice was sufficient in most cases until COVID-19 raised its ugly head in early 2020. This novel coronavirus (SARS-CoV-2) has presented infection control challenges that have not been seen for more than a century! In response to the emerging pandemic, the CDC updated its Healthcare Infection Prevention and Control Recommendations in February 2020 to meet the specific challenges of the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#previous

So, how do the CDC guidelines apply to the practice of speech-language pathology and how can we provide safe services to our clients during this (and perhaps the next) pandemic? Well, we are fortunate to have Dr. AU Bankaitis Smith to answer these questions and more in this 20Q article.

A.U. Bankaitis Smith, PhD, is a clinical audiologist and Vice President at Oaktree Products near St. Louis, MO. While at the University of Cincinnati, her research and publications on the effects of HIV on the auditory system led to niche expertise in infection control. For over 25 years, Dr. Bankaitis has published, taught, and lectured extensively on infection control and its applications to the field of audiology and speech-language pathology. She is the author of several popular textbooks including Infection Control in the Audiology Clinic, Infection Control for Speech-Language Pathologists, and Cerumen Management. 

This is a very important and relevant article with valuable information for the challenges we all experience today.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Infection Control Guidelines for SLPs

AU Bankaitis

NOTE: Information specifically presented in this article on COVID-19 was accurate as of March 2021.

1. Infection control has received a lot of attention this past year. Within the context of speech-language pathology, what does infection control mean?

Infection control is the conscious management of the clinical environment for the specific purposes of minimizing the spread of disease, regardless of how remote the possibility may seem (Bankaitis et al., 2005). It involves critically assessing how clinical procedures are executed and making necessary modifications to meet infection control goals. For SLPs, it is an established standard of care and an important element of routine clinical practice.  

2. Since each clinical practice is unique, is infection control somewhat of an arbitrary process?

On the contrary, infection control is not arbitrary.  It is a process based on established guidelines. SLPs and SLTs have been expected to practice infection control according to standard precautions which are the minimum measures taken to minimize the spread of disease applicable to all patients in any type of setting (CDC, 2018).  Standard precautions have been around since 1996 and are intended to not only protect health care workers from blood and blood-borne pathogens but from contact with all bodily fluids (except sweat), regardless of whether blood is present (OSHA, 2014; Bankaitis, 2010). The guidelines are very clear in terms of indications for use of personal protective equipment (PPE) such as masks and gloves, when and what to disinfect versus sterilize, when and how to properly perform hand hygiene, and the like. So, while there may be some procedural differences in the execution of oral motor examinations, feeding/swallowing assessments, resonance/voice disorder evaluations by SLPs within and between clinics, the infection control precautions practitioners must follow are universal and certainly not random.   

3. How has COVID-19 uniquely impacted infection control in terms of direct patient care by SLPs?

The emergence of a new disease always serves as a reminder of the importance of infection control. What makes COVID-19 unique is how easily and quickly the SARS-CoV-2 virus spreads among people as evidenced by the present-day pandemic. This is precisely why the Centers for Disease Control and Prevention (CDC) has advised the public to practice social distancing by maintaining a distance of at least 6-feet (about two arm lengths) from one another and to cover their own nose and mouth (CDC, 2020a).  This translated to the need for all health care workers, including SLPs, SLTs, speech-language pathology students, staff, and patients to wear masks at all times in the clinical setting at least in the interim while re-emphasizing diligence in properly disinfecting objects or areas and performing hand hygiene often and when needed.

4. Before diving into some infection control specifics, who should SLPs listen to when it comes to COVID-19 and related infection control policies?

In the United States, the CDC is the primary health protection agency of the people responsible for the public health response to COVID-19, offering current, evidence-based mitigation guidance on the pandemic (CDC, 2021a). While not a regulatory agency, the CDC has certain authorities to implement mandates related to protecting America from health and safety threats, foreign and domestic, and increasing public health security (CDC 2016). From this perspective, staying current and understanding CDC recommendations related to COVID-19 is important.

Infection control policy mainly falls within the jurisdiction of state, county, and/or local public health departments who ultimately dictate stay-at-home orders, determine whether a business is essential, define business re-opening policies, and the like (Rand Corporation, 2020). While most follow recommendations set forth by the CDC, SLPs must adhere to infection control policies issued by state, county and/or local health authorities. Unless employed in a larger health care organization or facility with a designated professional responsible for managing institutional infection control policy, SLPs should know how to contact appropriate state and territorial health authorities within their own state as regulations will vary both as a function of employment setting and the individual state the employment setting is located. The CDC has established a state-by-state health directory that serves as a great resource and is available at: cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html.

5. COVID-19 recommendations changed throughout the course of the pandemic. Is this cause for concern?    

Not at all.  CDC guidelines are based on available scientific data and are evidence-based wherever possible (CDC, 2003). As a new disease, the COVID-19 situation remains fluid and corresponding recommendations are not only subject to change but expected to change. For example, early on in the pandemic, masks were not endorsed for use by the general healthy public (Buchwald, 2020). As more information accumulated, however, the CDC called for all Americans to wear masks to control the spread of COVID-19 in July 2020 (CDC, 2020a). This is the nature of a new, emerging disease.

Since January 2020, the agency has published nearly 200 documents advising health care professionals on an aspect of infection control (CDC, 2021b), including guidance on viable alternatives during critical supply shortages of masks, disinfectants, and hand sanitizers. The CDC remains an invaluable resource in providing the most up-to-date information on infection control principles relevant to speech-language pathologists and their clinical practices.

6. Speaking of critical infection control supplies, what are the current mask recommendations for SLPs?

The speed and ease with which the COVID-19 virus spreads requires providers, staff, and patients to wear masks during every interaction within the clinical setting (Bankaitis, 2020a). Current recommendations for health care workers, including SLPs, generally include 3-ply surgical masks and N95 respirator masks (Honein et al 2020). Which mask to wear depends on management and treatment procedures.

7. When is an N95 mask warranted?

N95 masks are reserved for certain procedures including aerosol-generating procedures (AGP) that produce minute particles small enough to penetrate surgical masks and are known to increase transmission risk of respiratory pathogens (CDC, 2020b, 2020c). N95 respirator masks fit tighter than surgical masks and are specifically designed to reduce exposure to these smaller particles known as aerosols.

Unfortunately, there is no consensus on which procedures are aerosol-generating. According to the World Health Organization (WHO), intubation, noninvasive positive pressure ventilation, tracheotomy, cardiopulmonary resuscitation (CPR), bronchoscopy, and sputum induction definitely meet the definition of an AGP (Tran et al., 2012). The CDC also considers most of these medical procedures as AGP although the agency clearly states there is neither expert consensus nor sufficient data to create a comprehensive list of AGPs (CDC, 2021c).  When COVID-19 emerged, professional academies and organizations responded with their own lists of profession-specific AGPs although the actual aerosol generation of most newly defined procedures was not formally quantified (Klompas, Baker & Rhee, 2021).

The absence of a definitive list of AGPs may cause frustration, anxiety, and perhaps confusion. It makes sense for SLPs to wear N95 masks during any procedure that either promotes coughing, potentially triggers a cough reflex or emesis, and/or is associated with a greater potential for respiratory droplet exposure. According to the American Speech-Language-Hearing Association (ASHA, 2020), procedures include (but are not limited to):  swallowing assessments (with or without instrumentation), dysphagia care/treatment, instrumental assessment of voice via endoscopy (with or without stroboscopy), laryngectomy assessment and management procedures, assessment and treatment of tracheostomies (with or without mechanical ventilation), and non-invasive ventilation such as high-flow nasal oxygen and nasal cannulae. Appropriate discretion should be applied when performing any close proximity procedure due to the potential for greater exposure to respiratory droplets.

8. If a speech-language pathologist cannot source an N95 mask, is there a viable alternative?

Increased demand for infection control supplies has resulted in critical supply shortages, creating a lot of anxiety because the product SLPs need may not be readily available.  The CDC and the Food and Drug Administration (FDA) issued interim flexibilities, recognizing the use of respirator masks manufactured outside of the United States as acceptable alternatives as long as products meet specific standards (CDC, 2020d, FDA, 2020a). Specifically, KN95 respirator masks made in China meeting GB2626-2006 or GB2626-2019 performance standards represent suitable substitutes (NIOSH, 2020) as these masks are essentially equivalent to United States N95 respirator standards and capable of capturing 95% of small airborne particles (0.3 micron) (3M, 2021).  Look for or confirm with your supply source that the specific performance standard appears on product packaging.

9. Beyond respirator masks for non-AGPs, is a 3-ply cloth mask the only other option for a speech-language pathologist?

Masks are instrumental in containing the spread of COVID-19. Unfortunately, solid masks obscure the mouth, eliminate access to lip movements, and obscure other facial cues, posing significant challenges to individuals with speech disorders and hearing loss, and to the providers responsible for the provision of services. This is precisely why advocates pushed for the CDC to support and issue guidance on the use of masks with transparent panels.  Recognizing that the use of solid face masks may not be possible or appropriate when interacting with individuals with hearing and speech disorders, using a transparent mask is recommended (CDC 2021d). Having said that, incorporating a mask with transparent panels isn’t the end-all solution.

10. How so?

Research shows that all masks, including masks incorporating clear components, serve as low pass filters and degrade speech, with most of the attenuation occurring in higher frequencies above 1 KHz that are so critical for speech understanding (Corey et al., 2020). Depending on the type of mask used, the degree of attenuation can be as high as 12dB (Goldin et al., 2020). Certainly, integrating basic communication strategies like minimizing background noise and speaking slowly are important but integrating assistive technology like remote microphones or personal listening systems is an important consideration to reduce the potential burden face coverings, including face shields, have on effective communication.

11. I am glad you mentioned face shields.  Can SLPs use face shields in place of masks?     

It depends. Early during the pandemic, face shields were originally deemed an appropriate alternative to traditional masks throughout spring 2020 (CDC, 2020e).  By late summer 2020, updated guidance recommendations qualified face shields as a form of eye protection only (CDC, 2020f).  So, the answer to your question is no however there are exceptions. Providers who interact with individuals with hearing loss may find that a face shield helps facilitate more effective communication and wearing a hooded face shield or one that extends below the chin and wraps around both sides of the face may be considered (CDC, 2021d). In this situation, the answer to the question is yes.    

Keep in mind, there will be instances where it may not be practical for your patients to wear masks.  Children under the age of 2, individuals with a disability who cannot wear a mask for reasons related to the disability, or individuals for whom wearing a mask creates a workplace health, safety or job duty issue are exempt from wearing masks and may consider alternatives, including face shields (CDC, 2021d).

12. During the pandemic, the CDC has emphasized disinfecting. Is there anything specific SLPs need to keep in mind about disinfecting that may be different from general public recommendations?   

Disinfectants are chemicals designed to kill microorganisms residing on non-living surfaces. These products must be registered with the Environmental Protection Agency (EPA) and are required to display the designated EPA-Registration Number on the product label.  Early on during the pandemic, the EPA released a list of disinfectants deemed qualified effective against COVID-19 referred to as List N.  In the absence of a current test protocol to definitely evaluate the efficacy of disinfectants to specifically kill the SARS-CoV-2 virus, the CDC clarified that any hospital-grade, EPA-registered disinfectant is effective against COVID-19 and should be used in patient care-settings (Bankaitis, 2020b; CDC, 2020g).

While household products kill germs, EPA-registered, hospital-grade disinfectants kill a broad spectrum of microorganisms commonly found in hospitals and other facilities providing patient care services (Bankaitis, 2021). Qualified disinfectants are required to display the term “hospital-grade” and designated EPA-registration number on product labeling.  Be wary of products making disinfecting claims that do display an EPA registration number on the label.

13. Does the active ingredient of a disinfectant matter?  

The main ingredient in EPA-registered, hospital-grade disinfectants commonly used by speech-language pathologists range from some form of alcohol, quaternary ammonium compound (“quat”), hydrogen peroxide, citric acid, or a combination formula of alcohol/hydrogen peroxide or quat/alcohol mix. Alcohol chemically denatures acrylic, rubber, plastic, and silicone and many manufacturers recommend using alcohol-free products to clean and disinfect components composed of those materials.  So, for larger touch and splash surfaces (e.g. countertops, table surfaces, door handles, etc), any available EPA-registered, hospital-grade disinfectant is acceptable.  For equipment and related components comprised of acrylic, rubber, plastic, or silicone, an alcohol-free, EPA-registered, hospital-grade disinfectant should be considered.

14. Anything else to consider when making decisions about what disinfectant to use in the clinical environment?

Pay attention to dwell time.  The EPA registers not only the specific microorganisms a product kills but the amount of time it takes for the product to kill the specific organism.  Dwell time refers to the amount of time a product must stay wet on a surface in order for the product to be effective in killing microorganisms.  On average, dwell time ranges from 1 minute to 3 minutes although some products may require as much as 10 minutes to kill germs.  Be sure to read instructions for use and integrate necessary dwell times in infection control protocols.

15. What about hand hygiene?  What solutions are acceptable for SLPs to implement in clinical settings?

Hand hygiene is one of the most effective means of minimizing the spread of disease.  Alcohol-based hand sanitizers remain the preferred method of hand hygiene in patient-care settings (CDC, 2020h) although supply disruptions in these products resulted in the FDA to issue some interim flexibility, none of which endorse homemade solutions (FDA 2020b, 2020c). Acceptable alcohol-based hand sanitizers contain the main ingredients of either 60% ethanol (ethyl alcohol) or 70% isopropyl alcohol (CDC, 2020i). Read labels, make sure appropriate product is used, and make sure patients also have access to hand sanitizer.

16. Are we required to provide patients with access to hand sanitizer?

Yes.  New guidelines require clinical practices to provides patients with access to alcohol-based hand sanitizer.  Specifically, these products must be made available in reception/waiting areas and patient rooms (CDC 2020i). 

17. If supply disruptions reemerge and acceptable alcohol-based hand sanitizers become difficult to source, are there other options for performing hand hygiene?

The use of liquid soap, plain or anti-microbial, and water meets infection control standards and represents an acceptable form of hand hygiene (CDC, 2016).  

18. What about glove use? Any changes as a result of the pandemic?  

Unless state or local authorities mandate glove use, indications for glove use remain consistent with pre-pandemic standard precautions, including but not limited to situations involving possible contact with blood or bodily fluids, mucous membranes, non-intact skin, or during procedures likely to generate splashes or sprays of blood or other bodily fluids. At no time has the CDC recommended or endorsed double-gloving when providing care to suspected or confirmed COVID-19 patients (CDC, 2020j). During critical supply shortages of medical-grade gloves, food-grade and industrial-grade gloves represent viable alternatives (CDC, 2020k).

19. Based on the challenges experienced in the past year due to COVID-19, what advice would you offer to clinical practices about infection control?

Make sure your clinical practice has a written infection control plan that specifically outlines how speech-language pathology procedures are to be executed in a manner consistent with minimizing the spread of disease.  The Occupational Safety and Health Administration (OSHA) requires profession-specific procedures to be outlined in writing and for providers, staff, and students engaged in any degree of clinical care to be trained on how to execute those procedures (Bankaitis et al., 2005). While COVID-19 required clinics to integrate new policies like temperature checks, masks, and proper spacing in reception areas, clinics without a previously established written infection control plan had to unnecessarily scramble to get practices up to speed with basic protocol.

Also, increased demand for infection control products during the pandemic resulted in major shortages of critical supplies.  It is important for clinical practices to maintain appropriate stock of necessary infection control supplies including masks, gloves, hospital-grade disinfectants, and alcohol-based hand sanitizers.  In the event of a supply shortage, work with a reputable supplier that can not only answer questions or concerns but supply your clinic with acceptable product alternatives consistent with current CDC recommendations.

20. Any final thoughts?

On-going, clear communication is key with all parties. Communication with clinical providers and staff is critical to ensure the practice is implementing necessary infection control procedures and adapting when and where needed. Communication with patients is also important to ensure patients not only know what infection control protocols to expect but to reinforce what is expected of them when arriving at your clinical practice.

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