Hygiene management for long-term ventilated persons in the home health care setting: a scoping review

Background Evidence and recommendations for hygiene management in home mechanical ventilation (HMV) are rare. In Germany, few regionally limited studies show poor hygiene management or a lack of its implementation. This scoping review of international literature identified the evidence in hygiene management for ventilated patients in the home care setting which has to be implemented for infection prevention and control. Methods A review of international literature was conducted in CINAHL, PubMed and Web of Science. The search focused on four key domains: HMV, hygiene management, home care setting, and methicillin-resistant Staphylococcus aureus (MRSA). Data of included studies were extracted using a data charting sheet. Extracted data were assigned to the categories (1) study description, (2) setting and participants, and (3) hygiene management. Results From 1,718 reviewed articles, n = 8 studies met inclusion criteria. All included studies had a quantitative study design. The approaches were heterogeneous due to different settings, study populations and types of ventilation performed. Regarding aspects of hygiene management, most evidence was found for infectious critical activities (n = 5), quality management for hygiene (n = 4), and training and education (n = 4). This review identified research gaps concerning kitchen hygiene, relatives and visitors of HMV patients, and waste management (n = 0). Discussion Overall evidence was rather scarce. Consequently, this review could not answer all underlying research questions. No evidence was found for measures in hygiene management relating to ventilated patients’ relatives. Evidence for kitchen hygiene, waste management and interaction with relatives is available for inpatient care settings. However, this may not be transferable to outpatient care. Binding legal requirements and audits may help regulate the implementation of HMV hygiene measures. Conclusion Infection control programmes included qualified personnel, hygiene plans, and standards for MRSA and multidrug-resistant organisms (MDRO). The appropriateness of hygiene management measures for outpatient care is the basis for their application in practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07643-w.

-2 weeks after starting antibiotics: sputum collection + culture Setting, Participants Sample size 7 patients (Background: between 1998(Background: between -2002 patients within the program of long-term MV had an infection-related ARF + were therefore eligible for this study; 1 was excluded because he refused treatment at home) Sex 3 women, 5 men Age of participation 61 years (mean) Kind of disease -Idiopathic severe kyphoscoliosis (Cobb angle >70°) -Developed infection-related ARF during a 4 year period Kind of artificial ventilation (incl. duration) All patients had mechanical ventilation for 31 months (mean) -7/8 NPPV + commercial mask -3/8 volume-assist ventilator -4/8 pressure assist ventilator + circuit that includes an expiratory valve (backup rate of mean 16 breaths/min) -1/8 invasively ventilated Not specified Key Findings -Hygiene management Quality management for hygiene, e.g.

Infection control practitioner, duration h for infection prevention and control
Not specified

… -Cleaning and disinfection aspects
Not specified

… -Handling of medical devices
Ventilator tubing was changed weekly for all patients … -Waste management Not specified ... -Infectious critical activities (incl. MRSA, Screening, Surveillance) Tracheostomy suctioning (clean technique)

… -Caring for persons (prevention and infection control)
Not specified

… -Handling of medication
Not specified … -Laundry hygiene Not specified … -Kitchen hygiene Not specified

Conclusion/Limitations Conclusions:
-VAP-rates + mortality rates are much lower in HMV vs. ICU population -VAP was likely to occur during the first 100 days of HMV (caregiver learning curve for providing ventilator care?) à reducing risk of VAP should be focused on patients who require ventilation for longer daily durations/ who are new to receiving HMV -No association of VAP with age, sex, underlying disease, reason for/ type of ventilation, antacid therapy, steroid use

Limitations:
-Cohort from a homogeneous population from a university-affiliated single home care service -Very young patients (less comorbidities than patients in ICU) -Only 33/ 79 (42%) VAP-episodes had culture results available

Method:
Examination of un-cuffed + cuffed tubes: -Un-cuffed tubes were changed + collected after minimum of 1 day of use -Cuffed tubes were changed + collected after minimum of 3 days of use

Kind of artificial ventilation (incl. duration)
Not specified

Family participation
Not specified

Cooperation (e. g. Lung specialist, Weaning centre)
Not specified Key Findings -Hygiene management Quality management for hygiene, e. g.

Infection control practitioner, duration h for infection prevention and control
Not specified

… -Cleaning and disinfection aspects
Cleaning Methods A microbial reduction, but poor reliability + reproducibility Not specified

… -Caring for persons (prevention and infection control)
Not specified

… -Handling of medication
Not specified

… -Laundry hygiene
Not specified

… -Kitchen hygiene
Not specified Conclusion/Limitations Conclusion: -No standardized cleaning procedures or management policies on use + reuse of tracheostomy tubes exist -Inner lumen of tracheostomy tubes is colonised by Staph. aureus, Staph. epidermis, Pseudomonas aeruginosa + Candida spp. most frequently -Recommendation: manual cleaning + chemical or thermal disinfection (dishwasher seems to be optimal method for regular cleansing + disinfecting tracheostomy tubes, if tubes are placed in secure fixation) -No signs of material alteration -Cuff functionality after the single reprocessing regiments remained intact in all but one cuffed tubes

Limitations:
-No investigation on microbial reduction which can be achieved by using a dishwasher alone -Only one single reprocessing step Notes for review: -Some aspects remain unclear (e.g. setting + country) -No limitations discussed Abbreviations: Not specified Concept of home-based setting/Licensed beds 10 nursing services in Rhine-Main area -9 "normal" nursing service -1 IC service

Professions/Qualifications involved/Duration professional employment
Ambulatory nursing services (normal + intensive)

Cooperation (e.g. Lung specialist, Weaning centre)
Not specified Key Findings -Hygiene management Quality management for hygiene, e. g.

Infection control practitioner, duration h for infection prevention and control
Not specified

… -Cleaning and disinfection aspects
In case of MRSA-detection, requesting a free sanitation kit was possible -Represented 41% of cohort -Over 90% external feeding ->30% had prior CDI-infection -53% PPI within the last 60 days

Family participation
Not specified Concept of home-based setting/Licensed beds 80 bed ventilator unit (in a 320-bed medical centre-affiliated LTCF)

Not specified
Cooperation (e. g. Lung specialist, Weaning centre) Not specified Key Findings -Hygiene management Quality management for hygiene, e. g.

Infection control practitioner, duration h for infection prevention and control
Infection control isolation policies (not further described)

… -Cleaning and disinfection aspects
Not specified

… -Caring for persons (prevention and infection control)
Not specified

… -Handling of medication
Not specified … -Laundry hygiene Not specified … -Kitchen hygiene Not specified Microbiological findings

Colonisation rates
-19% asymptomatic CDI-colonisation -19% CRE-colonisation Colonisation with CRE was associated with -19% history of CDI -infection (median 240 days since prior episode) -45% history of CDI -infection + asymptomatic colonisation with CDI -26% history of CDI -infection + colonisation of CRE -17% history of CDI -infection + colonisation with CRE + CDI Factors associated with CDI, CRE + concurrent CDI/ CRE -Tracheostomy collar -Location on respiratory floor -Colonisation with CRE -Colonisation with CRE was associated with: MV, enteral feeds, PPI in the last 60 days, location on respiratory floors, hyperlipidaemia, COPD, colonisation with CDI -for patients with prior CDI-infection: lower number of days since prior CDI-infection was significantly associated with an increased risk of CDI-colonisation + concurrent CDI/CRE-colonisation Conclusion/Limitations Conclusion: -strong association of colonisation with CDI/ CRE with disruption of normal flora (by MV/ enteral feeds) + prior CDI-infection

Limitations:
-retrospective analysis -multiple persons collected swabs + tabulated data -study was conducted in a single LTCF à results may not be generalizable to others with different characteristics -no data on antibiotic use available -All respirators volumetric -All patients ventilated at home with EVA for >12 months (mean time ventilated: 7.7 years) -All patients: ventilation + tubing with valve between 6-12 months -Group (T): 16/39 tracheostomy (circuits connected to humidifier + water trap) -Group (N): 23/39 noninvasively with nasal mask (13 silicone custom made mask; 10 commercial mask) -24/39 continuously ventilated (16 by tracheostomy; 8 by mouthpiece during the day/ nasal mask at night)

Family participation
Not specified Concept of home-based setting/Licensed beds -11/39 lived in institution -28/39 lived at home

Not specified
Cooperation (e. g. Lung specialist, Weaning centre) Not specified Key Findings -Hygiene management Microbiological findings Experiment 1: -Dirtiness was worse in (T) than in (N) -EVA in (T) were more contamined than in (N) -Contamination rates (N): 22% (no presence of PPO) -Contamination rate (T): 81% (19% were PPO) -Significant correlation was found between the dirtiness of the complete tube + EVA -69% of EVA + 56% of circuits were visually dirty -Circuits from patients living at home were visually cleaner than those from patients living in institutions -46% of the valves were contamined by microorganisms + 22% by fungi (seldom contamined by potentially pathogenic organisms) Experiment 2: -Remained dirty after dishwasher cleaning (HAC bath): 14% (64%) of dirty EVA à EVA cleanliness was significantly better after dishwasher cleaning with similar bacteriological decontamination -choice of the dishwasher did not play any role in the quality of cleaning because all recent machines are equivalent Conclusion/Limitations Conclusion: -Circuits from patients living at home were visually cleaner than those from patients living in institutions à nurses in institutions need additional training sessions to improve their expertise in respirator equipment maintenance -Maintenance advice for HVC is not well adhered to à patients + their families need trainings in hospital to demonstrate the utility of simple basic hygiene -Dishwasher cleaning is more efficient than chemical HAC-bath à low-level disinfection is efficient + possible for families, patients + institutions Notes for Review: -There are no limitations discussed!! -Method of visual assessment remains unclear (10 point scale + 4 criteria of severity) + why < 2/10 decelerated as "dirty"?

Abbreviations:
EVA = expiratory valves HAC = Hospital Antiseptic Concentrate HVC = home ventilation circuits ICU = intensive care unit MV = mechanical ventilation