Infection control is a standard in audiology practice and new diseases serve as a reminder of its relevance in routine patient care. What makes COVID-19 unique is how quickly and easily it spreads among the general population. This has direct impact on infection control protocols and policies in ways previously not experienced. As audiology prepares for a new normal, here are a few key infection-control lessons learned in the past year.
The Centers for Disease Control and Prevention (CDC) is the nation’s primary health-protection agency at the forefront of the public health response to COVID-19, offering current, evidence-based mitigation guidance on the pandemic (CDC, 2021a). The agency has the authority to issue certain mandates and it remains important to stay current with recommendations.
The CDC is not a regulatory agency (CDC, 2016a), however. While most federal and state authorities mandate infection-control policy based on CDC recommendations, specific rules and regulations vary as a function of employment setting and the individual state in which the employment setting is located. Staying connected with the appropriate authority is critical.
Larger health-care facilities with dedicated infection-control departments employ designated personnel to implement and manage institutional infection-control policy and serve as an invaluable resource to audiologists employed in such settings. Otherwise, infection-control policy falls within the jurisdiction of state, county, and/or local public health departments that dictate stay-at-home orders, determine which businesses are considered essential, define business re-opening policies, and other safe business control policies (Rand Corporation, 2020).
Fluidity Requires Vigilance
CDC guidelines are based on existing scientific data and are evidence-based wherever possible (CDC, 2003). Given the fluid nature of COVID-19, recommendations remain in flux and are subject to change as more information is acquired.
Since launching a response to the COVID-19 pandemic in January 2020, the CDC (2021b) has published nearly 200 guidance documents and updates addressing some aspect of infection control for health-care professionals.
For example, early on in the pandemic, masks were not endorsed for use by the general healthy public (Buchwald, 2020). As more information was gained, the CDC called in July 2020 for all Americans to wear masks to control the spread of COVID-19 (CDC, 2020a). This is the nature of a new, emerging disease and underscores the importance of staying current with COVID-19 updates.
New Masking Dilemmas
The speed and ease with which the COVID-19 virus spreads requires providers, staff, and patients to wear masks during clinical interactions in the interim and, perhaps, for the longer haul (Bankaitis, 2020a). A wide variety of masks exist and it can be confusing to know what type of mask to wear during the provision of clinical services. Here is what we know at this time:
Three-ply surgical masks and N95 respirator masks are the current recommendations for health-care workers (Honein et al, 2020). N95 respirator masks are reserved for certain procedures, as this particular mask is tight fitting and designed to reduce exposure to smaller respiratory particles (CDC, 2020b). For example, aerosol-generating procedures (AGP) are associated with higher concentrations of infectious respiratory droplets than coughing and sneezing (Tran et al, 2012). For these type of procedures, N95 respirator masks should be worn (CDC, 2020c).
Currently, there is no definitive list of AGP procedures and appropriate discretion should be applied when the potential for a greater exposure to respiratory droplets exists. N95 respirator masks should be worn in the surgical suite and during vestibular procedures that can trigger emesis (American Academy of Audiology, 2020a, 2020b). This level of precaution should also be employed during procedures that potentially trigger a cough reflex (e.g., cerumen management) and perhaps during close proximity procedures including, but not limited to, otoscopy, preparing and taking earmold impressions, and probe-microphone verification procedures.
Critical N95 Respirator Shortages
The use of respirator masks manufactured in countries outside of the United States meeting certain standards is acceptable when N95 masks are not available (CDC, 2020d; Food and Drug Administration (FDA), 2020a). Heightened counterfeiting concerns about imported respirator products resulted in the National Institute for Occupational Safety and Health (NIOSH) and other federal agencies identifying specific products that meet standards similar to NIOSH-approved N95 masks manufactured in the United States.
For example, KN95 respirator masks made in China meeting GB2626-2006 or GB2626-2019 performance standards represent suitable substitutes (CDC, 2020d; FDA, 2020a; NIOSH, 2020). These masks are essentially equivalent to United States N95 respirator standards and are capable of capturing 95 percent of small airborne particles (0.3 micron) (3M, 2020).
Solid face masks obscuring the mouth introduce significant obstacles for the nearly 48 million Americans with hearing loss (Hearing Loss Association of America, 2021). Solid face masks hide facial expressions and access to lip movements. Because individuals with hearing loss often rely on these cues to understand speech, advocates support masks with some form of transparent panel or window. Recognizing that the use of solid face masks may not be possible or appropriate when interacting with individuals with hearing loss, the use of a transparent mask is recommended (CDC, 2021c).
Face shields are a form of transparent personal protective equipment (PPE) and were originally recognized as a viable substitute when traditional masks were not available (CDC, 2020d). Over the course of the pandemic, however, this recommendation changed.
The lack of substantiating evidence on the effectiveness of face shields in preventing the spread of COVID-19 led the CDC to qualify face shields as a form of eye protection only (CDC, 2020e). There are, however, a few exceptions. While face shields are not generally recognized as a substitute for masks, this form of PPE remains a viable alternative to masks for those interacting with patients with hearing loss (CDC, 2021c).
A Transparent Mask Is Not Enough
All masks, including masks incorporating clear components and face shields, degrade high-frequency speech sounds. Research shows attenuation occurs above 1 kHz, with most of the reduction occurring above 4 kHz (Corey et al, 2020). The degree of attenuation varies, depending on the type of mask, and ranges from 3 dB to as much as 12 dB (Goldin et al, 2020).
Basic communication strategies, such as speaking slowly and reducing ambient noise apply, although managing the patient’s overall communication needs requires additional support. For example, creating a separate “mask” program to compensate for social distancing and the low-pass filter qualities of face coverings should be explored.
Integrating necessary technology in the clinic, whether a remote-microphone accessory or traditional personal-listening device, will simultaneously make communication easier during appointments and effectively demonstrate the benefits of additional technology. This serves as an opportunity to elevate the patient experience, while facilitating the buy-in of pursuing necessary components to maximize communication.
Qualified Disinfectants for COVID-19
What to Use
Questions about disinfectants that kill germs and products that kill SARS-CoV-2, the virus that causes COVID-19, became a popular focus over the past year. At this time, there is no test protocol available to definitively evaluate which disinfectants kill SARS-CoV-2 (Bankaitis, 2020b).
The Environmental Protection Agency (EPA) (2020) published a list of disinfectants that qualify as effective against COVID-19. These disinfectants are referred to as List N and are available on the EPA website. The CDC (2020f) clarified that any EPA-registered disinfectants described as hospital-grade are appropriate for use against COVID-19 in a health-care setting.
While household products kill germs, hospital-grade disinfectants kill a broad spectrum of microorganisms commonly found in hospital and patient-care settings (Bankaitis, 2021). Qualified disinfectants are required to display the term “hospital-grade” and the designated EPA-registration number on product labeling. Be wary of products making disinfecting claims that do not display an EPA-registration number on the label.
How to Use Disinfectant
The specific microorganisms that an EPA-registered product kills and the amount of time it takes for those specific microorganisms to be killed is listed on the product label. The disinfectant must stay wet on a surface for the specified time indicated on the label to be effective.
Referred to as dwell time (or kill time), most EPA-registered, hospital-grade disinfectants require three-minute contact time before the surface should be wiped off. Dwell-time varies from product to product, ranging from 30 seconds to 10 minutes; read and follow product instructions for use.
Hand hygiene is one of the most effective means of minimizing the spread of disease. The use of alcohol-based hand sanitizers is the preferred method of hand-hygiene in patient-care settings (CDC, 2020g).
Supply disruptions in alcohol-based hand sanitizers resulted in the Food and Drug Administration (FDA) providing flexibility to manufacturers and other designated professionals, in an effort to increase the supply of sanitizers; this flexibility does not endorse home-made solutions (FDA, 2020b, 2020c). Appropriate alcohol-based hand sanitizers contain main ingredients of either 60 percent ethanol (ethyl alcohol) or 70 percent isopropyl alcohol (CDC, 2020h). During critical supply shortages, the use of soap and water meets infection-control standards and represents an acceptable form of hand hygiene (CDC, 2016b).
New guidelines also require clinical practices to provides patients with access to alcohol-based hand sanitizers. Specifically, these products must be available in reception/waiting areas and patient rooms (CDC 2020i).
Product Due Diligence
Maintaining an appropriate stock of infection-control products is a necessary element of a clinical practice (CDC, 2020j). The increased demand for infection-control products during the pandemic caused critical supply shortages, necessitating alternative sources for supply fulfillment.
Before purchasing a product, ask about the product and the return policy to make an informed purchasing decision. Some suppliers have implemented temporary or permanent no-return policies hidden in fine print on certain infection-control products. Ideally, align with a reputable supplier with established and fair return policies that is knowledgeable about the products and understands infection-control needs applicable to audiology and the hearing industry.
Communication Is Key
COVID-19 has introduced new infection-control precautions that underscore the need for clear and on-going communication with all parties in a clinical setting. Whether working with new CDC guidelines or the need for additional precautions due to an isolated COVID-19 outbreak, communication with clinical providers and staff is paramount in order for the clinical practice to effectively respond and adapt as needed.
Constant communication with patients is also important. Upcoming appointment-reminder phone calls position the practice to relay the infection-control precautions patients may expect, as well as to reiterate and remind patients what is expected of them at their appointment.
In summary, some key infection-control points learned from the pandemic:
- Stay current with evidence-based guidance issued by the CDC.
- Know how to contact and stay connected with public health authorities within your state.
- Infection-control guidelines will change as new information is gained.
- Integrate N95 or KN95 masks meeting outlined performance standards during procedures associated with inducing emesis or cough reflex.
- Transparent masks are acceptable forms of personal protective equipment when interacting with individuals with hearing loss, a general recommendation.
- Face shields are an acceptable alternative to solid face masks when interacting with individuals with hearing loss, although not a general recommendation. Understand the limitations of face shields in containing the spread of COVID-19.
- All masks, including transparent masks, are low-pass filters that attenuate high-frequency sounds. Create a new hearing aid program and/or integrate additional technology (remote mic) to compensate for known deficits.
- Use hospital-grade, EPA-registered disinfectants in the clinical setting.
- Use appropriate alcohol-based hand sanitizers as part of your hand-hygiene protocol.
- Make alcohol-based hand sanitizers accessible to patients in reception/waiting areas and patient rooms.
- Conduct necessary due diligence to make informed infection-control product-purchase decisions.
- Maintain constant communication about infection-control policies and procedures with colleagues, staff, and patients within your clinical practice.
Infection control is an important aspect of clinical practice. Commit to the necessary resources and training to ensure the implementation of the established standard of care.
The COVID-19 pandemic required the implementation of new protocols and exposed pre-pandemic gaps in the overall infection-control preparedness of the clinical practice. As vaccines roll out and “herd” immunity is approached, the focus on COVID-19 will eventually diminish and the tendency will be to put infection control on the back burner. If there is one thing to learn from the pandemic, it is that infection control should be an ongoing constant in audiology care—and not viewed as a burden or an inconvenient priority only when a new disease emerges.