Definitions for the strength of recommendation grading (IA-IC, II, and no recommendation) are provided at the end of the "Major Recommendations" field.
Protective Environment (see Table 4 in the original guideline document)
VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a Protective Environment as described in the "Guideline to Prevent Opportunistic Infections in HSCT Patients" ("Guidelines for preventing," 2000), the "Guideline for Environmental Infection Control in Health-Care Facilities" (Sehulster & Chinn, 2003), and the "Guidelines for Preventing Health-Care-Associated Pneumonia, 2003" (Tablan et al., 2004) to reduce exposure to environmental fungi (e.g., Aspergillus sp) (Humphreys, 2004; Thio et al., 2000). Category IB
VI.B. No recommendation for placing patients with other medical conditions that are associated with increased risk for environmental fungal infections (e.g., aspergillosis) in a Protective Environment (Sehulster & Chinn, 2003). Unresolved issue
VI.C. For patients who require a Protective Environment, implement the following (see Table 5 in the original guideline document) (Sehulster & Chinn, 2003; "Guidelines for preventing," 2000)
VI.C.1. Environmental controls
VI.C.1.a. Filtered incoming air using central or point-of-use high efficiency particulate (HEPA) filters capable of removing 99.97% of particles >0.3 micrometers in diameter (American Institute of Architects [AIA], 2006). Category IB
VI.C.1.b. Directed room airflow with the air supply on one side of the room that moves air across the patient bed and out through an exhaust on the opposite side of the room (AIA, 2006). Category IB
VI.C.1.c. Positive air pressure in room relative to the corridor (pressure differential of >12.5 Pa [0.01-in water gauge]) (AIA, 2006). Category IB
VI.C.1.c.i. Monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips) (Sehulster & Chinn, 2003; Rice, Streifel, & Vesley, 2001). Category IA
VI.C.1.d. Well-sealed rooms that prevent infiltration of outside air (AIA, 2006). Category IB
VI.C.1.e. At least 12 air changes per hour (AIA, 2006). Category IB
VI.C.2. Lower dust levels by using smooth, nonporous surfaces and finishes that can be scrubbed, rather than textured material (e.g., upholstery). Wet dust horizontal surfaces whenever dust is detected and routinely clean crevices and sprinkler heads where dust may accumulate (Noskin et al., 2000; Gerson et al., 1994). Category II
VI.C.3. Avoid carpeting in hallways and patient rooms in areas (Gerson et al., 1994). Category IB
VI.C.4. Prohibit dried and fresh flowers and potted plants (Taplin & Mertz, 1973; Walsh & Dixon, 1989; Lass-Florl et al., 2000). Category II
VI.D. Minimize the length of time that patients who require a Protective Environment are outside their rooms for diagnostic procedures and other activities (Sehulster & Chinn, 2003; Thio et al., 2000; Raad et al., 2002). Category IB
VI.E. During periods of construction, to prevent inhalation of respirable particles that could contain infectious spores, provide respiratory protection (e.g., N95 respirator) to patients who are medically fit to tolerate a respirator when they are required to leave the Protective Environment (Raad et al., 2002; Thio et al., 2000). Category II
VI.E.1. No recommendation for fit-testing of patients who are using respirators. Unresolved issue
VI.E.2. No recommendation for use of particulate respirators when leaving the Protective Environment in the absence of construction. Unresolved issue
VI.F. Use of Standard and Transmission-Based Precautions in a Protective Environment.
VI.F.1. Use Standard Precautions as recommended for all patient interactions. Category IA
VI.F.2. Implement Droplet and Contact Precautions as recommended for diseases listed in Appendix A in the original guideline document. Transmission-Based precautions for viral infections may need to be prolonged because of the patient's immunocompromised state and prolonged shedding of viruses (Weinstock, Gubareva, & Zuccotti, 2003; Elizaga et al., 2001; Hall, et al., 1986; Wood et al., 1988; Oishi et al., 1991). Category IB
VI.F.3. Barrier precautions, (e.g., masks, gowns, gloves) are not required for healthcare personnel in the absence of suspected or confirmed infection in the patient or if they are not indicated according to Standard Precautions ("Guidelines for preventing," 2000). Category II
VI.F.4. Implement Airborne Precautions for patients who require a Protective Environment room and who also have an airborne infectious disease (e.g., pulmonary or laryngeal tuberculosis, acute varicella-zoster). Category IA
VI.F.4.a. Ensure that the Protective Environment is designed to maintain positive pressure (AIA, 2006). Category IB
VI.F.4.b. Use an anteroom to further support the appropriate air-balance relative to the corridor and the Protective Environment; provide independent exhaust of contaminated air to the outside or place a HEPA filter in the exhaust duct if the return air must be recirculated (AIA, 2006; Murray et al., 1988). Category IB
VI.F.4.c. If an anteroom is not available, place the patient in an airborne infection isolation room (AIIR) and use portable, industrial-grade HEPA filters in the room to enhance filtration of spores (Rutala et al., 1995). Category II
Definitions:
Strength of the Recommendations
The recommendations are categorized on the basis of existing scientific data, theoretical rational, applicability, and when possible, economic impact, as follows:
Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required for implementation, as mandated by federal and/or state regulation or standard.
Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
No recommendation; unresolved issue. Practices for which insufficient evidence or consensus regarding efficacy exists.
