Update From The Clinical Team

Cross Infection Policy

By Starship Children’s Hospital CF Specialist Nurse Jan Tate

(This article was originally published in the Auckland Branch E-News, August 2015)

The Starship CF Clinical Guidelines have been in place on the Starship website for the past eight years and have been used by the rest of the CF teams throughout NZ to guide CF management. Recently a group of professionals (doctors, nurses, physiotherapists, dietitians, representatives from Cystic Fibrosis New Zealand) from different areas in NZ have met to update these CF guidelines to make them New Zealand CF Paediatric Guidelines.

The review is a lengthy process and involves many consultations and discussions as we have included many health professionals from around NZ. Each section has been allocated to different members of the group for them to involve other personnel for comment. I am part of the Infection Control section and have involved health professionals from around NZ, including charge nurses, clinic nurses, doctors and nurse specialists.

We are currently reviewing what other parts of the world are doing to keep the children with CF protected from each other and not to pass on their “bugs” to another person with CF.  The American Infection Prevention and Control Guidelines were published in August 2014 and the Starship CF team have reviewed these guidelines a few months ago.  To follow some of the suggestions we have made a few changes to the way we manage the Starship CF outpatient’s clinic:

  • A clinic room is allocated for each child and family to stay for the length of the appointment with the CF team coming in and out of the room (cleaning their hands each time!) for consultation. This does have impact on the number of children we can see each week as there are only a few clinic rooms allocated to our team – we are working with the Starship managers to rectify this and hopefully will have access to more rooms.   When the child and family leave the clinic room we clean all the surfaces and leave to air for 30mins before the next child comes in.
  • The change that most of the families will be aware of is that we ask all children over the age of 3yrs to wear a mask (green N95 mask) before they come into the outpatient’s area.  We appreciate that a lot of the families do not know the other children with CF and this is an easy way to protect their child from other CF children.   The hand-gel is available when you talk to the desk clerks to book in and we encourage you all to clean your hands when you first come to the clinic. The masks can be re-used so keep in the car or bag for the next clinic – keep in a plastic bag.
  • Another change is around lung function testing. Apart from the annual review testing these tests are now done on the portable machine in the clinic room. The respiratory physiologists wear yellow gowns and gloves to cover their clothing to help prevent contamination as this is a time that children potentially cough more than usual.
  • For younger children the toy box is for one child only then removed after the child leaves the room. The Play Room should have one child with CF at a time – check there are no other children with CF before your child goes there. Most of the families will bring activities for their child to do while waiting so they don’t go into the Play room.
  • Important facts:
    • People with CF should stay away from others with CF and if unavoidable be at least 2 metres apart (unless there are siblings with CF)
    • Hand hygiene is very important for everyone when coming into the clinic waiting area
    • Masks used while in the waiting area in clinic
    • Ask the CF team if you need further information around infection control measures in the outpatient’s department – remember these “rules” are there to help protect your child.

Travel tips and Spacer tips

By Auckland Hospital CF Specialist Nurse Cath Lamont

(This article was originally published in the Auckland Branch E-News, July 2015)

We are now well into winter but, the good news is spring will be upon us soon and back to that warmer weather. But, for now hopefully you are all warm and dry but, importantly keeping well and happy. For the adult service our patient numbers keep growing. From the 2013 Port CF data of the 444 registered CF cases in New Zealand that are recorded on the database (not all are) 53.8% are now adult. When chatting to some of the adults many are surprised to find out that our adult service in Auckland now has over 80 PWCF. A further 20 PWCF from the Auckland region are also under the transplant service. And, as New Zealand is an exciting tourist destination we see a few young travellers with CF also.

Meeting some of those on their O.E here it reinforces the need to be prepared before you leave home and know what costs you may incur if anything happens even the unexpected and not CF related concerns. So, if you are intending to go overseas for a holiday or extended time please talk to your CF team in advance. It is important PWCF discuss with the local consulate of the country you intend to visit to ask about costs of care in relation to your specific passport and or visa — especially if health insurance an issue. CFNZ can advise on travel insurance and the worldwide CF organisations are easily accessed on the internet.

Your CF team will help you with health related matters and identify CF teams overseas for you to access if required. The adult service provides a letter for immigration, just in case it is needed, to explain your need for at least 3 days’ supply of treatment, syringes, needles and equipment in case luggage goes missing. A copy of your last clinic letter is also given if you do need to consult a health professional when away. But, talk to your CF team and preferably well before you go.

There has been a request that this month we focus on the use of spacers for those who use inhalers / puffers. Spacer devices are given out at either clinic or the wards so, please feel free to ask for one if needed. Spacers are used with metered dose inhalers / puffers. Looking after your spacer is important to ensure you are getting the best from your inhaler. When getting a new spacer it is important to read the specific instructions for that device and ensure it is “primed” before use. What that means is the spacer’s inner wall needs to get a film on it so the medication particles within the inhaler go into your lungs and are not drawn by static electricity on to the inner wall of the spacer instead.

To prime your spacer the easiest way is to wash the spacer in warm soapy water and leave to drain and drip dry –don’t use a tea towel. The detergent then acts as the protective film of the inner spacer wall.  By washing your spacer weekly it will keep it clean and keep the inner film intact.

Always shake your inhaler between puffs. This is because the inhaler requires a propellant to attach to the drug in order for the medication to then be able to move out of the inhaler. So by shaking the inhaler every time this mixes the propellant with the inhaler medication so it does get into your lungs. If you don’t shake between puffs you are only getting the propellant and not the medication. So, firing two or more “shots” in quick succession from your inhaler into your spacer or mouth means you get the medication with the first “shot” and propellant with the other(s). Many people like to nebulize for example a “reliever” prior to having their hypertonic saline as an aid to preventing chest tightness. Others prefer to use their spacer and use the recommended number of puffs the CF team has advised prior to hypertonic saline. Many find the spacer quicker than the nebulizer and spacers are as effective as a nebulizer when used correctly.

So using a spacer —always sit up right. I know as tempting as it is when warm and snuggled up under the blankets to lie down to do this but you don’t get effective distribution of your medication in to your lungs. Shake the inhaler and place in it in the end opposite the mouth piece. Breathe out gently. Place the mouth piece between your teeth, and close lips around it with your tongue underneath while holding the spacer level , press down on the inhaler to deliver the first “puff” and either take 5 to 6 normal breathes in and out or 1 deep slow breathe in and hold for 10 seconds. Then breathe out through the nose or mouth. Wait a minute and repeat this process for the recommended number of “puffs”.  If breathless / wheezy some find it easier to do the gentle normal breathing used with a spacer than the one inspiratory breath as required with an inhaler.

There are many types of spacers and currently the Volumatic spacer is funded by Pharmac, but from 1 November the E chamber will be funded.  Some are large and others small. Mask attachments are available. It is best to talk to your team about the best one for you. But the bottom line is spacers are recommended to be use with puffers / inhalers as they are more effective in delivering medications into the lungs. Understandably spacers are big, bulky and don’t fit into your back pocket! Therefore it is important, if you do use an inhaler when out and about, without a spacer to ensure your inhaler technique is also effective. A good seal around the mouth is important. Again your CF team can assist with this to ensure you are getting the best from the treatments being provided.

So to recap:

  • Never share your spacer with other people.
  • Read the instructions specific to your inhaler —things can vary.
  • Always ensure any new spacer is “primed” before use.
  • Clean you spacer weekly in warm soapy water and drip dry. For some spacers (Volumatic) shake to hear the rattle of the valve is still moving freely. But refer to specific cleaning instructions
  • Sit up right
  • Always shake inhaler between puffs to mix medication and propellant
  • Place inhaler into the end opposite the mouth piece
  • Place the mouth piece into your mouth / mask over face to prevent air / medication leaks
  • Gently breath put and then either
      • 4-5 normal breathes in and out or
      • 1 long deep breathe in and hold for 10 seconds
  • Check you inhaler technique with and without a spacer with your CF team