What can healthcare facilities do to mitigate infestation?
The oncology nurse in the infusion center saw some crumbs on a patient’s shirt...but then they moved. She looked more closely and determined they were some type of insect, and it was later confirmed that the patient’s clothing was infested with bedbugs.
Many larger healthcare facilities have policies that address vector control and pest management, while smaller facilities may not have policies on eradicating mammals, birds, or insects or other arthropods that transmit disease pathogens. Bedbugs differ from other insects in that, according to the US Environmental Protection Agency (EPA), there have been no cases or studies that indicate bedbugs transmit diseases between humans. Nonetheless, bedbugs are difficult to eradicate, especially in healthcare facilities.
Some facilities require patients to eliminate bedbugs and obtain an extermination certificate to continue treatment. However, this may not be feasible for patients who reside in multiunit dwellings or have limited financial resources. While social services may be able to provide assistance with the patient’s home situation, the healthcare facility also needs to be considered. Is the infusion center now infested? Where and how should the patient receive future treatment? What can be done to minimize possible stigma from staff and other patients?
Bedbug prevention and control is institution specific because facilities vary in availability of private rooms and showers, treatment approaches, and use of canine scent detection (trained bedbug-detection dogs). The EPA recommends integrated pest management (IPM), which manages pests by the most economical means and with the least possible hazard to people, property, and the environment. IPM includes a number of nonchemical methods, such as heating bedding and clothing in a dryer at high temperatures for 30 minutes. Chemical methods of IPM include over 300 pesticides registered by the EPA for use against bedbugs. The EPA’s product search tool, available on the agency’s website, can be used to determine which product best meets a facility’s needs. This information may be especially helpful in smaller facilities that do not have an environmental services department. Bedbug control is challenging because bedbug populations in different areas of the United States have developed pesticide resistance, and multiple pesticides may be needed for effective eradication.
The first step in responding to suspicion of bedbugs is confirming that they are in fact present on a patient’s clothing and/or in the healthcare facility. It’s a myth that bedbugs cannot be seen with the naked eye. It’s also a myth that bedbugs thrive in unsanitary conditions; they are actually attracted to warmth, blood, and carbon dioxide.
ISOLATION IS KEY
In some facilities, patients are isolated, while in other facilities, isolation-type procedures are used. For example, one clinic has the patient go directly to a private room in the infusion center where the oncologist or the nurse practitioner examines the patient, blood is drawn, and the patient receives treatment. Staff entering the room are kept to a minimum, and they wear disposable jumpsuits, shoe covers, and hair bonnets while in the room. Personal protective equipment (PPE) is donned on top of the contact isolation jumpsuit, and adequate staffing is required to allow the nurse treating the patient to either remain in the room or minimize going into and out of it. Because PPE is the outermost garment worn, it is placed in a tightly tied bag and disposed of in a chemotherapy waste container in accordance with hazardous drug handling procedures. Jumpsuits, shoe covers, and hair bonnets are removed at the door upon leaving and placed into a securely sealed bag for disposal. The patient remains in the room and after treatment has completed and is escorted directly to the exit and waiting transportation. The patient’s room is then thoroughly cleaned. This approach limits bedbug exposure in other areas, such as waiting rooms and the laboratory.
If a contained private area is not available, a chair or a bed in an infusion room can be prepped, with white sheeting on the floor and chair/bed. To minimize bedbugs jumping from a patient’s clothing, the patient can wear a disposable jumpsuit, hair bonnet, and disposable shoe covers. Alternately, if the facility has an available shower, the patient can shower and change into hospital scrubs (or clean clothes provided by the facility) and disposable shoe covers and a disposable hair bonnet. The patient’s clothing is inspected and bagged. The goal is to contain the bedbugs and reduce the likelihood of spreading throughout the room. Preferably, the patient should be treated at the end of the day, when no other patients are present. The chair/bed, sheet on the floor, and surrounding area should be inspected for bedbugs and thoroughly cleaned after the patient is treated.
Other precautions to limit bedbug environmental exposure include removing or thoroughly cleaning cloth curtain dividers when present and removing other items containing fabric, such as upholstered chairs and extra blankets, prior to patient contact. Regardless of the method for mitigating a bedbug infestation, the patient’s skin needs to be examined for bites. Generally, bedbug bites occur in a defined area, usually in a straight row, and are itchy and red. Bedbug bites can disrupt sleep and increase the risk of infection.
Bedbug mitigation procedures may cause patients to feel stigmatized and isolated. Staff need to be sensitive to the situation and respectful, and also alert for reinfestation. Patients may or may not be able to mitigate bedbug infestation in their homes, especially in situations beyond a patient’s immediate control, such as living in an infested apartment complex or extended-stay hotel. Community outreach, including public health, may be needed. In addition, patients who have to discard items not amenable to heat treatment in a dryer, such as mattresses and furniture, may then be in need of these items and require referral to community resources.
A proactive approach with clearly defined procedures is important for mitigating bedbug infestation and for ensuring that patients are treated with sensitivity and respect.
Bed bugs: get them out and keep them out. Environmental Protection Agency website. epa.gov/bedbugs. Accessed February 28, 2018.