Infection Control: Basic and Advanced
November/December 2013
Special Advertising Section
Infection Control: Basic and Advanced
An estimated 30,800 fewer invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in the United States in 2011 compared to 2005, according to a study by the Centers for Disease Control and Prevention. That’s the good news.
APIC—the Association for Professionals in Infection Control and Epidemiology—conducted a survey in January 2013 to assess activities that have been implemented in U.S. healthcare facilities to prevent and control Clostridium difficile (C. diff), a healthcare-associated infection (HAI) that kills 14,000 Americans each year. Seventy percent have adopted additional interventions in their healthcare facilities to address C. diff since March of 2010, but only 42% have seen a decline in their healthcare facility-associated C. diff rates during that time period; 43% have not seen a decline. That’s the bad news.
The basic approach to infection control, regardless of the infection, has been careful hand hygiene. But there are aspects of hand hygiene that are often overlooked. Martin O’Toole, compliance systems vice president at GOJO Industries, explains, “The first is that the hospital leadership team and leadership across all the individual functions should be clear and focused about objectives and approaches. The second is that all functions need to be prepared to work together on specific initiatives. I think from leadership down, they need to really have cross-functional focus and agreement to execute against specific initiatives in pursuit of a greater clinical improvement.”
Indeed, there should be a culture of honesty on every front of the patient care conversation. “I think cultures that are just glaringly honest about these things, while they may be uncomfortable, they certainly evolve outcomes in the right direction,” comments O’Toole. “The thing that we hope to see happen is that the people closest to the challenges should really be empowered.”
GoJo, a preeminent provider of hand hygiene technology, is constantly working to improve its products. “At GoJo, our focus and our expertise is really in the area of hand hygiene process effectiveness,” acknowledges O’Toole. “Washing hands has evolved tremendously in terms of being prioritized in healthcare settings. We’re hoping the industry now is able to start having conversations around hand hygiene as a process—and hand hygiene process management. It’s a function of having the right products, of course, and that begins with the right antibacterial effectiveness and formulas that are gentle on the skin so people don’t avoid them for any personal reasons. Then we focus on highly robust and effective delivery systems for the skin care products—touchless devices and devices inside the zone of patient’s care. Beyond that we’re making a lot of investments in hand hygiene compliance monitoring systems. And that is creating metrics that help a hospital understand if hand hygiene is being done properly.”
Although hand hygiene is recognized as the primary infection control approach, compliance monitoring is still not a universal. O’Toole laments, “I would say that the industry right now is less than 1% penetrated with a meaningful use of electronic hand hygiene compliance monitoring, whether it’s at the community level or at the person-specific level. So the next step for us is just to work with leaders in the healthcare industry to make these systems standard and part of the way the industry does business. We have several years of good and interesting work ahead of us, trying to help the industry learn how to use these tools and help get the tools institutionalized.”
And hand hygiene isn’t just for the staff. PDI, Orangeburg, New York, has a product to help bridge one of the gaps in infection prevention—how to make hand hygiene available for bed-bound patients. Specifically designed for patients, the Sani-Hands Bedside Pack provides an accessible and effective hand-hygiene product to reduce the risk of pathogenic microorganisms.
“It is widely accepted by infection experts that patients can help minimize their risk by cleaning their hands often, especially after interacting with healthcare workers or touching objects such as remote controls, bed pans, and even themselves,” said Dr. J. Hudson Garrett, Jr., director of clinical affairs at PDI. “Because of their limited mobility, bed-bound patients can go a long time without washing their hands. A lack of hand hygiene coupled with a fragile medical status puts them at higher risk for infection.”
Monitoring staff hand hygiene compliance and providing healthcare workers with feedback on their performance are key components of infection control programs, but finding an accurate way to measure hand hygiene compliance has been a challenge. A leader in this field is DebMed, the program of the Deb Group, Charlotte, North Carolina.
Heather McLarney, vice president of marketing at DebMed, knows there is more to infection control than soap. “I think there are several factors including, obviously, the cleanliness of the environment, doctors not overprescribing antibiotics, which leads to drug-resistant organisms. But we know from studies and research that hand hygiene is the number one way to prevent infections because that’s the way that germs are most frequently transmitted between patients, on the hands of healthcare workers.”
She continues, “We recently did a survey of just over 400 infection preventionists and patient safety personnel at hospitals. Overwhelmingly, hand hygiene was the most important focus. What we’re trying to do is offer a very comprehensive program that consists of multiple components. There’s a line of skin care products that were developed specifically for the healthcare environment and the electronic hand hygiene monitoring system that calculates compliance rates based on the World Health Organization’s ‘Five Moments’ for hand hygiene. We also believe in getting longer term and better sustained outcomes around hand hygiene by having the unit work as a team and not singling out individuals. Our system gives feedback at every level.”
She adds, “We also understand the importance of being able to comply with hand hygiene at the point of care. In addition to the wall-mounted dispensers, we also have a new point of care dispenser that’s set up to track hand hygiene, especially in critical care units where staff can’t always access a wall unit. We know that training is important, so we have a full online library of materials, educational materials, and reminder tools, to help reinforce what the data is showing. Ours is a more comprehensive solution with the products, the monitoring, the ability to track hand care, and educational and social behavior tools.”
If we stop at hand hygiene, we’ve stopped too soon. Infection control and patient safety is a multifaceted challenge. While hand hygiene is considered the most important concern, contaminated surfaces also cause HAIs. Now, antimicrobial copper is the only touch surface material registered by the U.S. Environmental Protection Agency (EPA) to continuously kill more than 99.9% of the bacteria that cause HAIs within two hours of contact. These bacteria can reside for weeks and even months on stainless steel and plastic surfaces, thus becoming a threat to patient safety in the hospital. Modern hospital design using antimicrobial copper is just one of many hygienic options in the battle against HAI, though. Antimicrobial copper needs to be seen as a supplement to, not a substitute for, standard infection control practices.
Sarah Simmons, epidemiologist, Xenex Disinfection Services, San Antonio, Texas, explains, “The three most important considerations to prevent infections are hand hygiene, staff education on best practices, and environmental cleanliness. For example, the basic tools used to clean hospital rooms haven’t evolved a great deal over decades, which is unfortunate because bacteria and viruses have evolved quite a bit. The environment plays a critical role in infection control in healthcare. Room cleaning has truly become a matter of life and death.”
Hospitals understand that the stakes are getting higher. They will no longer be reimbursed when they are responsible for readmissions due to infections—and the pathogens are getting more dangerous. Use of a room decontamination system, such as the Xenex C-band ultraviolet light (UV-C) system, is one approach. “Our team integrates with the hospital’s infection control team, from training all of their key staff on device usage, to designing protocols and taking microbiologic samples to prove the effectiveness of the Xenex system,” notes Simmons.
At Lumalier Corporation, maker of the TRU-D SmartUVC system, president Chuck Dunn addresses their best practices approach. “We would start with a consistent protocol that offers each patient equal access to a successful outcome. Certainly there are a number of factors that fall into play: proper manual disinfection; hand washing protocols implemented properly; isolation procedures abided by; and delivering a thorough level of disinfection, particularly when we’re discharging an isolation patient known to have been infected with a multiple drug resistant organism. We want to know that what is left behind from that patient is eliminated from the environment before a new patient is introduced to the room.”
Dunn goes on to say, “It takes cooperation of the people that come in contact with patients, diligent manual disinfection, with properly labeled chemicals. But what we know is that even with the best of environmental services or housekeeping teams, that it is virtually impossible to thoroughly disinfect every high-touch surface in the patient room. In other words, to get on hands and knees and to scrub the bottom of a bedside table, where fingers go first, is quite difficult. Think about the backside of a flat screen TV as a high touch area, or the top of an overhead light, or the back of a headboard; these are places where hands go.”
It is very difficult to thoroughly manually disinfect a patient’s room. Studies involving fluorescent marking systems that show what workers miss indicate that almost 50% of these high touch surfaces that transmit disease are not disinfected. So to deliver a consistent disinfection outcome, UV automation is a new step that hospitals can take to improve their HAI rate.
“There are areas that UVC can’t reach; under a mattress that’s on a bed, for example, or under a magazine that’s placed on a counter,” Dunn admits. “But what the peer review data has shown is that when TRU-D’s measured dose is reflected back from the walls in a room, we’re able to deliver enough energy to disinfect all the surfaces that are available to UV both directly and through reflection.”
However, UV has not been shown to be able to disinfect fabrics. “UV is very efficient in disinfecting hard surfaces,” Dunn assures. “So we would remove the bed sheets from the bed, we would open drawers so we can have UV inside, we would open up bedside tables, pull the tray out, and if an object is touching the wall, like a cabinet or TV set, those objects that are moveable are moved slightly away from the walls.”
Since UV is a disinfectant, not a dirt remover, the room has to be cleaned first. As Dunn remarks, “While UV is very good at disinfecting biofilm that is essentially invisible to the human eye, it’s not effective at penetrating a visible contamination of blood and other proteins that might be on a surface in the room. So wipe those surfaces clean and then disinfect with UV.”
Humans can be injured by UV rays so people are restricted from the area during operation. However, as Dunn says, “There are many levels of safety. We start with physical barriers that we place outside the door that caution people not to enter the room. We use an infrared door sensor that picks up motion if you were to reach for that door and try to violate the barriers. There’s an audible that comes from the device that tells the operator, ‘The device will activate in 15 seconds. Leave the room,’ and then again a warning, ‘Five seconds. Leave the room now.’ The handheld remote requires the user to answer safety questions, ‘Is the room vacated and secure? Have I been trained to operate the unit?’ A PIN code must be entered to activate the unit. So there are multiple levels of safety to prevent exposure to workers or patients.”
Preventing injury to hospital workers and preventing infections for patients; a win-win for everyone.