Products, practices & partnerships key to prevention

Healthcare-associated infections (HAIs) are a troubling reality that healthcare providers have wrestled with for ages. Sometimes they win, sometimes they don’t.

According to the Centers for Disease Control and Prevention (CDC), an estimated 722,000 HAIs occur each year in U.S. hospitals and about 75,000 patients with these infections die during their hospital stays.

What’s important is that infection prevention (IP) professionals, clinicians and other healthcare workers continue to huddle and find ways to prevent and control them.

Infection rate update – confronting CAUTI (still)

Some of the most common types of HAIs that the CDC tracks annually include central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), select surgical site infections (SSI), hospital-onset Clostridium difficile (C. difficile) infections, and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections).

According to the CDC’s latest Healthcare-associated Infections Progress Report, healthcare facilities are making notable progress in most areas. But it also revealed an interesting development in the CAUTI category: Incidence remains unchanged in the acute care setting but is improving in long-term acute care and inpatient rehabilitation facilities.¹ Why?

To help patients reduce their risk of developing CAUTI, Avadim Technologies Inc. offers a patented, non-toxic, topical product called Theraworx which has helped several hospitals reduce its CAUTI rates from 85 percent to 100 percent,³ according to CEO Steve Woody. “When used in our patent-pending, protocol for standardized Foley insertion and perineal care, not only does it offer broad spectrum skin hygiene for creation of a true ‘zone of inhibition’ in the perineum, but also helps preserve the normal antimicrobial acidic mantle and integrity of the stratum corneum, the outer layer of the epidermis,” said Woody. “Hospitals using Theraworx have seen significantly reduced CAUTI rates from customers even in the most challenging environments, like neuro ICU.”

Ousting other infections

When it comes to catheter-associated bloodstream infections, J. Hudson Garrett Jr., PhD, MSN, MPH, FNP-BC, CSRN, VA-BC, Vice President, Clinical Affairs, PDI, says they often occur because the patient’s own endogenous flora wasn’t properly removed during the skin antisepsis process prior to device insertion.

“One of the other significant routes for contamination is that of the needleless access sites which includes needleless connectors, medication ports, and injection ports,” Garrett said. “Clinicians rarely dedicate the necessary time and attention to properly disinfecting these medical devices prior to each access with a syringe. This can lead to contamination and result in infection.”

PDI’s Prevantics Device Swab, which comes in strip format and hangs easily from IV poles, is a chlorhexidine gluconate/isopropyl alcohol medical device specifically available for the disinfection of needleless access sites prior to use. Studies show the product is more effective than isopropyl alcohol prep pads and Garrett says scrub and dry time is an efficient five seconds each. Clinicians favor the product because it makes it easier to comply with evidence-based recommendations.³

Reducing bacteria in the nose preoperatively is also a proven strategy for reducing SSIs, says Caroline Johnson, RN, BSN, Technical Services Specialist, 3M, maker of 3M Skin and Nasal Antiseptic.

“The nose works continuously to clear microorganisms and debris making it difficult for antimicrobials to reach and kill bacteria,” said Johnson. “3M Skin and Nasal Antiseptic is an innovative, patented formula that contains a polymer to help increase adhesion of the prep to nasal tissue.”

The product can also serve as a viable alternative to using topical antibiotics – a move that helps to support antiobiotic stewardship. The increasing prevalence of antibiotic-resistant bacteria causes two million illnesses and nearly 23,000 deaths annually, according to the CDC, but it doesn’t have to.

For example, researchers at the Johns Hopkins Bloomberg School of Public Health simulated how the superbug carbapenem-resistant Enterobacteriaceae (CRE) might spread across healthcare facilities over a five-year period while employing various coordinated efforts to thwart it. Taking specific IP control measures recommended by the CDC prevented more than 75 percent of the often-severe infections that would have otherwise occurred.⁴

Designed to be part of a pre-operative bundle to help reduce the risk of post-operative SSIs, Clorox Healthcare also makes ready-to-use swabs pre-saturated with a 10 percent povidone iodine formula that can be applied to patients’ nostrils prior to surgery.

Rosie D. Lyles, MD, MHA, MSc, Head of Clinical Affairs, Clorox Healthcare, says the swabs reduce 99.4 percent of Staphylococcus aureus in one hour, maintains persistence through 12 hours and are non-irritating and well-tolerated by patients.

“There is growing evidence of S. aureus becoming resistant to mupirocin, the most common antibiotic used for nasal decolonization,” said Lyles. “The consequent potential for nasal decolonization failure can increase the risk of infection and has made the evaluation of non-antibiotic methods a priority. There are a number of studies that show that preoperative bundles that include povidone iodine for nasal decolonization, chlorhexidine bathing as well as other elements are clinically effective, cost effective and can offer a good return on investment.”³

Providing patients with good oral care is also an important step in the fight against HAI, particularly for preventing hospital-acquired pneumonia linked to dental plaque, bacterial colonization and aspiration, says Dustin Lake, Product Manager – Oral Care, Sage Products. He says Sage oral care systems are a proven way to keep infection at bay and have been featured in numerous peer-reviewed publications, poster and podium outcomes and case studies, including one published in 2013 in The Journal of Nursing Scholarship that focused on infection rates at a California hospital.³

Healing hands are clean hands

“They discovered 115 incidences of NV-HAP in their facility over 12 months; the cost and mortality was equal to that of VAP patients,” said Lake. “After implementing a comprehensive oral care program for patients who were not on mechanical ventilation, the incidence was reduced by over 37 percent in 12 months. The investigators estimated eight lives saved and a net cost avoidance of over $1.6 million.”

Products for preventing infection work best when the hands administering them are germ-free. Unfortunately, hand hygiene (HH) compliance remains quite poor in some facilities. A recent APIC report pointed to a study published in the April issue of the American Journal of Infection Control which said “despite having policies in place to prevent infections, staffs at outpatient care facilities fail to follow recommendations for hand hygiene 37 percent of the time and for safe injection practices 33 percent of the time.” Furthermore, the authors said these clinicians had access to hand hygiene supplies 100 percent of the time.

How do we increase compliance? Studies indicate that direct observation works at first but the effect is only temporary. There is evidence that greater and longer-lasting compliance can be achieved using HH surveillance systems. According to HPN’sannual Infection Prevention Salary Survey (May 2016), which includes questions about clinical practice and product use, more than 57 percent of respondents said their facility has adopted the technology. However, a considerable number have not although some said they are considering it.⁵

The GOJO SMARTLINK Hand Hygiene Solution is an electronic compliance monitoring platform with clinician-based, on-site support, advanced hand hygiene formulations and dispensing systems, and technology that accommodates monitoring at a group, individual, role, and area level. Also, the GOJO SMARTLINK Observation System, a mobile application with accompanying web-based software facilitates the electronic auditing, collection, and collation of hand hygiene and personal protective equipment metrics.”Over the past three years we have seen the emergence of hand hygiene compliance technology,” said John Lerner, GOJOSMARTLINK Solutions Development Vice President, GOJO. “During this time, hand hygiene providers have been sharing information and healthcare systems have been doing their due diligence – testing and validating the systems and solutions – in an effort to determine what system is right for them. We are at a time now where electronic hand hygiene monitoring is beginning to proliferate in the acute-care setting.”

Defending the patient environment

Outside of good clinical practice, everything that exists between the walls of a facility must be safe and germ-free too but with pathogens lurking on every surface, it can be a real challenge to tackle. Plus, having so many cleaning methods and decontamination products available makes identifying what works best sometimes difficult.

The Environmental Protection Agency (EPA) issued draft guidance in early April to clarify the claims that manufacturers can state about their products’ ability to kill pathogens.

“The EPA document should help – I remember during the Ebola preparations, everyone insisted on bleach because that’s what was on TV yet there were other effective disinfectants,” said Smith. “It is confusing choosing the right disinfectants because in addition to the ‘kill’ claim (i.e., what organisms it can kill), you have to consider the contact time needed to reach that kill time, its compatibility with your equipment and, to a lesser degree, will your staff accept it, can the patients tolerate it and is it easy to use?”

“A disinfectant is only as effective as the process with which it is applied,” continued Homan. “DAZO Monitoring, a unique, patented fluorescent marking gel, provides an objective way to evaluate the thoroughness of cleaning and provide feedback to staff to drive continuous improvement.”Ecolab‘s Clinical Services Manager, Linda Homan, says both the product and the process are critical. “The product must be fast-acting, sporicidal, effective against a broad range of pathogens, and not damage surfaces,” she said. “OxyCide Daily Disinfectant Cleaner from Ecolab meets all of these needs with a five-minute contact time, sporicidal efficacy and excellent material compatibility. Another benefit of daily OxyCide use is the ability to standardize to one disinfectant for all cleaning – daily, discharge and isolation. Training and compliance is easier when one disinfectant is used for all situations.

Smith added, “To be really assured of the disinfectant’s capability and nuances, you must read the supporting documents – readily available from the vendor or on the Internet. It may help to have one designated ‘authority’ review this information – could be a microbiologist, a chemist, an IP, as long as they have the expertise to understand the reports from the manufacturer.”

Carolyn Cooke, Vice President, Healthcare, NA, Sealed Air, Diversey Care, says Oxivir Tb Wipes, powered by Accelerated Hydrogen Peroxide technology, also reduce HAI rates.³ “The wipes are effective against a broad spectrum of bacteria and viruses in just one minute, while being gentle for staff and on surfaces,” Cooke said. “Because of the safety rating (EPA Category IV- non-irritating), they can be conveniently placed in patient care areas to facilitate point of care disinfection. There was a recent study published by the American Journal of Infection Control which demonstrated that the implementation of Oxivir Tb Wipes, in conjunction with ongoing procedure training and compliance monitoring, reduced key healthcare associated infections, including VRE, MRSA and C. difficile, by more than 20 percent.”³

George Clarke, CEO, UMF Corporation, says to facilitate compliance with best practices in operating room (OR) cleaning many facilities have adopted the PerfectCLEAN Operating Room Processing & Checklist System which helped some hospitas reduce C. difficile rates by more than 50 percent.

The system comprises best-practice processing techniques, tools and training with a hygiene specialist handbook and a series of detailed, comprehensive checklists for terminal OR cleaning, cleaning between procedures, the 24-hour idle OR, and pre-first procedure cleaning. “More hospitals are including UMF Corporation’s nationally recognized PerfectCLEAN Operating Room Processing & Checklist System as part of their comprehensive efforts to prevent the transmission of infections in ORs,” said Clarke. Several hospitals in Kentucky have recently adopted the system, which recently earned the AORN Seal of Recognition for the fourth consecutive year.  

“Each of these Kentucky hospitals was seeking a comprehensive process that includes cleaning, disinfecting and laundering to make a positive difference in providing safer surgical suites,” he said.

Taming transmission via textiles

Harmful microorganisms live on uniforms and linens too and facilities can take a variety of steps to arm textiles with agents that will help defend against the risk of transmission.

“When hydrogen peroxide, a well-documented, eco-friendly, and highly effective antimicrobial agent, is combined with patented InvisiArmor Medical RHP Textile Activator, it becomes Residual Hydrogen Peroxide (RHP),” said Robinson. “Once treated with RHP, clothes maintain residual antimicrobial activity against a wide variety of dangerous pathogens, such as MRSA, for 20 launderings. For $1.50 per day, per person, healthcare workers can eliminate their uniforms as a fomite for colonization at home and at work, reduce the risk of cross-contamination to surfaces, patients, visitors and staff, and take an active role in the antimicrobial stewardship of their healthcare facility. Rigorous laboratory testing has proven that when properly mixed and applied, RHP provides a 99.999 percent kill of MRSA and many other pathogens, even after 20 launderings.”Jeffrey Robinson, CEO, dReiniger LLC, believes that when employees clean their own work clothes they also risk contaminating patients. Sending them home with the InvisiArmor Medical RHP Textile Activator treatment kit might help.

In a similar vein, Sean Morham, Co-Founder, CEO and Board Member of Applied Silver, suggests facilities consider SilvaClean when laundering patient textiles. This antimicrobial silver ion solution is designed to protect them during storage, handling and use. “The core technology is a water-based ionic silver treatment for textiles, applied during each laundry cycle, which provides continuous antimicrobial performance during the time between launderings,” explained Morham, noting several in vitro studies and a multi-hospital study currently undergoing peer review.³

According to SilvaClean literature, silver ions in the product bind to surface proteins and disrupt bacteria cell production by stopping the transfer of nutrients and energy, basically suffocating the cell to inhibit reproduction.

The Healthcare Laundry Accreditation Council (HLAC) announced recently that “there is ‘legitimate and increasing concern’ of a ‘widespread’ and ‘unsafe’ industry practice regarding the back-and-forth on exchange carts of unused healthcare textiles (HCTs) between hospitals and laundries.”³ They say while The Joint Commission provides direction on the safe transport of unused linens to the healthcare facility it does not address the return of unused linen from the healthcare facility back to the healthcare laundry.

“Mixing unused, unprocessed linens with clean linens and returning all of them to the hospital is a failure of functional separation as is defined in our 2016 Standards,” said Board President John Scherberger. “However, with regard to exchange cart systems, there seems to be some confusion that we will address and endeavor to clarify.”

Maintaining air and water quality

APIC member Thom Wellington, Co-founder, Infection Control University (ICU), a cloud-based IP learning and certification center for hospital and vendor employees, says implementing a protocol for not opening OR doors during a procedure reduces SSIs.OR humidity levels are also critical. Steve Ulm, director of marketing, SEMCO LLC, says keeping relative humidity levels below 60 percent decreases risk of HAI. SEMCO’s award-winning Ascendant allows facilities to achieve that goal. “The ASCENDANT can provide humidity levels of 30 percent or lower and it does so saving substantially on energy costs of conventional systems used still today,” Ulm said. “The product uses energy recovery wheels to help in lowering the humidity levels and lower amounts of cooling BTUs from the chillers. By looking at the total system costs not just the equipment costs, a design can be achieved to minimize energy required from existing heating and cooling supplied to the system to achieve a total energy savings of the system.”

“Researchers stated ‘door openings affected air contamination, potentially jeopardizing operating room sterility,'”³ said Wellington. “The highest frequency of OR door openings occurs between wound closure and patient exit. Educating the surgical staff on the impact of door openings to positive pressure and possible air contamination should be performed monthly. Since 17 percent of HAIs are airborne-related and with even one colony forming unit (cfu) of fungi or bacteria-laden migrating dust can cause an HAI, contractors and maintenance personnel working within a healthcare setting need to be trained on how to avoid infecting immune-compromised patients from their work.”

Molly McKain, Application Engineer, AquiSense Technologies, says water filtration systems are commonly used to control pathogens such as Legionella or Clostridium but can be expensive due to frequent replacement – and she says the technology removes only larger particles, not small viruses or organic matter. Ultraviolet technology works too but McKain said “traditional, mercury-based ultraviolet disinfection systems are too cumbersome and energy hungry for intermittent flow, point-of-use applications.

“The state of the art UV-C LED light-sources, AquiSense Technologies’ PearlAqua’s compact design is ideal for such applications,” McKain continued. “The PearlAqua is small enough to be incorporated into medical devices such as autoclaves, patient temperature control systems, or laboratory water. Its third-party validated performance is able to protect the most immune-compromised patients by being part of chemotherapy dosing systems and dialysis machines.”

Lighting the path to protection

When whole room disinfection is the goal, ultraviolet systems, misters, foggers and other technologies add another layer of protection after standard cleaning and disinfection.

Chuck Dunn, President, CEO, Tru-D Smart­UVC, says his company’s disinfection robot uses patented Sensor360 technology to measure the precise amount of UV energy needed to disinfect any size room entirely.

“It is important to remember that germs and pathogens can live anywhere-underneath a surface, in low-use spaces such as room corners or around various surgical products tables-which is why every touchable surface should be a priority; Tru-D focuses on and guarantees total room disinfection, eliminating up to 99.9 percent of pathogens in a space,” said Dunn, noting a CDC-funded, randomized clinical trial that indicated significant decreases in the cumulative incidence of C. diff, MRSA and VRE.”³

Morris Miller, CEO, Xenex, says his company’s product, the LightStrike Germ-Zapping Robot, uses pulsed xenon instead of mercury bulbs to create full spectrum germicidal light to kill pathogens. “Xenex Germ-Zapping Robots work in four or five minute disinfection cycles (depending on the robot model) so hospitals are able to disinfect dozens of rooms per day and bring down the facility’s bioburden,” asserted Morris. “Multiple hospitals using Xenex Germ-Zapping Robots have reported significant decreases in their infection rates – and published their results in peer-reviewed journals. These are not case studies or field reports – these are actual infection rate reduction studies that have been through the peer-review process and published in scientific journals.”³

Miller also pointed out that other UV systems may cause damage to the equipment inside rooms that receive treatment.

“Increasingly, hospitals are reporting materials damage as a result of exposure to continuous UVC light. An article published in 2008, before Xenex was founded, in the International Ultraviolet Association magazine described how a violin maker chose to age the wood on his violins using continuous UV mercury lamps, which validates reports from hospitals that have experienced materials damage after their equipment was exposed to UV light from mercury UV devices,” Miller said.

In response, Dunn questioned whether Miller’s claim has scientific merit and said “UVC light, regardless of source, may cause slight cosmetic discoloration on materials lacking UV inhibitors that are common to the healthcare environment; however, UVC light cannot penetrate materials and doesn’t affect the makeup, integrity or intended use of the objects.” 

Maryalice Panarello StClair,Vice President, Business Development, Halosil International Inc., says the Halo Disinfection System (HDS) is a cost-effective alternative to UV treatment altogether and the first to be validated by the EPA for a 99.9999 percent kill rate against C. difficile spores.

“Hospitals using the HDS have experienced significant reductions in HAIs and tremendous ROI. Pennsylvania Hospital – a 496-bed teaching hospital in Philadelphia – saw a 67 percent reduction in hospital-acquired C. diff cases.””The HDS dispenses a hydrogen peroxide and ionized silver mist that eradicates pathogens in all the nooks and crannies of complex patient, treatment and operating rooms,” said Panarello StClair. “The ‘dry mist’ is safe for decontaminating expensive electronics and bedside computers as no surfaces are wetted and nothing is corroded. This ‘No Touch’ method eliminates the risk of ‘high-touch surfaces’ and policing an EVS staff’s every spray and every wipe during room changes.

Can’t touch this

Remember also to disinfect smaller, high-touch items such as handheld devices, glasses, badges, blood pressure cuffs and other medical and non-medical equipment. Allen Gehr, Director,Hospital Safety Solutions says the compact UV flash system will do the job.

“High Touch items are known culprits of disease transmission,” Gehr said. “Cell phone manufacturers don’t recommend cleaning with moist wipes. How are you cleaning these items? In a recent multi-center study, a one-minute UV Flash cycle decimated CFU’s on hand-washed sensitive medical equipment. The UV Flash’s highly reflective chamber and UV-C lamps breaks the molecular bonds inside microbial DNA, inactivating pathogens. One customer uses their UV Flash at the hospital entrance labeled “Disinfection Station” where visitors wash their hands and disinfect their phones before entering.”

Gehr says the UV Flash has been validated by third-party labs to kill C-diff, S. aureus and A. baumanni.”³

Another UV product to hit the market this year is the KR615 UV Germicidal Enclosure from Advanced Ultra-Violet Systems (AUVS). CEO Jim Psihas says the system is used at the bedside in patient rooms, OR, ICU and ED to kill pathogens including C. diff. and MRSA on stethoscopes, blood pressure cuffs, nurse call buttons, pillow speakers, EKG wires, blood glucose meters, cell phones, small tablets, TV remotes and more in just 45 seconds.

“The KR-615 fills the critical gap between robots, wipes and bleaches by decontaminating devices which, although necessary, do put healthcare workers, patients and their visitors at risk, both in and out of the hospital,” Psihas said.

Products vs. practice

James Russell, RN-BC, MBA, Value Analysis Facilitator, UF Health Jacksonville, says when seeking solutions for combating HAI’s, including pressure ulcers, SSIs and ventilator-associated pneumonia (VAP), his team works alongside their Infection Prevention and Control (IP & C) department and clinical staff to evaluate products and services.

“As these events are now carrying financial penalties, there is more organizational will towards providing resources to help attack these negative outcomes,” Russell said. Still, collaborations can get a little bumpy when patient safety and savings is the combined goal.

“Imagine this scenario: Value Analysis provides data to show that other hospitals that use the same products for CLABSI prevention have lower infection rates than our hospital,” Russell said. “Then, IP & C presents data on central line surveillance to show that clinical staff are not managing central lines according to the hospital’s protocol. The message to the clinicians in the room is that both departments are criticizing their competence, in essence, ‘calling their baby ugly.’ It takes real skill to present data that shows clinicians that it might be their practice, rather than products, that are contributing to the poor infection rates.”

Having evidence-based data to support IP purchasing decisions can definitely prove helpful. “One clinician submitted a Product Request Form for a new product; as part of the process, a literature search was performed and opinions from other facilities were sought,” explained Russell. “Once the data was gathered and presented to the team, all agreed not to bring the product in. This was an evidence-based decision that was made after careful consideration of facts, using logic and reason, rather than emotion. This is exactly how the process should go.”

Advanced data collection becoming a necessity

IP professionals today must collect and report more HAI data than ever before which can make it difficult for many to dedicate as much time as they would like to other IP responsibilities.

“IPs feel this additional time removes them from activities that could further reduce the actual HAIs we are reporting – such as conducting tracer rounds, providing on-unit education or observing staff technique,” said Smith. “One abstract presented at the APIC 2015 conference calculated that IPs are spending five hours per day collecting, analyzing and reporting this data. Surveillance technology can further streamline our time with paper and permit us to interact more directly with the patients and staff. Fundamental benefits of these programs include reduced redundancy, more efficient review of relevant data, automated reporting for regulatory and financial purposes and identifying trends more rapidly.”

It can also help support patient safety, product management and clinical practice. “For example, an internally developed system I work with can notify the IPs and managers when a patient does not have an order for their indwelling catheter,” Smith said. “Previously, one would have to check each medical record for this information. This has been instrumental in eliminating unnecessary catheters and contributed to the success of our CAUTI prevention program. The system has also identified lapses in the measures to prevent CLABSI (e.g., lack of dressing change or chlorhexidine bath). Previously, this data was collected manually so it was time consuming and prone to missed cases.”

References:

1. The Centers for Disease Control and Prevention, “Healthcare-associated Infections (HAI) Progress Report,” March 2016. (http://www.cdc.gov/hai/surveillance/progress-report/index.html) The White House, National Action Plan for Combating Antibiotic-Resistant Bacteria, March 2015.

2. American Nurses Association, “Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention” (http://nursingworld.org/CAUTI-Tool).

3. Contact the manufacturer for references.

4. Lee, Bruce, Bartsch, S, et.al., The Potential Trajectory of Carbapenem-Resistant Enterobacteriaceae, an Emerging Threat to Health-Care Facilities, and the Impact of the Centers for Disease Control and Prevention Toolkit. Am J Epidemiol. 2016 Mar 1; 183(5): 471–479.

5. Healthcare Purchasing News, “Educators gain ground as SPD compensation continues climb,” April 2016.