Special Advertising Section – Infection Control
Controlling the Spread of Infections
By Tom Inglesby
Middle East Respiratory Syndrome (MERS) is an illness first reported in Saudi Arabia in 2012. It is caused by a coronavirus, MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness. They had fever, cough, and shortness of breath. More than 30% of these people died.
On May 2, 2014, the first U.S. case of MERS was confirmed in a traveler from Saudi Arabia to the United States. CDC (Centers for Disease Control and Prevention) and other public health groups are investigating the case and implementing measures to prevent the spread of MERS-CoV in the United States. As of May 10, no additional MERS cases had been identified in association with this case or otherwise in the United States.
The rise of so-called “superbugs” and illnesses such as MERS, warrants increased care and observation to prevent the spread of these infectious agents. All the health groups, including the World Health Organization (WHO) and the CDC, have published protocols for fighting infections in the hospital environment. In each case, the first line of defense is hand hygiene.
According to Mario Soares, director of infection prevention and control at Houston Methodist Hospital, “The three most critical areas for infection prevention in a hospital environment include Operating Rooms, Intensive Care Units, and Oncology/Transplant Units. Antibiotic stewardship is best practice for preventing the development of new strains of ‘superbugs.’ And preventing new strains taking hold requires thorough cleaning of healthcare facilities and compliance with isolation practices to control the spread of any new infections. Still, washing one’s hands is the single most effective way to prevent infections before, during and after hospitalization.”
At Houston Methodist, they are using an additional layer of prevention, a robotic one—the TRU-D ultraviolet room sanitizer. Chuck Dunn, president of Lumalier, manufacturer of TRU-D, says, “Obviously, prevention is critical for facilities. Hospital staff members already go to great lengths to prevent HAI (hospital acquired infections) with traditional methods and protocols. TRU-D steps in to add the ultimate layer of protection, eliminate lingering pathogens to provide the safest environment for patients and their families, nurses, doctors and healthcare workers.”
O’Connor Hospital, San Jose, Calif., was the first hospital in the Bay Area to deploy TRU-D SmartUVC, a pathogen-eliminating robot that uses powerful ultraviolet light to kill harmful viruses, bacteria and fungi that are responsible for healthcare-associated infections. Short for Total Room Ultraviolet Disinfection, TRU-D “finishes the job” after a hospital staff member completes traditional disinfection routines, reducing the risk of HAI. The remotely operated robot generates UV light energy that modifies the DNA structure of an infectious cell so that it cannot reproduce — and a cell that cannot reproduce cannot colonize and harm patients.
“The acquisition of this technology is simply another way that we’re working to protect the integrity of our healthcare environment, and ultimately, safeguard the well-being of every single patient who walks through our doors,” said Suzanne Cistulli, RN, CIC, director of infection prevention and control at O’Connor Hospital.
The technology allows O’Connor Hospital to confidently clean its patient environments, including ICUs, patient rooms, surgery suites, emergency rooms, and public areas. In addition to influenza and norovirus, the robot’s microscopic foes include Clostridium difficile (C. diff), Methicillin-resistant Staphylococcus aureus (MRSA), and other pathogens.
TRU-D’s Sensor360 technology uses eight calibrated sensors to scan an entire room and utilize the 360-degree image to calculate an accurately timed cycle, which insures a consistent and thorough disinfection outcome. After the room is cleaned using traditional methods, TRU-D is rolled into the room to finish the job. Set-up for TRU-D is quick and easy and does not require input of room measurements or covering of windows and vents. The system can disinfect an entire room — including shadowed spaces — from one central location, eliminating the need to move the robot to multiple randomly selected positions within the room.
As Dunn points out, “We meet with hospitals to provide a solution that fits their needs. Some purchase TRU-D because they are struggling with eliminating an outbreak, whereas others purchase TRU-D as a prevention strategy. We’ve seen hospitals eliminate an outbreak in as little as four days after bringing TRU-D in. Many hospitals need multiple TRU-D robots to fit their needs. Also, TRU-D now offers innovative infection prevention data tracking technology, called iTRU-D. So, after a patient room is disinfected with TRU-D, customized reports are securely sent to a private cloud-based portal so authorized users can access the information at any time. Hospitals using TRU-D can expect to never miss another spot in a patient’s room or operating room again.”
Obviously, some environments are more prone to harboring infections than others. The critical care unit, for example, will have patients who are more likely to be infected, a little sicker than in other units. “While some patients are medically fragile or immune compromised,” acknowledges Heather McLarney, vice president of marketing at DebMed, Charlotte, N.C., “I think the focus shouldn’t be so much on different areas of the hospital, but on when staff members needs to clean their hands. In many facilities, they have little catch phrases like, ‘Foam in and foam out.’ Basically, don’t forget to wash up when you walk into a patient’s room and then again when you walk out.”
At the end of the day, that’s really not enough. The CDC and WHO guidelines say you also need to clean your hands before doing an aseptic task. That could be something like inserting a catheter or an IV, or after contact with body fluid. “And then the one that I think people get busy and forget or don’t think about it as much,” notes McLarney, “is after touching the patient’s surroundings. It’s fairly intuitive when you’ve come in contact with body fluids — you’re instinctively going to clean your hands. But people don’t remember touching the bedrail or the curtain, or something in the patient’s room, and those are just as high risk areas for spreading infection as touching the patients themselves.”
If you think about cleaning hands as you enter a patient’s room, it’s for the patient; when you’re coming out, that re-cleaning is more for the healthcare worker. It’s really about cleaning their hands from what they’ve touched in the room, including the patient. But what about all those things that happened while they were in the room? McLarney explains, “You’re feeding the patient or changing a bandage or touching things in the room. Those events are critical. Studies that have been published show if you’re only doing hand hygiene when entering and leaving the room, it only accounts for 50% of the hand hygiene opportunities. So if you’re only doing in and out, you’re missing the other 50% when you could be transferring germs between patients.”
What DebMed is doing to help make it easier is a new product that is monitored at the point of care. “Most of the soap and sanitizer comes from wall based dispensers,” admits McLarney. But not all, and there is where monitoring needs to be improved. “In the critical care units, where the patients are so sick that the nursing staff stays by the bedside, a sanitizer wall-mounted dispenser might be just five feet away but they can’t get to it because the patient’s needs are so high that they require constant attention. What they do is use a pump bottle at the patient bedside.”
Sound familiar? McLarney: “When we first turned on our system in some hospitals, it looked like those critical care unit hand hygiene scores were really low. The staff would tell us, ‘We are cleaning our hands, we just aren’t getting credit for it because we’re using this pump bottle, right within arm’s reach.’ And so we created a special plastic dispenser that has electronics in it to monitor pump bottle usage. Now they get credit for using that pump bottle.”
Having access to sanitizer at the point of care is something that the CDC, Joint Commission, and WHO all advocate. You hear it all the time: “If I can see the sanitizer, right in front of me, if I don’t have to walk to the wall dispenser to access the product, chances are I’ll use it more frequently.”
“We know that a nearby dispenser does boost hand hygiene compliance,” claims McLarney. “But it needs to be properly monitored, actually recording that hand hygiene activity. It’s really all about having accurate data, and then being able to do something with that data. Since our system works at the group level and doesn’t track individuals, we recommend that the staff work as a team to come up with ways to improve compliance as a group, to work together as a unit.”
In agreement is Andrea Aluisi, MPA, BSN, RN, CIC, director of infection prevention and control at Valley Hospital, Bergen County, N.J. The Valley Hospital is a fully accredited, acute care, not-for-profit hospital with 451 beds serving more than 440,000 people in 32 towns in Bergen County and adjoining communities. The hospital is part of Valley Health System, which also includes Valley Home Care and Valley Medical Group.
Aluisi remarks, “Our Infection Prevention and Control Department monitors our infection rates on a daily basis. Surveillance rounds are conducted daily in all units and all cultures are reviewed as well. The Valley Hospital follows the guidelines set forth by National Healthcare Safety Network (NHSN). We have a comprehensive infection prevention program to eliminate HAI and we focus on standard precautions for every patient, barrier precautions, excellent environmental services practices, and hand washing protocols. In addition to these initiatives, we decided to take it a step further and include patients and families in our process to eliminate HAIs.”
That step was to implement Sani Hands wipes from PDI Healthcare, Orangeburg, N.Y. “Our organization has been actively incorporating multiple ways to help reduce any HAIs,” recalls Aluisi. “While we have been focusing on employee hand washing for some time now, we decided it was time to include the patient component. In June 2013, we introduced the patient hand washing campaign.”
That campaign had an interesting result. “We trialed Sani Hands wipes on three adult medical-surgical units. There was a variation in how the wipes were utilized on each unit. Two units provided the wipes upon admission and explained to the patient the importance of hand hygiene and the other unit provided the wipes to patients after toileting or before meals. After much discussion with staff and solicited patient feedback, it was decided to move forward providing the wipes upon admission.”
In November 2013, they fully implemented Sani Hands wipes to all adult medical-surgical units. “An educational card about the ‘how’ and ‘why’ of using these wipes is also provided to the patients,” explains Aluisi. “In addition, as part of our Patient Family Centered Care model, we have a retired, volunteer nurse who does rounds weekly to these units to discuss the importance of hand hygiene.”
Since they implemented the use of Sani Hand Wipes, Valley’s Multiple Drug Resistant Organism rate has decreased by 17% and the HAI rate has decreased by 8%. “Infection reduction success does not happen overnight,” admits Aluisi. “The hospital has to have a team approach to problem solving, making sure that all the right people are involved, especially patients. Eliminating HAIs takes hard work and dedication by all. We have seen that even with all of the multiple vectors we are currently using to tackle HAI’s, consistency and communication has been the key.”
Many critical items in the hospital environment present a high risk for infection if they are contaminated with any microorganism. Often overlooked are the mobile devices found rotating throughout the hospital. This equipment requires a written procedure for best practices for disinfection. To this end, PDI has released a whitepaper addressing an often missed opportunity for infection prevention: the disinfection of mobile equipment. The paper, titled “Microorganism Movers: Mobile Equipment and Implications for Infection Prevention,” discusses equipment such as wheelchairs, wheel chairs, crash carts, IV poles, and workstations on wheels. The paper highlights this key issue as healthcare staff, patients, and visitors can interact with mobile equipment hundreds of times each day. Moreover, the 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities states, “Noncritical environmental surfaces frequently touched by hand potentially could contribute to secondary transmission by contaminating hands of healthcare workers or by contacting medical equipment that subsequently contacts patients.” Wipes like those from PDI (Sani Hands, Sani Cloth) have application in these and many other situations.
Dr. Mark Stibich is the chief scientific officer and co-founder of Xenex Disinfection Services, San Antonio, Texas. He believes that hospitals need an integrated approach to infection control. “When we are talking to hospitals about infection control, we advise an evidence-based approach,” he says. “Every facility is different when it comes to the most critical areas and preventing infections. We believe the right way to approach this is to work collaboratively with their infection control team and use data from the facility to guide decisions. Then we identify the areas where the most infections are occurring, and develop a protocol on how to address the those areas with the greatest likelihood of improvement.”
Hospitals must take a bundled and integrated approach to infection prevention, which includes following the standards for infection prevention, such as hand hygiene. “But if you really want to prevent superbugs from taking hold in your facility and take infection control to the next level,” Stibich cautions, “you must prevent the reservoir of pathogens from developing. Enhanced environmental cleaning can accomplish this. Superbugs can’t take hold when you routinely disinfect the environment and prevent a reservoir of that germ from developing in your facility.”
This approach must include the patients. “First and foremost,” Stibiuch explains, “as a patient, ask your doctor and the hospital representatives what they are doing to keep you safe and prevent an infection. Follow the pre-op instructions you are provided and then take all the medications you are prescribed, as directed. Follow your wound care instructions carefully. When you are in the hospital, be vigilant about hand hygiene — with your visitors as well as the doctors and nurses caring for you. Everyone is human and can make mistakes.”
Technologies are available to automatically disinfect pathogens and prevent infections. Make sure your EVS team has the best tools for eradicating dangerous germs. “Don’t go bargain shopping,” Stibich warns. “Not all room disinfection technologies are the same. Make sure you find a disinfection system that works quickly and effectively. Ask to see peer-reviewed studies showing decreased infection rates at facilities using the technology.”
He continues, “We manufacture a portable UV room disinfection system that uses pulsed xenon ultraviolet light to quickly destroy the viruses, bacteria, mold, fungus and bacterial spores in the patient environment that cause HAIs. Uniquely designed for ease of use and portability, the Xenex germ-zapping robot is operated by hospital staff without disrupting hospital operations. With a five minute disinfection cycle, the device disinfects dozens of rooms per day, including patient rooms, operating rooms (ORs), equipment rooms, emergency rooms, intensive care units (ICUs), and public areas.”
High-energy ultraviolet light in the area of the spectrum known as UV-C is produced by either mercury or xenon gas lamps. This UV-C energy passes through the cell walls of bacteria, viruses and bacterial spores. Once the UV-C energy is inside the microorganism, it is absorbed by the DNA, RNA and proteins. One of the primary mechanisms of damage created by UV-C is the fusing of the strands of DNA creating what is known as “thymine dimers.” Once the DNA is fused, the organism can no longer replicate and is, therefore, no longer infectious. The technical term for this is “deactivation.”
“When a hospital purchases our robot,” Stibich concludes, “they also gain access to our infection prevention and process consulting services. We ensure our devices are being used correctly and efficiently so that hospitals can target their problem areas and see results. The good news is, it works. Hospitals across the U.S. are reporting fewer infections after using our pulsed xenon UV room disinfection robots to quickly destroy the deadly pathogens lurking in healthcare facilities.”
While UV can be used to sanitize rooms and the equipment, both fixed and mobile, in the room, it isn’t practical for people. So we come back to hand hygiene as the starting point for personal infection control. Charles P. Johnston, vice president of sales, UltraClenz, Jupiter, Fla., points to the some of the concerns, “No matter what the infection question is, it all loops back to the same point: preventing infections begins with vigilant hand hygiene practices. If the staff isn’t sanitizing or washing between and during trips to patient rooms, they’re putting lives at risk. Not to sound too dramatic, but it is a pretty simple equation. If you don’t clean your hands before you interact with a patient, you are at risk and the patient is now at risk. And when you leave that room to visit another patient and you don’t sanitize or wash? Now you are casting a wider net with respect to spreading germs.”
As noted before, information from the Centers for Disease Control (CDC) indicates hand hygiene is the most important way to prevent the spread of infection. “Not all superbugs are the same,” Johnston notes. “Some only respond to hand washing with soap, others can be contained by hand sanitizing with an alcohol based sanitizer. To minimize the spread of any infection, each and every health care worker should be cognizant of their role in spreading and/or preventing the spread of infections. If you wash or sanitize before and after you visit patient A, then repeat the same procedure when you visit patients B and C, you’re becoming part of the solution. All healthcare workers and facilities need to follow the proper safety guidelines as recommended by the CDC and The World Health Organization.”
Patients and their loved ones can play a role in helping to prevent infections by practicing hand hygiene themselves while in a healthcare facility and after they are sent home. “Patients should also be aware that the staff visiting them should be sanitizing or washing before they approach the bed,” Johnston says.
Since 1995, Ultraclenz has focused solely on hand hygiene solutions. Johnston, remarks, “Our trademark system, The Patient Safeguard System (PSS), has as its primary function to remind the healthcare worker to sanitize their hands, prior to patient contact and after patient contact. Our unique system monitors hand hygiene at the patient bed level, accompanied by our integrated compliance software; we can easily assist healthcare facilities with analyzing and real-time compliance data. PSS prides itself on helping healthcare facilities improve their hand hygiene protocols, ultimately reducing the spread of infection, making a safer environment for both the patient and healthcare workers.”
PSS is an automated hand hygiene monitoring system designed to increase hand hygiene awareness in a healthcare facility. PSS can help prevent the spread of hospital acquired infections (HAIs) by monitoring and modifying clinician behavior to improve hand hygiene compliance. It prompts healthcare workers to sanitize prior to patient contact, after patient contact, and after touching patient surroundings.
Perhaps the best known names in hand sanitizers are Purrell and GOJO. But those products are only part of the company’s approach to infection control. Another aspect is education. As David McKay, vice president sales and marketing for healthcare markets at GOJO Industries, Akron, Ohio, explains, “One topic that we’ve really been trying to drive hard in the marketplace is education about product efficacy in hand sanitizers used in clinical settings. Studies done with third-party labs using the FDA test methods show that there is a huge disparity in performance between alcohol-based hand rubs. Some products that are used in healthcare settings leave 1,000 times more germs on hands than other products. We’ve been trying to help the market understand what the test methods are, what the FDA’s requirements are, and to educate our customers to ask for the data before they make product selection decisions.”
He adds, “Observation as a measurement method gives an inflated number in terms of compliance with hand hygiene standards. We believe observation has a place, but it’s more on the qualitative side. Once you identify where the number is lower than other areas, then you investigate and use observation to try and figure out why. That’s where we help our customers to try and bridge the gap between what they want and what’s actually happening, to help find the root cause, resolve the root cause, and then continue to work those cycles to try and improve performance.”
There is new technology that can automate that process and take the burden off the infection preventionists. “What we can do then is get on with the task of moving the number up, rather than thinking there’s nowhere to go on the up side,” notes McKay.
As important as it is to accurately measure hand hygiene compliance, what are you going to do with this data? “That’s where we’ve developed a program of clinician based support,” comments Jane Kirk, RN, CIC, clinical director in healthcare for GOJO. “We go into hospitals and work with the infection preventionist, or whoever owns the hand hygiene program, and help them with the front line care givers, find a way to target what they see the problems is, and then help them to improve. We’re all about technology but we’re also all about providing the support to do something about the data, which is a foundation in infection prevention.”
GOJO conducted an independent research study at the John Peter Smith Hospital in Fort Worth, Texas, to determine the impact on hand hygiene compliance rates when the hospital program included an electronic compliance activity monitoring system. The compliance technology system used in the study was the GOJO SMARTLINK Activity Monitoring System.
During the study, SMARTLINK was installed to monitor all patient room entries and exits and all hand hygiene events from GOJO touch-free soap or PURELL hand sanitizer dispensers. Compliance was measured as number of events in contrast to number of opportunities, and included the entire community, not only healthcare workers. The study duration was three months during which a comprehensive hand hygiene program for healthcare workers, patients, and visitors was implemented. Additional education was established including the development of a hand hygiene improvement goal, leadership support, and feedback opportunities for the staff.
“It’s actually broader than just the technology,” injects McKay. “We view SMARTLINK as being the whole programmatic side, which includes multiple types of measurements that our systems enable plus the clinical support. These are all areas that are part of our core proposition, plus all the training and research that we do and make that available to our customers. We have communicating dispensers that are capturing hand hygiene events and sending that data to different dashboards, such as a real time location system, or our stand alone system, and to clinical support. That’s what SMARTLINK is all about.”
Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.