Emerging Infectious Disease

By Angela Krile

According to a study published in the November 2010 New England Journal of Medicine, patient safety issues persist in hospitals across the country. The study concluded that, as a nation, we have made little progress since the Institute of Medicine’s landmark report in 1999, To Err is Human, which put a spotlight on patient safety issues that were the result of preventable medical errors. The November 2010 study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients—complications from procedures or drugs and hospital-acquired infections—was still common, and the study’s lead author concluded that it was unlikely that other regions of the country had fared better.

However, Ohio hospitals have a different story to tell. Through the collaborative efforts of the Solutions for Patient Safety initiative, these hospitals have fared better, and in fact, have demonstrated results by significantly improving patient safety and eliminating unnecessary healthcare costs from the system. In January 2009, Ohio business leaders and healthcare providers launched Solutions for Patient Safety, a collaborative effort with the aspiration of making Ohio the safest place in the nation for healthcare.

The Cardinal Health Foundation, the Ohio Business Roundtable, the Central Ohio Hospital Council, the Ohio Hospital Association and the Ohio Children’s Hospital Association created this collaboration to improve quality and reduce costs of healthcare statewide. The partnership brought together 25 hospitals—17 Central Ohio hospitals and 8 children’s hospitals throughout the state—to reduce healthcare-associated infections (HAIs) and medication errors.

Solutions for Patient Safety was funded by a $1.5 million investment from the Cardinal Health Foundation. Funding was used to foster collaborative opportunities among the participating institutions, support improved data collection, provide for required technology and deliver training programs for clinicians and hospital leaders. The work took place in central Ohio general hospitals, corresponding with Cardinal Health’s headquarters location in Columbus, and in eight children’s hospitals from around the state.

“Cardinal Health is proud to be a founding sponsor and ongoing partner in this groundbreaking initiative that has and will continue to save lives—not only throughout Ohio, but across the nation,” said George S. Barrett, chairman and CEO, Cardinal Health. “The impressive results of the Solutions for Patient Safety initiative prove that true collaboration among healthcare leaders and clinicians can create meaningful transformation in patient care.”

The Goals

Over an 18-month period,

Central Ohio hospitals and children’s hospitals across Ohio worked together to:

• Set and meet specific error-reduction goals—measuring lives and costs saved;
• Gather baseline data;
• Identify sustainable and replicable processes to improve quality;
• Share best practices and learning across institutions; and
• Engage hospital leaders in promoting a culture of safety in their institutions.

Participating Central Ohio hospitals (17 hospitals) worked to:

• Reduce central line associated blood stream infections (CLABSI) hospital-wide by 50 percent, by June 2010.
• Significantly reduce healthcare-associated methicillin-resistant staphylococcus aureus (MRSA) infections by June 2010.

Ohio children’s hospitals (eight hospitals statewide) worked to:

• Reduce overall adverse drug events (ADE) by 33 percent by June 2010.
• Reduce surgical site infections (SSIs) in designated cardiac, neurosurgery and orthopedic procedures by 50 percent by June 2010.

Central Ohio Hospitals Take on MRSA and CLABSI

Baseline data collected in the collaborative suggests that prior to the start of the Solutions for Patient Safety project, an average hospital-onset MRSA was approximately 60 isolates per month, with the average additional cost for MRSA infections totaling approximately $25,000-$36,000 per case. The average CLABSI rate before the project began was approximately 25 cases per month, and the average additional cost for a CLABSI infection is approximately $3,700-$29,000 per case.

Most hospital projects to reduce CLABSI rates typically focused exclusively on Intensive Care Units (ICU). However, the collaborative made the decision to report CLABSI infection rates hospital-wide—ICU and non-ICU infections—and in doing so, discovered a patient population outside the ICU that warranted in-depth analysis and identification of additional interventions.

Through its collaborative efforts, Central Ohio hospitals achieved an 11 percent reduction in hospital-onset MRSA isolates (incidences of MRSA that occur anywhere on the patient, not just in the bloodstream), a 42 percent reduction in MRSA bloodstream infections and a 37 percent reduction of catheter-associated bloodborne infections.

As a result of this work, Central Ohio hospitals saved 14 lives, avoided 918 additional patient days in the hospital, and saved approximately $7.5 million per year in unnecessary healthcare costs.  Jeanne Emmons, BS, MT (AMT), the infection prevention director for Licking Memorial Hospital in Licking County, Ohio, noted that working with other institutions allowed her to leverage data for better results. “As a smaller operation with limited data on actual infections, having access to aggregate data when educating staff and physicians about best practices in preventing MRSA and CLABSI infections was very helpful,” said Emmons.

Best practices to ensure infection prevention success

Together, members of the collaborative identified opportunities for improvement in data collection to enable participants to achieve and sustain reductions in MRSA and CLABSI infections. Solutions for Patient Safety hosted two learning sessions for participating hospitals, which resulted in the creation of standardized definitions for data, outcomes and process measurements; and a unique data collection tool that eliminates data entry errors using an automated classification system.

Additionally, the Central Ohio hospitals identified processes, best practices and opportunities for increased collaboration among community and larger hospital systems, including:

1. Facilitating monthly quality improvement conference calls that create a forum for sharing best practice ideas, discussing barriers and possible solutions and collaborating toward rapid cycle improvements.
2. Conducting regular quality improvement coordinator site visits, focusing on clinical and technical assistance. The coordinator effectively evaluates the unique needs of each hospital within the collaborative, strengthening their contribution to the continuous efforts to reduce MRSA and CLABSI infections.

Another key process that contributed to the collaborative’s success was the hiring of five student nurse process observers (SNPOs) to conduct more than 12,000 observations to monitor compliance with proper hand hygiene practices, environmental decontamination processes and processes related to the insertion and maintenance of catheters. Through the SNPOs observations, two processes emerged as critical to significantly reducing infection rates for MRSA and CLABSI, hand hygiene and “hub” scrubbing.

First, hand hygiene emerged as the primary area of focus for the collaborative’s efforts to reduce MRSA infections, observing an inverse relationship between hand hygiene and incidence of MRSA. Since the beginning of hand hygiene data collection by the SNPOs in September, the rate of compliance with washing hands upon entering and leaving a patient’s room, even while wearing gloves, improved by more than 20 percent. And, participants noted that the observation and feedback process had a significant impact on compliance.

SNPOs also helped to identify a critical point of infection transmission for CLABSI related to the length of time the “hub” (access point in a catheter where fluids and medications are administered) is cleaned. While the hub was wiped before accessing the point of entry 98 percent of the time, the scrub was usually performed for a period of 15 seconds (the preferred threshold by medical standards) only 20 percent of the time.

As a result of this additional process measure and the group’s findings, it created a “Seconds Count” educational and reminder poster for wide distribution and use in the hospitals to encourage all clinicians to extend their scrub period to the full 15 seconds. The “Seconds Count” materials developed through the Solutions for Patient Safety efforts have been made available to hospitals throughout the state and nation via the Ohio Hospital Association Quality Institute Web site.

Even the SNPOs involved in the observations noted that the process had a significant impact on their awareness. “I honestly can say that this experience has allowed me to become more aware of the importance of hand hygiene and the use of isolation and sterility practices,” said Ashley Mitchell, SN. “What we observed within the hospitals seems so simple, but it is so overlooked. I know the days can get busy going in and out of patient rooms; if the medical staff could just slow down to take15 seconds to either wash their hands or put on the correct protective barriers, it could save lives.”

The Central Ohio hospitals will continue to work together to build upon these results. Specifically, participating hospitals have committed to continued hand hygiene monitoring by external observers, extending the hand hygiene project to other regions of the state, continuing internal audits to ensure ongoing improvement, and monitoring CLABSI through a statewide program that is part of a national initiative facilitated by the American Hospital Association, Michigan Hospital Association and Johns Hopkins.

Children’s Hospitals Reduce SSIs

Preliminary data on SSIs in Ohio’s children’s hospitals indicated there were approximately four infections per month across the state. The average additional cost per-case for hospital-based SSI is approximately $28,000. Through the Solutions for Patient Safety efforts, Ohio’s children’s hospitals achieved a 60 percent reduction in surgical site infections (SSIs) over a 12-month period of time. This reduction, coupled with a 34.5 percent reduction adverse drug events, allowed Ohio children’s hospitals to save 3,583 children from unnecessary harm and $5.3 million in unnecessary health costs. Clinicians at participating institutions were excited to see the tangible results of the collaboration. “In addition to saving the lives of our patients, this initiative has improved the quality of these lives and reduced the expense of caring for these children,” said Ed Shepherd, PhD, interim section chief of neonatology at Nationwide Children’s Hospital.

Best practices for SSI reduction success

The children’s hospitals identified standard processes that were used across the institutions during the collaborative project. These standards included a process to increase the reliability in the use of order sets—or the manner in which medication is ordered for each patient—to reduce opiate over-sedations; and the use of a unique bundle of care for all hospitals for each surgical procedure group, including no razors in the operating room, use of the most effective prep for surgery (i.e. chlorhexidine) and the appropriate timing for the administration of antibiotics.

Additionally, the children’s hospital collaborative created opportunities for participating institutions to build capacity for safety and quality improvement efforts by:

• Hosting five learning sessions for participating hospitals to learn about quality improvement process and share learning and best practices.
• Creating an integrated data management application designed specifically to support multi-center quality improvement initiatives. The application provides a single point of contact for informational, collaborative and data-related activities. The application’s tools allow for rapid feedback of performance data, preparation of progress reports over the Internet and communication among teams.
• Hosting monthly quality improvement webinars and conference calls on various quality improvement science topics.
• Conducting site visits from a quality improvement consultant to provide hands-on technical assistance to hospital improvement teams.

The process of identifying and sharing best practices was one of the key benefits for the clinicians involved.  “Being a part of the SSI team for the collaborative has allowed us to assess our strengths and weaknesses as well as share ideas and benchmark with other children’s hospitals,” said Debbie Hawk, RN, ONC, CNOR, RNFA, clinical coordinator of orthopaedic surgery, Akron Children’s Hospital. “This process has enabled us to utilize a standard, reliable process to help minimize surgical site infections and improve patient care. It has also allowed the operating room nurses, anesthesia care providers and surgeons to collaborate as a team on preventing SSIs. This team approach has now carried over to help improve other aspects of patient care in the operating room.”

Emerging Infectious Diseases

by Wava Truscott, PhD

The 2009 H1N1 pandemic was not the catastrophic global event many government agencies, healthcare overseers and hospital officials feared. At the time, however, there was every indication it had the potential to be a worldwide disaster. Looking back, was it all just a massively expensive response spurred on by fear mongers and media hype? Or was there a legitimately interpreted threat that pulled the pandemic warning lever, causing us to break open our emergency response protocols, testing our readiness? Are we maximizing the lessons learned?

To fairly answer these questions, we absolutely must:

• Understand why the decision was made to activate the pandemic crisis alarm;
• Assess where response system inadequacies occurred;
• Correct what was weak or missing—both at the facility and staff procedural levels;
• Be alert to new research and global outbreak reports;
• Be prepared if the next wave hits and is more lethal.

In addressing these points, this article will also review the results of a recent survey of 525 Magnet nurses assessing their facility’s state of preparedness. This survey was jointly conducted by Baylor Health Care System and Kimberly-Clark in cooperation with the American Nurses Credentialing Center (ANCC).

What led to the decision to sound the pandemic alarm on the 2009-H1N1 influenza?

On April 12, 2009 public health officials in Mexico reported high numbers of pneumonia/influenza-like illness to the Pan American Health Organization (PAHO), the regional offices of the World Health Organization (WHO). This date marked the first in a series of milestones leading to the declaration of a worldwide H1N1 pandemic on June 11.  A look at the timeline of events over this two-month period helps us understand the informational framework in place as decisions were made.

The severity of the new highly communicable H1N1 influenza A strain became apparent by the beginning of May, when WHO reported a 5.4 percent mortality rate—higher than the 2.5 to 5 percent of the historic 1918 flu pandemic. Statistics reported by the CDC in June indicated that 39 percent of the 2009-H1N1 patients who died in the United States were age 25 to 49 years, similar to the 1918 influenza. Peripartum mothers and their infants were identified to be at higher risk, as were ethnic American Indian and Alaskan natives.

By June 11, 2009, H1N1 influenza cases were confirmed in 74 countries and all continents but Antarctica—just  two months after the initial reports from Mexico. As a result, WHO raised the pandemic alert status to Phase 6—Full Pandemic.

What were additional findings leading to the U.S. decision?

By the time flu season officially started in the United States on October 4, the 2009-H1N1 influenza had already spread to all 50 states. As the highest incidence of seasonal flu historically occurs in February, it was feared there was ample time for the new virus to acquire the genetic capability for increased virulence.  Typical pandemics normally present in three waves—in fact, the most lethal of the 1918-H1N1 influenza wave was the second phase. Since the 2009-H1N1 was just winding down its first phase, the fear was justified. The first pilot lots of H1N1 vaccine became available in July, but full production took several additional months, and vaccines did not become widely available until November 2009.

A scientific and medical report to President Obama in June stated that the 2009-H1N1 virus was the closest match to the 1918-H1N1 influenza A pandemic virus of any naturally emerging influenza strain identified to date. The most significant difference was that the 2009-H1N1 virus was missing the PB1-F2 protein that causes significant lung cell death. However, because it was so contagious, spreading globally in only a few months, there was significant concern that the virus would have plenty of opportunity to pick up the genetics for the lethal protein in any part of the world. The 1918-H1N1 was estimated to have killed up to 100 million people globally, primarily in its second wave. If the 2009-H1N1 had followed a similar pattern, the pandemic could have been catastrophic. Those most vulnerable to severity of disease and death continued to be vibrant young and middle aged adults. This situation had the potential to destabilize our already weakened economy for years to come and to threaten our family and social structure.

The decision to take this very seriously was based on protecting the nation against potentially horrific consequences. If the decision had been to ignore the potential threat and a catastrophic wave had hit, we could never have forgiven our unpreparedness. Pandemic periods last two to three years, and infectious waves emerge unpredictably with uncertain variations in virulence. Vigilance without panic is wisdom, preparing us not only for major disaster scenarios, but also for improving care during less severe, but similar events such as seasonal flu.

Are we better prepared now?

To assess lessons learned from those who saw the 2009-H1N1 pandemic surge of infected patients first-hand, Baylor Health Care System and Kimberly-Clark, in cooperation with the American Nurses Credentialing Center (ANCC), conducted a survey of 525 nurses. The 10-question surveys were distributed both at the Magnet Annual Conference and via e-mail to conference attendees in October 2010. Of the 2,050 surveys disseminated, 25.6 percent were completed. Results of the survey are presented below along with a discussion of the responses.

Question 1: Do you feel that your hospital is more prepared for the upcoming flu season than in years past?

As a result of the 2009-H1N1, hospitals were forced to seriously address preparation and best practices, and more research was focused on virus contamination and transmission. Those who were part of the experience now undoubtedly have more effective procedures in place and better ways to address airborne and droplet transmission.

Question 2: Has the potential for a pandemic influenza outbreak been incorporated into your hospital’s emergency management planning?

From the 2009-H1N1 experience, hospitals found the need to re-examine their pandemic planning and disaster planning. Areas of increased focus for the future include better isolation of potentially infected patients during in-processing, enhanced care of critical patients with respiratory illness, and improved procedures for care of large patient population of patients under airborne, droplet, and/or contact precautions. Additionally, increased attention to proper PPE selection and use are warranted, evaluating performance and likelihood of user compliance along with proper donning and removal techniques.

Question 3: Does your hospital have a pandemic planning executive or committee?

Hospitals should have a pandemic, or a combined pandemic and disaster committee to ensure the most up-to-date strategies are incorporated into the plans, and communicated to management and staff.

Question 4: Has a system been established at your hospital to report unusual cases of influenza-like illness and/or influenza-related deaths to the appropriate health authorities?

One of the take home lessons from 2009-H1N1 was that delayed, inaccurate, and incomplete reporting was a problem hindering accurate situation assessments and appropriate conclusions.

Question 5: How severe do you think this year’s flu season will be?

Results from this question are consistent with current predictions for a mild seasonal flu period in 2011. However, we must not drop our guard, remembering that pandemic waves follow their own time schedule. The 2009-H1N1 wave 1 started in March (immediately after the seasonal flu ended) and was winding down in the fall of 2009, at the official start of the next flu season.

Question 6: Hand washing is critical in helping to prevent the spread of the flu virus. How confident are you that your colleagues follow proper hand washing protocols?

The results from this question indicate room for improvement in hand hygiene. The hands of nurses and other healthcare professionals come in contact with many potentially contaminated surfaces: the patient, the patient’s linens, contaminated PPE, the open box of gloves or masks near the patient, and items contaminated by others who have not washed their hands. Hand hygiene and surface disinfection destroy significant pathogen reservoirs.

Question 7: Do you plan to get a flu vaccine this year?

The flu vaccine is critical to ensure healthy medical staff, reduce absenteeism and prevent the spread of influenza to colleagues, family, friends and contacts. While this result is encouraging, the goal should be 100 percent vaccination rate for healthcare professionals.

Question 8: Public health experts believe that enhanced programs aimed at preventing/reducing healthcare-associated infections (HAIs) are critical to preventing a flu pandemic. Assess your hospital’s HAI prevention program(s).

Only 40 percent of the responders to this question reported their hospital showed “much improvement.” This result could suggest that hospitals have already made great strides and required only minor additional improvements. However, it is more probable that hospitals devoted less attention to HAI prevention improvements generally because they were spending available resources handling staff absenteeism and the surge of influenza patients.

Question 9: Do you believe that the public is sufficiently educated about health benefits of HAI prevention programs?

The responses to this question were clearly divided; however, it is likely that all agree on the importance of public and patient education in HAI prevention. Additional educational efforts especially need to focus on understanding how visitors and patients can impact the spread of infections.

Question 10: Has your hospital developed language- and reading-level appropriate educational materials on pandemic influenza that are easily accessible for all staff?

Physicians and nurses focus a considerable amount of their formal education on infectious diseases and their prevention. However, allied health professionals often do not receive in-depth education training beyond their immediate responsibilities. Education on the “why’s” and “how’s” of infection prevention for aides, orderlies, central service staff, instrument technicians, and other hospital staff is a critical component of infection prevention programs, and requires language- and level-appropriate training.

What new research findings have emerged?

The 2009-H1N1 pandemic generated new research on both the pathology of the influenza virus and on the effectiveness of infection prevention measures. Below are some important findings from recent studies.

Pathogenicity of H1N1

A recent report in <I>Emerging Infectious Diseases<$> described the results of research on genetic reassortment of 2009-H1N1 virus with seasonal H1N1 and H3N2. “The data showed that pandemic (H1N1) 2009 virus has the potential to reassort with seasonal influenza viruses, which may result in increased pathogenicity while maintaining the capacity of transmission through aerosols or respiratory droplets.” This increased virulence occurred without acquiring the PB1/F2 protein (Schrauwen, 2011). The implications of these findings are evident when taken in the context of the situation in Southeast Asia, where cases of the extraordinarily lethal avian influenza A H5N1 still occur.  The 2009-H1N1 spread widely throughout this region as well. The WHO has calculated the current H5N1 human mortality rate to be approximately 60 percent—thus the possibility of a catastrophic combination of highly communicable, highly lethal reassortment is real.

Personal Protective Equipment (PPE)

The Institute of Medicine (IOM) recently published “Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases” emphasizing the need for better education addressing proper selection, use and safe removal of PPE. Research has shown that although respiratory droplets (>5 microns) are thought to be primary route of transmission for influenza, both respiratory and airborne droplet nuclei (<5 microns) are infectious. Thus, N95 respirators are appropriate for exposed, vulnerable care providers, especially while performing aerosol-generating procedures. The CDC has established a hierarchy to describe levels of respiratory protection appropriate for patient vulnerability and exposure risk of procedure (IOM, 2011).

Surface disinfection

The role of environmental contamination has become recognized as an important reservoir for pathogens. Historically, studies have demonstrated influenza virus survival to range from minutes to 48 hours. Recent studies on avian H5N1 influenza A demonstrated survival of up to two weeks on non-porous surfaces in low temperature, low humidity environments (Wood, 2010). Considering the many surfaces contaminated when an influenza patient coughs or is undergoing aerosol generating procedures, it is only logical that surface cleaning and stringent hand hygiene protocols are absolutely critical for transmission prevention. The influenza is easy to destroy using alcohol hand sanitizers or soap and water for hand hygiene, and detergent and water or EPA approved disinfectant wipes or fluids for surface disinfection.

Will there be more waves of infection?

Historically, pandemic outbreaks have occurred cyclically, with each episode lasting over several years. Even the infamous 1918 influenza was unremarkable during its first wave, with a low mortality rate; it was the second wave that was so catastrophic. Facing the history lesson of the 1918 pandemic and the similarities in the 2009-H1N1 virus, the CDC and the President appropriately prepared the nation for a disease that could have caused much more devastation. We must now incorporate the lessons learned from 2009-H1N1 wherever appropriate and educate healthcare staff, stressing the “why’s” along with the “how’s,” in order to improve patient care and staff protection.

I would like to acknowledge Leah Bernstein, PhD, for her writing assistance.

References

• Schrauwen EJA, Herfst S, Chutinimitkul S, et.al. Possible increased pathogenicity of pandemic (H1N1) 2009 influenza virus upon reassortment. <I>Emerg Infect Dis<$> 2011, [Accessed 4-Feb-2011]. http://www.cdc.gov/EID/content/17/2/200.htm.
• Institute of Medicine (IOM). Preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel update 2010. National Academy of Sciences. 2011. http://www.iom.edu/Reports/2011/Preventing-Transmission-of-Pandemic-Influenza-and-Other-Viral-Respiratory-Diseases.aspx.
• Wood JP, Young WC, Daniel J, et.al. Environmental persistence of a highly pathogenic avian influenza (H5N1) virus. Environ Sci Technol<$> 2010;44(19):7515-20.

Wava Truscott PhD, MBA, is director of Medical Sciences & Education at Kimberly-Clark Health Care. Ms. Truscott received her doctorate from the University of California, Davis (UCD) in Comparative Pathology with major emphasis areas of Microbiology, Immunology, and Pathology. Her MBA is from the University of La Verne (ULV) and her BS in Botany and Zoology from Brigham Young University (BYU). Dr. Truscott utilizes her years of experience in healthcare, knowledge of disease states and passion for infection prevention, to support product research, create accredited continuing education courses in healthcare, and author healthcare and scientific articles. She is a well known international speaker and has written several book chapters and over 60 professional articles.

Threats in Healthcare Settings

MRSA in Healthcare Settings

MRSA stands for methicillin-resistant Staphylococcus aureus. This type of bacteria causes “staph” infections that are resistant to treatment with usual antibiotics. MRSA occurs most frequently among patients who undergo invasive medical procedures or who have weakened immune systems and are being treated in hospitals and healthcare facilities such as nursing homes and dialysis centers. MRSA in healthcare settings commonly causes serious and potentially life-threatening infections, such as bloodstream infections, surgical site infections or pneumonia.

In addition to healthcare associated infections, MRSA can also infect people in the community at large, generally as skin infections that look like pimples or boils and can be swollen, painful and have draining pus. These skin infections often occur in otherwise healthy people.

How MRSA Spreads in Healthcare Settings

When we talk about the spread of an infection, we talk about sources of infection—where it starts, and the way or ways it spreads—the mode or modes of transmission. In the case of MRSA, patients who already have an MRSA infection or who carry the bacteria on their bodies but do not have symptoms (colonized) are the most common sources of transmission. The main mode of transmission to other patients is through human hands, especially healthcare workers’ hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized patients. If appropriate hand hygiene such as washing with soap and water or using an alcohol-based hand sanitizer is not performed, the bacteria can be spread when the healthcare worker touches other patients.

MRSA and the Expensive Results of Antimicrobial Resistance

Along with Staphylococcus aureus, many significant infection-causing bacteria in the world are becoming resistant to the most commonly prescribed antimicrobial treatments. What causes this and what does it mean? Antimicrobial resistance occurs when bacteria change or adapt in a way that allows them to survive in the presence of antibiotics designed to kill them. In some cases bacteria become so resistant that no available antibiotics are effective against them. At this time, treatment options still exist for healthcare-associated MRSA but are limited because healthcare-associated MRSA is resistant to many antibiotics.

People infected with antibiotic-resistant organisms like MRSA are more likely to have longer and more expensive hospital stays, and may be more likely to die as a result of the infection. When the drug of choice for treating their infection doesn’t work, they require treatment with second- or third-choice medicines that may be less effective, more toxic and more expensive. So this means that if you or I get an MRSA infection, we may suffer more, and we may pay more for our treatment. Yet American society as a whole suffers more and pays more too because of the increased burden and expense in the healthcare system.

A Growing Problem in the Healthcare Setting,

MRSA is becoming more prevalent in healthcare settings. According to CDC data, the proportion of infections that are antimicrobial resistant has been growing. In 1974, MRSA infections accounted for 2 percent of the total number of staph infections; in 1995 it was 22 percent; in 2004 it was some 63 percent. The good news is that MRSA is preventable. The first step to prevent MRSA is to prevent healthcare infections in general. Infection prevention guidelines produced by CDC and the Healthcare Infection Control and Prevention Advisory Committee (HICPAC) are central to the prevention and control of healthcare infections and ultimately, MRSA in healthcare settings. To learn more about infection control guidelines to prevent infections and MRSA go to www.cdc.gov/ncidod/dhqp.

CDC, state and local health departments, and partners nationwide are collaborating to prevent MRSA infections in healthcare settings. For example, CDC:

• monitors trends in infections and MRSA through surveillance systems such as the National Healthcare Safety Network, formerly the National Nosocomial Infection Surveillance System and the Dialysis Surveillance Network to identify which patients are at highest risk and where prevention efforts should be targeted.
• works with multiple prevention partners including state health departments, academic medical centers, and regional and national collaboratives to identify and promote effective strategies to prevent MRSA transmission.
• developed an overarching strategy to help guide healthcare facilities to control antibiotic resistance called The Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. This campaign includes specific strategies for various healthcare populations, including hospitalized adults and children, dialysis patients, surgical patients and long-term care patients.

Important Facts for Healthcare Personnel

Methicillin-resistant Staphylococcus aureus (MRSA) has become a prevalent nosocomial pathogen in the United States. In hospitals, the most important reservoirs of MRSA are infected or colonized patients. Although hospital personnel can serve as reservoirs for MRSA and may harbor the organism for many months, they have been more commonly identified as a link for transmission between colonized or infected patients. The main mode of transmission of MRSA is via hands (especially healthcare workers’ hands) which may become contaminated by contact with a) colonized or infected patients, b) colonized or infected body sites of the personnel themselves, or c) devices, items or environmental surfaces contaminated with body fluids containing MRSA. Standard Precautions, as described in the “Guideline for Isolation Precautions in Hospitals” (Infect Control Hosp Epidemiol 1996;17:53-80), should control the spread of MRSA in most instances.

Standard Precautions

Handwashing

Wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.

Gloving

Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

Masking

Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.

Gowning

Wear a gown (a clean, nonsterile gown is adequate) to protect skin and prevent soiling of clothes during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions, or cause soiling of clothing.

Appropriate device handling

Handle used patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed, and that single-use items are properly discarded.

Handling of laundry

Handle, transport and process used linen soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.

Contact Precautions

If MRSA is judged by the hospital’s infection prevention program to be of special clinical or epidemiologic significance, then Contact Precautions should be considered. Contact Precautions consist of:

• Placing a patient with MRSA in a private room. When a private room is not available, the patient may be placed in a room with a patient(s) who has active infection with MRSA, but with no other infection (cohorting).
• Wearing gloves (clean, nonsterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (e.g., fecal material and wound drainage). Remove gloves before leaving the patient’s room and wash hands immediately with an antimicrobial agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients and environments.
• Wearing a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces or items in the patient’s room, or if the patient is incontinent, or has diarrhea, an ileostomy, a colostomy or wound drainage not contained by a dressing. Remove the gown before leaving the patient’s room. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients and environments.
• Limiting the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.
• Ensuring that patient-care items, bedside equipment and frequently touched surfaces receive daily cleaning.
• When possible, dedicating the use of noncritical patient-care equipment and items such as stethoscope, sphygmomanometer, bedside commode or electronic rectal thermometer to a single patient (or cohort of patients infected or colonized with MRSA) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use on another patient.

Culturing of Personnel and Management of Personnel Carriers of MRSA

Unless the objective of the hospital is to eradicate all MRSA carriage and treat all personnel who are MRSA carriers, whether or not they disseminate MRSA, it may be prudent to culture only personnel who are implicated in MRSA transmission based on epidemiologic data. MRSA-carrier personnel who are epidemiologically linked to transmission should be removed from direct patient care until treatment of the MRSA-carrier status is successful. If the hospital elects to culture all personnel to identify MRSA carriers, a) surveillance cultures need to be done frequently, and b) it is likely that personnel colonized by MRSA who are not linked to transmission and/or who may not be MRSA disseminators will be identified, subjected to treatment, and/or removed from patient contact unnecessarily. Because of the high cost attendant to repeated surveillance cultures and the potential of repeated culturing to result in serious consequences to healthcare workers, hospitals should weigh the advantages and the adverse effects of routinely culturing personnel before doing so.

Control of MRSA Outbreaks

When an outbreak of MRSA infection occurs, an epidemiologic assessment should be initiated to identify risk factors for MRSA acquisition in the institution; clinical isolates of MRSA should be saved and submitted for strain typing. Colonized or infected patients should be identified as quickly as possible, appropriate barrier precautions should be instituted, and handwashing by medical personnel before and after all patient contacts should be strictly adhered to.

All personnel should be reinstructed on appropriate precautions for patients colonized or infected with multi-resistant microorganisms and on the importance of handwashing and barrier precautions in preventing contact transmission. If additional help is needed by the hospital, a consultation with the local or state health department or CDC may be necessary.

Sources:

Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion (DHQP), National Center for Preparedness, Detection, and Control of Infectious Diseases. For more information visit www.cdc.gov.

Emerging Infectious Diseases

Heavy metals, sharps, cleaners, blood, blood products and other infectious materials, are abundant in hospital stings.. The risk for infection and cross-contamination exists in every area of every hospital. Wet or soiled dressings, devices used in diagnostics and treatment, and surfaces such as doorknobs, floors and toilets can all act as vehicles for the transmission of infection. The stakes are high. But infection can be limited and reduced.

Infectious waste  in the OR.

Training, policies and regulations are tools not cures. An effective waste management program incorporates all aspects of infection prevention, beginning with the acquisition of materials that eventually become waste, to appropriate training, safe handling, labelling, storage, segregation, disposal and other healthy workplace initiatives. We most often think of infection control from the patient to healthcare worker and sometimes from the healthcare worker to the patient. Rarely do we think about patient to patient, healthcare worker to apparatus or apparatus (even as simple as a garbage disposal) to healthcare worker transmissions. Since there are such a wide variety of ways to get infected, members of your infection control team need to work with waste management and with environmental services (laundry, cleaning) to ensure that all employees are well trained.

Train each employee several times using employee orientation programs, annual updates and as-needed while doing rounds. Remember that each individual learns differently, so use different training methods, including lots of physical examples of wastes, during training. Ensure your training schedule catches all staff, including relief and night shifts. Adapt your training to the needs of different departments (emergency versus ICU) and different stakeholders, especially physicians working in the operating room versus nurses doing emergency intake.

Consider introducing departmental specific policies, which work in areas such as laboratories. Work with lab employees and the infection control team to identify appropriate methods of segregation for pipettes, syringes, loops and other items. Gather the various items together and make decisions based on regional regulations and local input. Then write down what you have decided, and create posters with pictures that indicate each type of waste. Ensure that all new lab personnel are trained in proper waste segregation and do annual “reminder” training with all lab staff.

Legislation is in place at the federal, state and local level to ensure waste is handled and disposed of in ways that will prevent the spread of infection. Different facilities have different rules depending on who, what and how much waste is produced. It’s up to us to know what laws and rules apply to our own particular facility. Under the Resource Conservation and Recovery Act (RCRA) for example, hospitals are required to minimize waste generation, but toxins still slip through the cracks, down drains that flow into rivers and lakes, into landfills that contaminate soil and streams, or into the air through incineration. We still see the dangerous practice of mixing materials (infectious waste with food leftovers, batteries and chemicals with newspaper, memos and coffee cups) and using unnecessary and costly high-level treatments.

Before any improvement in infection prevention can occur we need to establish good definitions of waste, outline who handles waste and identify the processes for disposing of all these infectious materials. The three main categories of waste are:

1. Hazardous materials; Raw materials or products stored and used in a healthcare facility. These materials are considered to pose a significant risk to people or property.
2. Hazardous wastes; Applies to certain materials generated as wastes from processes at your facility. Materials meet criteria in the federal Resource Conservation and Recovery Act.
3. Universal wastes; A category of wastes established by the Environmental Protection Agency (EPA) to encourage recycling of items that may otherwise be classified as hazardous wastes. Examples include batteries, thermostats, lamps and pesticides.

The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. Under this plan when standards fail to be met a hospital would be refused accreditation. Many states anticipated stricter regulations and already have waste management plans that meet the EPA’s MACT rule. Various Acts, such as the Resource Recovery and Conservation Act, the Clean Air Act, and the Clean Water Act are also in place to guide our actions. Several other agencies are involved in regulating hazardous waste and materials, including the EPA, the Occupational Safety and Health Administration (OSHA), and the U.S. Department of Transportation. Ensure you know the rules, and how the management of waste can impact infection prevention procedures.

Who Is Responsible For Safety?

It’s not enough to just know our job anymore. We need to know the hazards associated with our industry, how to prevent incidents and what to do in an emergency. Training for infection control needs to be thorough, relevant and understood, built into every employee orientation session, updated and reinforced at regular intervals. Infection prevention is everyone’s responsibility.

Employers are responsible for safe handling policies and clearly establishing roles and responsibilities. They are also obligated to keep staff in the loop concerning all new health and safety requirements, for ensuring incidents are properly investigated and reported and for monitoring practices within the organization.

Employees are responsible for being familiar with emergency and waste management policies and must act in their own best interest as well as their coworkers, patients and the facility. Employees should be prepared to:

• Report any unsafe condition involving waste materials or substances, with the goal of eliminating a hazard before it causes a problem.
• Assist with the reporting process. Keeping track of incidents may point to a need for additional training or a new process. Analyzing what went wrong is critical to reducing the possibility of a reoccurrence.
• Ensure waste is correctly sealed and labelled prior to being collected and transported. All waste must be handled and correctly disposed of by trained, authorized staff.
• Assist in waste reduction initiatives and recommend safe work practices.

Segregation

To determine what waste poses the most risk, we must have a clear knowledge of the waste stream. Failure to properly separate wastes means some of the waste leaving our facilities is potentially infectious and hazardous. Colors indicate specific waste types; however, these color categories may vary at your facility. Normally, colors mean:

• Red—Biohazardous, biomedical, infectious, regulated medical;
• Yellow, White—Chemotheraphy—trace/debris or hazardous waste;
• Blue—Chemotherapy—trace/debris;
• Purple, Magenta, Yellow—Radioactive;
• Dark Blue—Hazardous waste.

When handling waste, always use appropriate protective clothing and equipment (gloves, aprons, etc.) and maintain good hand hygiene. To prevent the risk of spills or injury do not carry waste bags for long distances and restrict storage areas to authorized personnel only. Keys to proper segregation include:

• Standardize all waste receptacles, placement and signage;
• Place Red bags in a central location;
• Use open containers for clean waste, closed for Red bag waste;
• Use signage above and on all containers to explain acceptable waste;
• Avoid placing Red bag waste containers under sinks and in hallways;
• Always place a non-regulated waste container beside the regulated container;
• Remove Red bag containers from patient rooms except those in isolation;
• Check state regulations regarding isolation waste requirements;
• Pay special attention to high generating areas (operating room, labs and dialysis);
• Monitor work areas;
• Consider tracking generation rates, employee training and rounding through the Hazardous Material and Waste Management Plan.

Special Items to Consider

Waste generated by healthcare facilities includes sharps and non-sharps, blood, body parts, chemicals, medical devices and other materials, some more likely to cause infection than others.

Sharps

Healthcare workers are at greatest risk for sharps injuries. Sharps are singled out for special regulatory provisions by many states. The Centers for Disease Control and Prevention (CDC) estimates that more than 800,000 accidental needlesticks occur each year among healthcare workers. Sharps (syringes, needles, scalpels, lancets, contaminated glassware or plastics such as vials, tubes and slides) should be placed in rigid, puncture and leak-resistant containers that cannot be easily opened after locking. Research identifies the ideal mounting height of 52 to 56 inches from the floor to the collector opening. Containers should be placed in visible locations away from pedestrian traffic, swinging doors and other obstacles. Containers must be clearly marked with the biohazard symbol and placed in bio-hazardous waste containers.

Best practice should emphasize the need for correct handling before, during and after use, and the safe disposal of sharps. Consider purchasing sharps that have built-in safety features that are aimed at reducing the risk of needlestick injuries. Safety features can be classified as:

• Integrated safety features that form part of the basic design of the device and cannot be removed;
• Passive safety features that don’t need users to activate them and are effective before, during and after use;
• Active safety features that need users to activate them before the device is used.

Ensure your sharps containers are puncture-resistant and leak-proof even if they are dropped or fall over. To reduce infection transmission, the containers should have an opening aperture that when the container is being used normally doesn’t allow the contents to be removed, but is of a size such that items can be disposed into the container using one hand without contaminating the outside of the container.

Other points to keep in mind:

• Do not re-sheath needles by hand;
• Do not bend or break needles before or after use;
• Do not pass sharps directly from hand to hand—an exception to this may be when passing the scalpel to/from the scrub nurse to the surgeon, though many facilities have chosen hands-free methods for this as well;
• Only dispose of syringes/cartridges and needles intact;
• Never overfill sharps containers (keep below the manufacturer’s fill line);
• Do not mix sharps with other clinical waste;
• Do not place sharps containers in yellow bags for disposal;
• Position sharps bins away from public areas, and out of reach of children;
• Do not remove sharps from clinical settings.

Infectious Substances and Materials

This waste includes infectious or potentially infectious pathological waste, blood, other body fluids, waste cultures and stocks. One area to look at to reduce infection from these wastes is in the OR. Suction canisters can be responsible for up to 40 percent of infectious waste in the OR. Because a solidifying material is usually added to the canister, employees can be exposed to splashing and spills when adding the solidifier. Fluid management systems offering mechanical disposal of waste and disinfection of the canisters may help reduce risk of exposure. Mechanical disposal and disinfection reduces transportation cost, removes canisters from the waste stream and meets OSHA’s standards. Canister-free vacuum systems reduce the risk of employee exposure and the amount of waste needing to be shipped out.

Laundry

Soiled laundry, except from patients in isolation, represents a small risk of infection as long as commonsense prevails for handling, processing and storage. Minimal handling and agitation of soiled laundry to prevent air and surface contamination is recommended. These textiles should be bagged or placed in labelled or color-coded containers at the location in which they were used. Linens contaminated with blood or body fluids require leak-proof bags.

Chemicals, Cleaners, Pesticides

While we recognize cleaning, disinfection and sterilization processes are designed to maintain a safe environment, the chemicals used in these procedures have a degree of toxicity necessary to kill micro-organisms. Chemicals are technically hazardous materials that produce hazardous wastes, but are sometimes not managed as such. To minimize exposure to chemicals, select the lowest level of product or process that will still do the job.

Reviewing your operations may lead to new ways of reducing infection. Remove carpeting from areas where moisture is present, and install walk-off mats at entrances to reduce use of harsh cleaners. Replace sprays with pour-and-wipe products to reduce airborne contaminants. Buffing floors can aerosolize polymers and because respiratory problems, however vacuum attachments help minimize exposure. Relatively new introductions such as microfiber mops, auto-scrubbers and extraction machines are also helping to reduce chemical use, while providing the same if not a better level of infection prevention.

Weak Link

These are just a few of the processes and innovations taking place in everyday healthcare to manage waste and prevent infection. Does it seem like we’ve thought of everything? Unfortunately, we have not. There’s always the unknown. The human component is both our greatest weakness and our strongest defense in the fight against infection. Take care, arm yourself with information, get to know your surroundings, ask questions and learn what you can do to contribute to a safer workplace. Help train others and be a role model for them. Remember that infection can be transmitted in many ways, some that we may not normally think of, and from many different places and people in your facility.

Sources

• www.nihe.org/elevreng.html: The Nightingale Institute for Health and the Environment—The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. The plan is when standards fail to be met a hospital would be refused accreditation. Many states anticipated stricter regulations some years ago and have already taken steps to develop waste management plans that meet the EPA’s new MACT rule.
• www.oeconline.org/our-work/kidshealth/toxics/air/dioxins: Dioxin link to birth defects may be found here and on several other Web sites.
• www.leedsteachinghospitals.com/sites/infection_control/documents/uniinf00.pdf:Universal Infection Control Precautions—Sharps.
• www.wildirismedical.com/courses/167/index_mand.html: Infection Control Guidelines (Continued education) CDC recommendations for blood, fluids, ground tissues.
• www.surgistrategies.com/articles/or-arena-jan-09-wastemanagement.html: Sharps container placement.
• www.practicegreenhealth.org
• www.osha.gov/SLTC/hazardcommunications/whatishazcom
• www.epa.gov/epawaste/hazard/wastetypes
• www.cdc.gov
• www.des.state.nh.us/nhppp/Healthcare_p2/default.asp?link=faq5.
• www.healthcarea2z.org/stdPage.aspx/home/Wastemanagement/CoreContent/Sharpsmanagement#sec_780
• The federal Resource Conservation and Recovery Act.

Emerging Infectious Diseases

Pertussis is the most common vaccine-preventable childhood disease and can be more severe than often assumed. Most pertussis-related deaths occur in infants younger than 4 months. All infants less than 6 months of age, and any infant who has not yet received three doses of pertussis-containing vaccine, are especially vulnerable to pertussis infection and often require hospitalization for supportive care for coughing spasms and feeding difficulties. Adolescents and adults with pertussis generally have mild symptoms that do not require hospitalization.

Pertussis rates have increased over the last two decades, primarily in adolescents and adults who have waning immunity from previous pertussis vaccinations or infection; however, it is infants who are too young to be vaccinated that bear the burden of severe pertussis. Low vaccination rates against pertussis among adolescents and adults are a contributing factor to the rise of the highly contagious and sometimes deadly disease, commonly known as whooping cough.

A new monograph from The Joint Commission, “Tdap Vaccination Strategies for Adolescents and Adults, Including Health Care Personnel – Strategies from Research and Practice,” aims to help healthcare organizations implement or enhance tetanus, diphtheria and acellular pertussis (Tdap) vaccination programs for adolescents and adults, including healthcare workers who can both acquire pertussis from and spread it to patients, other staff and family members.

The Tdap vaccine has been available only since 2005 and information from the Centers for Disease Control and Prevention (CDC) shows that vaccination rates for adults are very low. Tdap vaccination rates among healthcare workers stands at about 16 percent, according to the CDC, despite the evidence that Tdap improves patient outcomes and reduces staff illness and absenteeism. The CDC reports that adults may not realize that some of the vaccines they received in childhood will not protect them throughout their lives or that newer vaccines have been developed since they were first immunized.  In addition, some adults simply were never vaccinated. These adolescents and adults play a significant role in the transmission of pertussis to vulnerable infants at home, in the community, and in healthcare and day care settings.

The monograph, which was supported by an educational grant from sanofi pasteur, was produced and published in partnership with infection prevention and infectious disease leaders from the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA) and the National Foundation for Infectious Diseases (NFID).

“Recent pertussis outbreaks should be a reminder of how serious and contagious pertussis can be and the value of Tdap vaccination,” said Jerod M. Loeb, PhD, executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission. “This monograph includes strategies that organizations can implement and provides a foundation to improve vaccination rates among key populations. It is also a timely reminder that vaccinations save lives.”

The monograph includes:

• Information about pertussis and the Tdap vaccine.
• Barriers to successful Tdap vaccination programs and strategies for overcoming them.
• Evidence-based guidelines and literature that highlight practical Tdap vaccination strategies.
• Examples of initiatives that organizations have used to establish or enhance their Tdap vaccination programs.

The Joint Commission solicited leading practices to incorporate into the monograph and received more than 80 submissions from healthcare organizations. A subset of submissions was evaluated by the project’s editorial review panel; ultimately, 17 submissions were included in the monograph. Electronic copies of the monograph are available on The Joint Commission’s Web site at www.jointcommission.org, and can be downloaded free of charge.

Catheter-associated urinary tract infections

Urinary tract infections (UTIs) account for 40 percent of all healthcare-associated infections (HAIs), according to the Centers for Disease Control and Prevention (CDC). Urinary catheters are associated with the vast majority of those healthcare-acquired UTIs.(1) Floyd Medical Center is utilizing the ERASE CAUTI Foley catheter management system along with facility-wide physician and nurse education on the appropriate use of catheters and the importance of avoiding catheters when not medically necessary, to reduce its CAUTI rates. Floyd earned first place in VHA Georgia’s 2010 Clinical Excellence award category.

A comprehensive catheterization process improvement initiative has led Georgia-based Floyd Medical Center to an 83 percent reduction in catheter-associated urinary tract infections (CAUTIs) and a 23 percent decline in the number of catheterizations performed at the hospital. In recognition of its accomplishments.

“We forged a hospital-wide initiative focused on reducing catheter use and related urinary tract infections,” said Darrell Dean, DO, MPH, medical director for clinical and operational performance improvement at Floyd Medical Center. “The ERASE CAUTI Foley catheter management system and tray has many design elements and product enhancements that were integral in our program to reduce variation in practice and achieve our goal of reducing CAUTI.”

Dr. Dean cited the kit’s larger sterile barrier drape and one-layer tray design versus the industry standard two-layer tray as important factors to helping the nursing staff maintain aseptic technique. He also pointed to the tray’s checklists as vital tools to CAUTI prevention—one that helps document a valid clinical reason for inserting a catheter and another that reviews the proper steps to catheter insertion. Upon completion, the checklists are then adhered to the patient’s chart for proper documentation of insertion.

In 2008, Floyd had 14 documented CAUTIs or 2.74 per 1,000 catheter days, which falls between the National Health Safety Network’s (NHSN) 50th and 75th percentile for all hospitals. The hospital began its initiative to reduce HAIs in March 2009 with the goal of reducing CAUTIs by 25 percent. For all of 2009, the hospital had only six CAUTIs or 1.17 CAUTIs per 1,000 catheter days, which represented a 53.7 percent reduction, exceeding the initial goal. This placed the hospital between the NHSN’s 10th and 25th percentile. For the first quarter of 2010, the hospital has experienced zero CAUTIs.  In addition to CAUTI reduction, the number of days a catheter was used went from 1,209 to 925, or a 23 percent drop, from March 2009 to March 2010.

Dr. Dean led the hospital’s CAUTI prevention team. He performed a chart analysis of 30 random patients with urinary catheters hospitalized during 2008 with a principal or secondary diagnosis of urinary tract infection. He identified several issues that guided his team through the improvement process, including the practice of inserting urinary catheters in the emergency department in order to collect a urine sample and then failing to remove the catheter once the sample was obtained. He also discovered that 73 percent of all catheters were inserted in the emergency department.

“We started using Medline’s Foley InserTag, a yellow sticker that wraps around the drain tubing with the date and time of the Foley insertion clearly visible to the caregivers, said Dr. Dean. “We also used a checklist sticker placed on the patient’s chart as a daily reminder for our nurses and physicians about the reason for catheter insertion, when it was inserted and whether the need for the catheter still exists or can be removed.”

References

1. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 2008; 24(6).

Floyd Medical Center, based in Rome, Ga., is a 304-bed non-profit teaching community hospital serving Northwest Georgia and Northeast Alabama. Floyd Medical Center has a state-designated Level II Trauma Center, a behavioral health center, primary care and urgent care network of providers. Floyd Medical Center also hosts a realm of outpatient services, including operation of the Floyd County Clinic and an associated pharmacy for uninsured patients who cannot otherwise afford healthcare.

Sponges Left Behind

by William W. Steward, MD

The most commonly reported surgical error is retained surgical sponges?  The February 2011 edition of The Joint Commission Journal for Quality and Patient Safety includes the publication of a comprehensive, independent research study on what is estimated to be the most commonly reported surgical error is retained surgical sponges.

According to occurrence rates substantiated in the study, a surgical sponge is left behind in a patient once every approximately 8,000 operations.(1) Additionally, consistent with previous studies,(2,3) the vast majority of retained sponges were found to occur despite a “correct” count being reported before completion of the operation. Given how these items are used in surgery, the number of individual sponges used and their physical properties, combined with the inherently demanding, chaotic and pressured environment of the operating room, surgical teams should be applauded for getting their counts correct the vast majority of the time.

However even this seemingly low occurrence rate translates into a significant number of actual events. With an estimated 32 million procedures performed annually in the United States, an occurrence rate of one in 8,000 implies approximately 4,000 retained sponge annually, just under 11 events every single day. Data made publicly available through state mandated reporting of adverse events in hospitals sheds additional perspective on the prevalence of this error, as the information consistently demonstrates that retained surgical sponges are the most commonly reported surgical adverse event.(4)

For the patient, retained sponges are typically associated with significant morbidity, including intestinal obstruction, intra-abdominal abscess, peritonitis, discharging sinus, visceral perforation, re-operations to remove the object and even death.(5,6) Though not physically impacted, the human cost of these events extends beyond the patient, as the entire surgical staff involved can typically expect a range of legal and professional ramifications.

Though estimates vary of the actual total costs involved with retained sponge incidents, the economic consequences are undeniably significant. Direct costs can include legal fees, settlement payments, non-reimbursable additional healthcare services (additional surgery to remove the item, the treatment of any infections, additional hospital stays), loss of reputation (including both healthcare institutions and all involved surgical staff), government fines, higher insurance premiums, compromised operating room efficiency and loss of time (establishing and maintaining root cause committees, implementing corrective measures, staff meetings, depositions). Taking a closer look at just the estimated legal and additional healthcare service costs alone helps put the total costs of these events into perspective. According to the U.S. Health and Human Services, the average medical malpractice payment since 1990 has been $234,318.(7) Non-reimbursable additional surgery and related care expenses from retained sponges are estimated by the Center for Medicare & Medicaid Services to average $63,000 per incident.(8) These two variables alone imply approximately $300,000 in costs per retained sponge. Assuming the 4,000 annual events estimated above, the legal and medical costs from retained sponges are costing hospitals in the United States over $1.2 billion every year.

The study mentioned above recently published in The Joint Commission Journal on Quality and Patient Safety, entitled, Using a Data-Matrix-Coded Sponge Counting System Across a Surgical Practice: Impact After 18 Months, is the most comprehensive study ever published on the subject of retained surgical sponges. In addition to trials over a multi-year period, over 1.8 million sponges were used in over 87,000 procedures. Completely independent in nature and performed by researchers at one of the most renown healthcare institutions in the world, the study suggest that retained surgical sponges, and the costs associated with them, are entirely preventable with a proven and cost-effective solution. The institution implementing the solution, called the SurgiCount Safety-Sponge® System, eliminated the occurrence of retained surgical sponges over the course of the entire 18 months of use.

The peer-reviewed study details two randomized, controlled trials conducted at a high-volume surgical practice, the subsequent implementation of the Safety-Sponge System across all 128 operating rooms at the affiliated institution, and a comprehensive evaluation of the solution after 18 months of use. The trial evaluated the Safety-Sponge System’s effectiveness on reducing retained surgical sponges, efficiency, impact on operative time, ergonomics and staff satisfaction. Key results of the study include:

Prior to implementation, a retained surgical sponge occurred at the institution approximately every 64 days.

• During the study, 87,404 procedures were performed over 18 months using 1,862,373 Safety-Sponges. None were retained.
• Use of the Safety-Sponge System caused no workflow disruption or increase in case duration.
• Staff satisfaction with the Safety-Sponge System was acceptable with a high degree of trust in the system.
• The Safety-Sponge System was found to be highly reliable and cost-effective.

Though this study alone presents a significant amount of evidence as to the clinical effectiveness of the Safety-Sponge System, the aggregate usage data of the solution is overwhelming. To date, an estimated 36 million Safety-Sponges have been used in over 1.6 million procedures with no retained sponges in any case where the solution was utilized. Additionally, current users include a growing number of teaching, community and government hospitals, including five of the 14 U.S. News and World Report 2010-2011 Honor Roll Hospitals. This represents more Honor Roll Hospitals than all other sponge technologies combined.

The SurgiCount Safety-Sponge System is a complete sponge counting and documentation system shown to help prevent the occurrence of retained sponges by assuring a more accurate accounting of those items before and after surgery. By labeling each sponge with a unique identifier, the system helps to prevent users from incorrectly counting the individual sponges and unintentionally leaving one inside the patient. In addition to a world class customer base already successfully using the product, the solution is the most cost effective sponge technology available.(9) Further, unlike radio frequency based solutions that have been shown in numerous studies to introduce the possibility of electromagnetic interference,(10,11) the SurgiCount Safety-Sponge technology introduces no such risk.

With a cost-effective solution proven to help hospitals eliminate the most commonly reported surgical adverse event, hospitals should highly consider implementing the SurgiCount Safety-Sponge System to better protect their surgeons and operating room staff, reduce preventable costs and provide the highest standard of care to their patients.

References

1. Robert R. Cima, M.D., et al: Using a Data-Matrix-Coded Sponge Counting System Across a Surgical Practice: Impact After 18 Months, The Joint Commission Journal on Quality and Patient Safety, February 2011, pg. 51-58.
2. Robert R. Cima, M.D., et al: Incidence and Characteristics of Potential and Actual Retained Foreign Object Events in Surgical Patients, Journal for the American College of Surgeons, Vol. 207, No. 1, July 2008.
3. Caprice Greenberg, MD, MPH, Atul Gawande, MD, MPH, Beyond Counting: Current Evidence on the Problem of Retained Foreign Bodies in Surgery?, Annals of Surgery, Volume 247, Number 1, January 2008.
4. Minnesota Department of Health, Adverse Events in Minnesota; First, Second, Third, Fourth, Fifth, Sixth and Seventh Annual Public Report.
5. Gonzalez-Ojeda A., et al; Retained foreign bodies following intra-abdominal surgery. <I>atogastroenterology 46:808-812, Mar.-Apr. 1999.
6. Ahmad G., et al; Retained sponge after abdominal surgery, J Coll Physicians Surg Pak. 2003 Nov; 13(11):640-3.
7. U.S. Health and Human Services, 2006 Annual Report of the National Practitioner Data Bank.
8. Center for Medicare & Medicaid Services, Proposed Changes to the Hospital IPPS and FY2009 rates.
9. Atul A. Gawande, MD, MPH, FACS, et al; Novel strategies to prevent retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness, Journal of the American College of Surgeons, 2008.06.183.
10. 10.  Seth J. Seidman, Food and Drug Administration, et al; Electromagnetic compatibility of pacemakers and implantable cardiac defibrillators exposed to RFID readers, Int. J. Radio Frequency Identification Technology and Applications<$>, Vol. 1, No. 3, 2007.
11. 11.  Binita S. Ashar; Ann Ferrier, Radiofrequency Identification Technology in Health Care: Benefits and Potential Risks, JAMA, November 21, 2007, Volume 298, No. 19.

William W. Stewart, M.D., is a board certified urologist who has been in practice for more than 30 years. He has researched patient safety issues for the past 20 years and is the co-founder of SurgiCount Medical and co-inventor of the Safety-Sponge® System.

Emerging Infectious Diseases

Medical waste poses a wide spread threat throughout a hospital facility. Workers and patients are surrounded by heavy metals, sharps, cleaners, blood, blood products and other infectious materials The list is endless. The potential for infection and cross-contamination exists in every area of the hospital. Wet or soiled dressings, devices used in diagnostics and treatment, and surfaces such as doorknobs, floors and toilets can all act as vehicles for the transmission of infection. The stakes are high. But infection can be limited and reduced by incorporating solid and strict principles of waste management.

Careful handling of potentially infectious pathological waste is essential in the OR.

An effective waste management program incorporates all aspects of infection prevention, beginning with the acquisition of materials that eventually become waste, to appropriate training, safe handling, labelling, storage, segregation, disposal and other healthy workplace initiatives. We most often think of infection control from the patient to healthcare worker and sometimes from the healthcare worker to the patient. Rarely do we think about patient to patient, healthcare worker to apparatus or apparatus to healthcare worker transmissions. Since there are such a wide variety of ways to get infected, members of your infection control team need to work with waste management and with environmental services such as laundry and cleaning to ensure that all employees are well trained.

Employee training

Training each employee several times using employee orientation programs, annual updates and daily as-needed sessions while doing rounds. Each individual learns differently, so use different training methods, including lots of physical examples of wastes, during training. Ensure your training schedule catches all staff, including relief and night shifts. Adapt your training to the needs of different departments. For example emergency room versus ICU, and different stakeholders like physicians working in the operating room versus nurses doing emergency intake.

Make department specific plans

Department specific policies are effective in areas such as laboratories. Work with lab employees and the infection control team to identify appropriate methods of segregation for pipettes, syringes, loops and other items. Gather the various items together and make decisions based on regional regulations and local input. Then write down what you have decided, and create posters with pictures that indicate each type of waste. Ensure that all new lab personnel are trained in proper waste segregation and do annual “reminder” training with all lab staff.

Legislation is in place at the federal, state and local level to ensure waste is handled and disposed of in ways that will prevent the spread of infection. Different facilities have different rules depending on who, what and how much waste is produced. It’s up to us to know what laws and rules apply to our own particular facility.

Under the Resource Conservation and Recovery Act (RCRA) for example, hospitals are required to minimize waste generation, but toxins still slip through the cracks, down drains that flow into rivers and lakes, into landfills that contaminate soil and streams, or into the air through incineration. We still see the dangerous practice of mixing materials (infectious waste with food leftovers, batteries and chemicals with newspaper, memos and coffee cups) and using unnecessary and costly high-level treatments.

Establish good definitions

Before any improvement in infection prevention can occur we need to establish good definitions of waste, outline who handles waste and identify the processes for disposing of all these infectious materials. The three main categories of waste are:

1. Hazardous materials.  Raw materials or products stored and used in a healthcare facility. These materials are considered to pose a significant risk to people or property.
2. Hazardous wastes.  Applies to certain materials generated as wastes from processes at your facility. Materials meet criteria in the federal Resource Conservation and Recovery Act.
3. Universal wastes. A category of wastes established by the Environmental Protection Agency (EPA) to encourage recycling of items that may otherwise be classified as hazardous wastes. Examples include batteries, thermostats, lamps and pesticides.

The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. Under this plan when standards fail to be met a hospital would be refused accreditation.

Many states anticipated stricter regulations and already have waste management plans that meet the EPA’s MACT rule. Various Acts, such as the Resource Recovery and Conservation Act, the Clean Air Act, and the Clean Water Act are also in place to guide our actions. Several other agencies are involved in regulating hazardous waste and materials, including the EPA, the Occupational Safety and Health Administration (OSHA), and the U.S. Department of Transportation. Ensure you know the rules, and how the management of waste can impact infection prevention procedures.

Whose Job is it?

It’s not enough to just know our job anymore. We need to know the hazards associated with our industry, how to prevent incidents and what to do in an emergency. Training for infection control needs to be thorough, relevant and understood, built into every employee orientation session, updated and reinforced at regular intervals. Infection prevention is everyone’s responsibility.

Employers are responsible for safe handling policies and clearly establishing roles and responsibilities. They are also obligated to keep staff in the loop concerning all new health and safety requirements, for ensuring incidents are properly investigated and reported and for monitoring practices within the organization.

Employees are responsible for being familiar with emergency and waste management policies and must act in their own best interest as well as their coworkers, patients and the facility. Employees should be prepared to:

• Report any unsafe condition involving waste materials or substances, with the goal of eliminating a hazard before it causes a problem.
• Assist with the reporting process. Keeping track of incidents may point to a need for additional training or a new process. Analyzing what went wrong is critical to reducing the possibility of a reoccurrence.
• Ensure waste is correctly sealed and labelled prior to being collected and transported. All waste must be handled and correctly disposed of by trained, authorized staff.
• Assist in waste reduction initiatives and recommend safe work practices.

Segregation

To determine what waste poses the most risk, we must have a clear knowledge of the waste stream. Failure to properly separate wastes means some of the waste leaving our facilities is potentially infectious and hazardous. Colors indicate specific waste types; however, these color categories may vary at your facility. Normally, colors mean:

• Red—Biohazardous, biomedical, infectious, regulated medical;
• Yellow, White—Chemotheraphy—trace/debris or hazardous waste;
• Blue—Chemotherapy—trace/debris;
• Purple, Magenta, Yellow—Radioactive;
• Dark Blue—Hazardous waste.

When handling waste, always use appropriate protective clothing and equipment, gloves, aprons, etc. and maintain good hand hygiene. To prevent the risk of spills or injury do not carry waste bags for long distances and restrict storage areas to authorized personnel only. Keys to proper segregation include:

• Standardize all waste receptacles, placement and signage;
• Place Red bags in a central location;
• Use open containers for clean waste, closed for Red bag waste;
• Use signage above and on all containers to explain acceptable waste;
• Avoid placing Red bag waste containers under sinks and in hallways;
• Always place a non-regulated waste container beside the regulated container;
• Remove Red bag containers from patient rooms except those in isolation;
• Check state regulations regarding isolation waste requirements;
• Pay special attention to high generating areas (operating room, labs and dialysis);
• Monitor work areas;
• Consider tracking generation rates, employee training and rounding through the Hazardous Material and Waste Management Plan.

Special Items to Consider

Waste generated by healthcare facilities includes sharps and non-sharps, blood, body parts, chemicals, medical devices and other materials, some more likely to cause infection than others.

Sharps

Healthcare workers are at greatest risk for sharps injuries. Sharps are singled out for special regulatory provisions by many states. The Centers for Disease Control and Prevention (CDC) estimates that more than 800,000 accidental needlesticks occur each year among healthcare workers. Sharps. syringes, needles, scalpels, lancets, contaminated glassware or plastics such as vials, tubes and slides should be placed in rigid, puncture and leak-resistant containers that cannot be easily opened after locking. Research identifies the ideal mounting height of 52 to 56 inches from the floor to the collector opening. Containers should be placed in visible locations away from pedestrian traffic, swinging doors and other obstacles. Containers must be clearly marked with the biohazard symbol and placed in bio-hazardous waste containers.

Best practice should emphasize the need for correct handling before, during and after use, and the safe disposal of sharps. Consider purchasing sharps that have built-in safety features that are aimed at reducing the risk of needlestick injuries. Safety features can be classified as:

• Integrated safety features that form part of the basic design of the device and cannot be removed;
• Passive safety features that don’t need users to activate them and are effective before, during and after use;
• Active safety features that need users to activate them before the device is used.

Ensure your sharps containers are puncture-resistant and leak-proof even if they are dropped or fall over. To reduce infection transmission, the containers should have an opening aperture that when the container is being used normally doesn’t allow the contents to be removed, but is of a size such that items can be disposed into the container using one hand without contaminating the outside of the container.

Other points to keep in mind:

• Do not re-sheath needles by hand;
• Do not bend or break needles before or after use;
• Do not pass sharps directly from hand to hand—an exception to this may be when passing the scalpel to/from the scrub nurse to the surgeon, though many facilities have chosen hands-free methods for this as well;
• Only dispose of syringes/cartridges and needles intact;
• Never overfill sharps containers (keep below the manufacturer’s fill line);
• Do not mix sharps with other clinical waste;
• Do not place sharps containers in yellow bags for disposal;
• Position sharps bins away from public areas, and out of reach of children;
• Do not remove sharps from clinical settings.

Infectious Substances and Materials

This waste includes infectious or potentially infectious pathological waste, blood, other body fluids, waste cultures and stocks. One area to look at to reduce infection from these wastes is in the OR. Suction canisters can be responsible for up to 40 percent of infectious waste in the OR. Because a solidifying material is usually added to the canister, employees can be exposed to splashing and spills when adding the solidifier. Fluid management systems offering mechanical disposal of waste and disinfection of the canisters may help reduce risk of exposure. Mechanical disposal and disinfection reduces transportation cost, removes canisters from the waste stream and meets OSHA’s standards. Canister-free vacuum systems reduce the risk of employee exposure and the amount of waste needing to be shipped out.

Soiled laundry, except from patients in isolation, represents a small risk of infection as long as commonsense prevails for handling, processing and storage. Minimal handling and agitation of soiled laundry to prevent air and surface contamination is recommended. These textiles should be bagged or placed in labelled or color-coded containers at the location in which they were used. Linens contaminated with blood or body fluids require leak-proof bags.

Chemicals, Cleaners, Pesticides

While we recognize cleaning, disinfection and sterilization processes are designed to maintain a safe environment. Chemicals used in these procedures have a degree of toxicity necessary to kill micro-organisms. Chemicals are technically hazardous materials that produce hazardous wastes, but are sometimes not managed as such. To minimize exposure to chemicals, select the lowest level of product or process that will still do the job.

Reviewing your operations may lead to new ways of reducing infection. Remove carpeting from areas where moisture is present, and install walk-off mats at entrances to reduce use of harsh cleaners. Replace sprays with pour-and-wipe products to reduce airborne contaminants. Buffing floors can aerosolize polymers and because respiratory problems, however vacuum attachments help minimize exposure. Relatively new introductions such as microfiber mops, auto-scrubbers and extraction machines are also helping to reduce chemical use, while providing the same if not a better level of infection prevention.

The human component

The human component is both our greatest weakness and our strongest defense in the fight against infection. Take care, arm yourself with information, get to know your surroundings, ask questions and learn what you can do to contribute to a safer workplace. Help train others and be a role model for them. Remember that infection can be transmitted in many ways, some that we may not normally think of, and from many different places and people in your facility.

Sources

• www.nihe.org/elevreng.html: The Nightingale Institute for Health and the Environment—The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. The plan is when standards fail to be met a hospital would be refused accreditation. Many states anticipated stricter regulations some years ago and have already taken steps to develop waste management plans that meet the EPA’s new MACT rule.
• www.oeconline.org/our-work/kidshealth/toxics/air/dioxins: Dioxin (link to birth defects) may be found here and on several other Web sites.
• www.leedsteachinghospitals.com/sites/infection_control/documents/uniinf00.pdf:Universal Infection Control Precautions—Sharps.
• www.wildirismedical.com/courses/167/index_mand.html: Infection Control Guidelines (Continued education) CDC recommendations for blood, fluids, ground tissues.
• www.surgistrategies.com/articles/or-arena-jan-09-wastemanagement.html: Sharps container placement
• www.practicegreenhealth.org
• http://www.osha.gov/SLTC/hazardcommunications/whatishazcom.html
• http://www.epa.gov/epawaste/hazard/wastetypes
• www.cdc.gov
• Suction canisters: http://www.des.state.nh.us/nhppp/Healthcare_p2/default.asp?link=faq5.
• http://www.healthcarea2z.org/stdPage.aspx/home/Wastemanagement/CoreContent/Sharpsmanagement#sec_780
• The federal Resource Conservation and Recovery Act.

The Accelerated Seldinger Technique

By Ron Stoker

The over-wire technique of catheter insertion that offers considerable advantages over the standard techniques that were available at that time  In 1953, Dr. Sven Ivar Seldinger (1921-1999), an innovative radiologist, described an over-wire technique of catheter insertion that offered considerable advantages over the standard techniques that were available at that time.(1)

The equipment required to perform the basic technique included a thin wall introducer needle, a wire guide and a plastic catheter. Through a simple puncture, access is gained to any part of the body via the cardiovascular system, using a series of X-ray films as a guide.

Dr. Seldinger was a pioneer in interventional radiology and applied his technique to the localization of tumors by arteriography; selective renal angiography; percutaneous transhepatic cholangiography; and portal venography. The simplicity of the Seldinger technique revolutionized cardiology and radiology.  But this technique does have certain unavoidable risks. Let’s take a look at some of the challenges of the technique that, with some minor changes since its invention, is now known as the Modified Seldinger Technique.

First, a bare needle is inserted directly into a blood vessel or it is attached to an aspirating syringe. Once the needle is in place, it is left momentarily without a cap on it, resulting in its proximal end being open to air. As a result, negative intravascular pressure risks air embolism and contamination of the bloodstream. If the intravascular pressure is high, then excessive bleeding can occur—a situation that is not good for the patient and can potentially contaminate healthcare workers. (See Figure 1.) Next, a long and floppy guidewire is inserted into the needle. While the clinician is reaching for the guidewire, there can be a loss of vascular access. In addition, the long length—often exceeding 40 cm—risks contamination of its proximal tip.

Wand Bleeding

Once the Seldinger needle is in place it is open to air and can cause an air embolism, or excessive bleeding can occur.  The round tipped guidewire is then advanced through the lumin of the needle and the needle is then removed. Remember that the needle is a hollow bore, blood-filled needle that is a biohazard (at least, until the safety mechanism is actuated). Moreover, many Modified Seldinger Technique kits do not have a safety needle.

At this point a coaxial dilator/sheath is threaded onto the guidewire—taxing both visual acuity and manual dexterity (see Figure 2). As clinicians thread a guidewire into a sheath-dilator combination, some of them are very successful, while others have to hunt and peck for a second or two. The sheath dilator is then threaded down the guidewire. As the sheath dilator is threaded onto the guidewire, the proximal end of the guidewire is momentarily lost to view. As one interventional radiologist commented, “If you do enough of these procedures, eventually you will lose the guidewire.”

Wand Insert

When gloved hands are wet with blood, threading the guidewire through the sheath dilator can sometimes be difficult.

Wand and Guidwire

When the sheath-dilator is threaded onto the guide, the proximal end of the guidewire is lost to view. The literature describes cases where a sheath dilator was placed over a guidewire and then the guidewire was inadvertently pushed into the body.(2) The loss of the guidewire into a body cavity or blood vessel is a significant and generally preventable complication.(3) In cases like this, the procedure must be terminated and the focus of the clinician must be to find and remove the errant guidewire.

After the sheath dilator is placed over the guidewire, the guidewire and sheath are removed as one unit. Another danger: as the guidewire and dilator are removed together they can potentially splash contaminated fluid onto the clinician. At this point a second “open to air” condition exists in which an air embolism or excessive bleeding can occur. The sheath may then be used to introduce catheters or other devices to perform a variety of procedures. Upon completion of the procedure, the sheath is withdrawn.

In summary

The Modified Seldinger Technique allows clinicians to use a relatively small needle graduating to a larger catheter, with somewhat improved first-attempt success. But it is far from perfect, entailing real risks to both healthcare workers and patients. Among potential hazards of the Modified Seldinger Technique are:

• “Open to air” events leading to contamination, bleeding or air embolism;
• Needlestick injury;
• Loss of cannulation;
• Guidewire loss or contamination; and
• Splash contamination.

Clearly, a better, safer approach is needed. I recently had an opportunity to review a new product that has just been introduced to the market. The WAND®, manufactured and distributed by Access Scientific, is an all-in-one, micro access, safety introducer. The device was developed by the same team that invented StatLock catheter stabilization devices, which greatly improved the ease and safety of IV and other catheters.

The WAND combines a needle, guidewire, dilator and sheath into one unit. The WAND allows clinicians to perform what the manufacturer calls the Accelerated Seldinger Technique—a faster, safer and simpler technique that will assist in all over-wire vascular access procedures.  The WAND combines a needle, guidewire, dilator and sheath into one unit.

The Accelerated Seldinger Technique reduces the number of exchanges and steps necessary for vascular access. It reduces the risk of air embolism, contamination, guidewire embolus, loss of cannulation during the procedure, and accidental needlestick injury. So how is The WAND used in actual practice? The patient is prepared and draped according to hospital policy and procedures. Aseptic technique should be used during insertion, maintenance and removal of The WAND.

The WAND is removed from its packaging and placed onto a sterile field. The clinician should verify that the guidewire cap is in the locked and upright position and that all components are properly aligned. The Wand is held by the needle hub with the fin pointing up. The needle bevel should also be pointed out as well. The 21-gauge introducer needle is inserted into the target vein. As soon as the “fast-flash” is observed through The WAND’s translucent sheath, the needle is held still.

Wand Blood

Once the needle is inserted into the target vein, a fast flash is observed through The Wand’s translucent sheath. The guidewire cap is disengaged from the track and the guidewire is advanced. The guidewire should advance smoothly, without resistance. The guidewire cap is snapped onto the needle hub. While the clinician holds the needle hub, the dilator collar is turned one-quarter-turn clockwise to disengage. With the needle hub held still, the dilator and sheath are advanced. This generally locks the needle hub to the track, thereby sheathing the needle tip and preventing an accidental needlestick injury.

In patients with more remote vessels, the needle may not lock automatically. In such cases, hold the sheath and dilator hubs firmly in place and carefully withdraw the needle hub until it locks. Now, disengage the dilator hub from the needle hub and remove the guidewire, dilator and needle as a unit. Immediately cover the sheath hub with your gloved thumb to prevent bleeding or air embolus. The sheath may then be used to introduce other diagnostic or interventional devices.

Using the WAND to perform the Accelerated Seldinger Technique is faster, safer and simpler than all other over-wire insertion techniques.

Again, to summarize the usage of this product the clinician:

• Inserts the needle and observes the “fast flash”;
• Advances the guidewire;
• Disengages and advances the dilator and sheath;
• Withdraws the guidewire, needle and dilator as a unit.

For more information about this product, contact Access Scientific at 801.280.8797 or visit their Web site at www.the-wand.com.

References

1. Acta Radiologica.1953.
2. Baltalalarli A, Adiguzel E, Gurses E, Coskun E, Subclavian vein cannulation in a different position. Norol bilim derg 2000;17:29.
3. Schummer W, Schummer C, Gaser E, Bartunek R (2002). “Loss of the guidewire: mishap or blunder?” British journal of anaesthesia 88 (1): 144–6.

Ron Stoker, MS, is the executive director of the International Sharps Injury Prevention Society (ISIPS). He has 29 years experience in the medical device industry as a researcher, marketer, educator, consultant and healthcare worker advocate. He has written more than 200 medical journal articles, primarily on sharps injury prevention, infection control, and hand hygiene. Mr. Stoker has his BS in Pre-Medical Zoology from Brigham Young University, an MS in Bioengineering from the University of Utah. A result of a surgical mishap he was rendered a quadriplegic in December 2006. Informed that he would never walk again, with tenacity and a “supportive and mean wife,” Mr. Stoker taught himself how to walk again. Mr. Stoker has conducted workshops and Congresses on sharps safety at national and international meetings for the last 10 years. He is a founder and lecturer for the Infection Preventionist Boot Camp Series. For more information contact Mr. Stoker at info@isips.org.

<Re-posted>

The Safe Disposal of High-Level Disinfectants: Dumping Medical Disinfectant Waste is Dangerous

by Philip Coles

In some areas of the country it is illegal to dispose of used OPA and glutaraldehyde into a Publicly Owned Treatment Works without first neutralizing. The manufacturer of OPA has informed Department of Toxic Substances Control that the solution at use-dilution (failed MEC test) fails the California aquatic bioassay toxicity characteristic and thus is hazardous waste when discarded without treatment.  A popular misconception is that used OPA or glutaraldehyde is no longer biocidal (dangerous) after its reuse date has passed or it has failed a MEC test. In fact, both OPA and glutaraldehyde remain highly biocidal after the reuse date or after failing the MEC test.

OPA & Glutaraldehyde

OPA and glutaraldehyde are the most widely used liquid High Level Disinfectants (HLDs) for heat sensitive devices such as endoscopes and endocavity ultrasound probes. OPA and glutaraldehyde based HLDs can be reused for up to 14 days (some for up to 30 days). In addition to the maximum reuse period, the HLD has to pass the manufacturers Minimum Effective Concentration (MEC) testing to confirm efficacy of the product. This should be conducted before each disinfection cycle. This is done by using the manufacturers test strips and comparing the color against a color chart. In the case of high volume automated reprocessors, the MEC test can often fail long before the reuse date expires. As mentioned earlier, a failed MEC test does not mean that it is safe to dump the HLD without first deactivating it.

What’s the Danger?

It is dangerous to you because the simple act of pouring used disinfectant into a sink or hopper breaks the surface tension and results in a rapid off-gassing of vapor. Testing routinely shows levels above 1 ppm in the breathing zone during disposal (this is 20 times higher than the ACGIH level of 0.05 ppm). It can also result in splashes and spills adding to the off gassing of vapor. Even worse is the risk of a dropped container causing the HLD to shoot up into a person’s face. The simple and inexpensive act of neutralizing the used chemical disposal eliminates these very real risks.

Is it Illegal?

In some areas of the country it is illegal to dispose of used OPA and glutaraldehyde into a Publicly Owned Treatment Works (POTW) without first neutralizing. The manufacturer of OPA has informed DTSC (Department of Toxic Substances Control) that the solution at use-dilution (failed MEC test) fails the California aquatic bioassay toxicity characteristic and thus is hazardous waste when discarded without treatment. The conditions of treatment are that: 1. The waste (HLD) is generated by a medical facility during the disinfection of medical devices.

2. That it is treated at the site where it was generated. 3. That the sole active chemical of the neutralizing solution is glycine. For more information visit: http://www.dtsc.ca.gov/HazardousWaste/upload/HWM_FS_Generator_Requirements.pdf

Exposure Levels

The current maximum vapor exposure level of glutaraldehyde set by The American College of Governmental Industrial Hygienists is 0.05ppm. It is an instantaneous level, which means you can not exceed it for a single moment. The highest risks occur when pouring fresh HLD into a container, or an automated reprocessor, during disposal, or any time the surface tension is disturbed. The MSDS warnings for both OPA and glutaraldehyde read almost identically, requiring the use of personal protection equipment including mask/glasses, gloves and gowns as well as at least 10 air exchanges or the use of a ductless fume hood or local exhaust.

Automated Reprocessors

HLDs are typically used in automated endoscopic reprocessors (AERs) or in manual soaking containers. Obviously, open soaking containers pose a greater risk during disposal than an enclosed AER. The latter are plumbed directly into the drain and at the touch of a button the used chemical can be dumped directly into the sewer system without first deactivating it. The drain line from an AER is much like a washing machine drain and is open to atmosphere, so vapor can easily rise up from the drain.

It is a common practice to pour neutralizer directly into an AER prior to disposal. This is an unsafe practice (and is strongly discouraged by the AER manufacturers). Most AER reservoirs do not get rinsed after disposal and residual neutralizer can remain in the reservoir and degrade the fresh HLD. To avoid this problem it is first necessary to pump used disinfectant into a holding tank where it can be deactivated prior to disposal.

The Medi-Newt™ from Medivators is a semi-automated mobile disposal system that allows up to 12 gallons of used OPA or glutaraldehyde to be safely deactivated. A proprietary glycine based powder neutralizer (Neutra-Hyde™) is poured into the tank before the transfer of waste from the AER. After deactivation the inert HLD is safely pumped to drain. Vapor, splashes and spills are eliminated and the sewer system is protected.

Glycine Active Ingredient

To comply with the California disposal regulations, the sole active chemical of neutralizer should be glycine. Sodium bisulfite is another chemical very effective at neutralizing glutaraldehyde and OPA, but it creates a new compound that is toxic. Glycine is effective because it is an amino acid, essentially the building blocks of proteins. Both OPA and glutaraldehyde attack protein, so by adding a sufficient amount of glycine to the used disinfectant, the HLD is quickly overwhelmed and neutralized without creating toxic new compounds. To prove this, the deactivated product is subjected to tough fish toxicity tests.

Glute-Out^® Neutralizer

PCI Medical is the manufacturer of Glute-Out^® brand neutralizer for OPA and glutaraldehyde.  Glute-Out^® is a glycine-based neutralizer with a proprietary buffer that accelerates the process of neutralization. Both used Cidex 14-day glutaraldehyde and Cidex OPA were independently collected from a Kaiser facility in California, and delivered directly to Aquatic Testing Labs in Ventura, Calif. Glute-Out^® was added according to the label directions. Both the Cidex glutaraldehyde and the Cidex OPA passed the rigorous fish toxicity tests. (Copies of the tests are available upon request). Strict chain of custody was observed that did not involve any PCI personnel.

Philip Coles is president of PCI Medical in Chester, Conn. PCI Medical has manufactured over 17,000 GUS^® disinfection soak stations for use with OPA and glutaraldehyde. In addition, PCI is the manufacturer of Glute-Out^® neutralizer, spill kits, and numerous other high-level disinfection related products. Visit  www.pcimedical.com.