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Yes, interesting paper.
This is obviously another high risk patient group where such an intervention is effective. Similar studies have shown good results in ICU patients with chlorhexidine body-washing and other bundled interventions.(see also a systematic review of targeted measures by Kock R et al in Euro Surveill 2014:19(29) and a large intervention study in VA facilities by Jain R et al in NEJM 2011;364(15):1419-30)
Regards,
Irene—–Original Message—–
To add to the debate
FYI….just published.
Regards Giulietta
Giulietta Pontivivo CICP RN/RM/MPH| CNC/NM Infection Prevention Management and Staff Health Services- St Vincent’s Hospital (Unit Level 6, DeLacy Building), 390 Victoria Street Darlinghurst NSW 2010 Contact Details: t: 61 2 8382 3284 | f: 61 2 8382 3892 |M-0457 533 452 e: Giulietta.Pontivivo@svha.org.auMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Dear colleagues,
I find this whole debate on decolonisation strategies interesting. I agree with Michael that the literature seems to support a role for decolonisation of carriers prior to high risk procedures, but is not necessarily effective as a strategy for overall decrease of carriage rate. I did note that the intervention group showed a slightly greater decrease in carriage rate compared to the control group, although this was not statistically significant.The interesting thing I thought about this study is that in both groups of nursing homes the colonisation rate decreased significantly, which I would suggest was due to better reinforcement of standard precautions. The overall adherence to standard precautions in nursing homes is generally rather poor. The usual excuse I have heard: “this is the resident’s home, and we don’t want to alarm them by wearing PPE, etc.” doesn’t wash with me. I believe residents would be relieved to know that the standard of infection control in their home was of the highest order. I think it is a matter of proper risk communication.
My thought for the day!
IreneIrene Wilkinson
Manager, Infection Control Service
Communicable Disease Control Branch
SA Department of Health
PO Box 6 Rundle Mall, Adelaide SA 5000http://www.sahealth.sa.gov.au/infectionprevention
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Yes, it is vexing that the majority of infection risk is within acute care. My understanding of previous studies seems to indicate that decolonisation as a strategy is useful to minimise short term risk (ie decolonisation prior to a major procedure), but is not as useful as a long term carrier-eradication strategy. This study would support that idea.
This may suggest that acute care facilities need to continue look at checking carrier status and then providing appropriate decolonisation/antibiotic prophylaxis regimes prior to high risk procedures, rather than depend upon residential care decolonisation strategies.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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P Please consider the environment before printing this emailIt is interesting indeed that even though this being said the majority of patients presenting to acute care facilities and now an even greater burden on healthcare than healthcare associated staphylococcus aureus (MRSA & MSSA) blood stream infections seem to come from the community with a significant number of these coming from long term care residential facilities.
Makes me wonder whether these infections are being costed to, LTCRF or to acute care facilities, just saying.Isnt this the whole idea of decolonisation to9 prevent simple colonisations turning into life threatening and debilitating infections?
Kind Regards
Verily Thomas
Clinical Nurse Consultant | Infection Prevention and Control
SWSLHD-Bankstown/Lidcombe Hospital
Eldridge Road, Bansktown.NSW 2200
Tel 02 97228000 pager 28230
Tel 02 9722 8633 | Fax 02 9722 7822 | verily.thomas@sswahs.nsw.gov.au
http://www.health.nsw.gov.au[cid:image001.jpg@01D0736C.5A999060]
LET’S KEEP OUR HOSPITAL ENVIRONMENT CLEAN
HAND HYGIENE SAVES LIVESThis recently published study on nursing home MRSA in Switzerland demonstrated a screening and decolonisation programme had no effect on MRSA carriage rates.
Great to see such a negative study published from the non-acute sector.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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Dear colleagues,
There is not much value in performing air sampling in a HEPA filtered room provided the filters have been correctly installed. This is usually checked at the time of installation by use of pressure differentials and particle counts. Air sampling in such environments tends to pick up airborne contaminants associated with the testing process, rather than from the air supply. The expected count in a HEPA filtered environment is extremely low (less than one cfu per cubic m of air).
There is more logic (although not much guidance) for air sampling in an area used for storage of sterile stock that is not supplied with HEPA filtered air. I believe Terry’s earlier advice about the use of clean room standards to be most appropriate.
Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________Beth
We have recently opened a brand new SSD in Victoria and apart from the required validation of the sterilisers, the only area that we did do air sampling was in our sterile store room where we had Hepa Filtration. In our clean/packing room no microbiological sampling was undertaken as these areas do not have Hepa Filtration.
Happy for you to discuss off-line if you have further questions.
Leanne Houston
Associate Director
INFECTION PREVENTION & CONTROL SERVICE (IPAC)Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
—–Original Message—–
Good Evening
I am someone within the AICALIST brains trust can provide some advice regarding the necessity for microbial sampling of newly constructed SSD. I have not been able to find any reference to this being recommended prior to opening.
Does anyone know of any guidelines that apply to NSW?
Or, national or international references that may indicate that this would be recommended from a best practice point of view.
I would be grateful for any advice within the next few days, if possible.
Thank you
BethBeth Bint
Infection Prevention and Control Clinical Nurse Consultant | Infection Management and Control Service
Level 1 Lawson House Wollongong Hospital
Tel 02 4222 5898 |beth.bint@SESIAHS.HEALTH.NSW.GOV.AU
http://www.health.nsw.gov.au
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I agree with Rebecca’s assessment of the state of the art on air sampling and acceptable limits. I had some communication last year with Peter Hoffman from the HPA in the UK, who was part of the HIS Working party that drew up the recommendations published in 2002. He has indicated that the recommendations are due for review, but feels that they are not likely to change significantly. His view is (and I agree from personal experience) that in a HEPA-filtered environment, there should be virtually no cfu per cu metre of air if the filters have been correctly installed; this is the primary purpose of doing air sampling in commissioning – as a QA check of the filter installation.
The majority of microorganisms that are grown in this situation generally originate from the operator of the air sampler! (skin, clothing, etc). The technique in setting up the sampler and having a remote operation is very important in minimising this contamination. In my experience of performing air sampling over many years at the RAH the limit suggested by the HIS document of 35 bacterial cfu per cu metre of air and <1 cfu of fungi appears reasonable, and usually there will be far fewer organisms than this.Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________Thanks Michael
The WA Operational Directive is somewhat outdated and is currently under review, so perhaps not the best reasonable starting point!
In undertaking the review of the OD, a recent literature review has found very limited evidence since the work done by the HIS Working Group back in 2002 and published in the Journal of Hospital Infection- hence making review of our OD and production of something evidence informed difficult. The most recent work I can find is from one group in NZ in 2005- which was in the HI Journal as a letter to the editor- cant find a fuller reference on this- and they concluded that microbiological sampling was redundant when ventilation testing shows acceptable engineering performance. Loddon Mallee give us a nice long list of why not too air sample in line with CDC recommendations, however supports the practice for the purpose of Commissioning ORs. There is some work by Edmiston (2005) and then 2 papers out of Italy in 2012 but all 3 of these are in relation to sampling in active ORs and the effect microbial air loads have on development of SSIs.
So, I guess still a contentious issue but maybe we just accept that we do it for our own peace of mind and it is what it is a quality assurance exercise to support other more scientific based testing of HVAC systems.
Would greatly appreciate further discussion from others on this issue
Kindest Regards
Rebecca
Rebecca McCann Program Manager
Healthcare Associated Infection Unit (HAIU)
Communicable Disease Control Directorate Department of Health
Grace Vaughan House
227 Stubbs Terrace
SHENTON PARK WA 6008
T:08 9388 4859 M:0439 920 819 F:08 9388 4888
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Rebecca
Oops the WA document I cited is apparently under review, and shouldnt be taken as current best practice.
Apologies.
There is obviously a need for more robust and evidenced guidance on this within Australia.
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email[cid:image001.jpg@01CFC5FA.A23C2420]
Hi Fiona
I have found it very hard to get a definite consensus on this within Australia. This document from Dept of Health in WA is a reasonable starting point for internal discussions in your facility to come to an agreement over what is acceptable.
http://www.health.wa.gov.au/CircularsNew/circular.cfm?Circ_ID12021
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email[cid:image001.jpg@01CFC5F8.566318D0]
Dear members,
I know that air sampling in a new building is a contentious issue but we are currently undergoing it as part of the commissioning process for new operating theatres and one of the difficulties I face is people asking for the acceptable limit of certain organisms. Aside from fungal organisms I have been unable to find any references to guide me on specific organisms counts.
I would like to hear peoples views on the isolation of skin or environmental flora when doing this sampling how many CFU would be acceptable per air sample ?
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
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Hi all,
Having been involved in the creation of a Graduate IC program at the University of Adelaide, my strong belief is that you need to teach basic microbiology, because you cannot understand TBP unless you understand something about the various infectious agents and the way they behave, their reservoirs in the hospital environment, and ability to survive on surfaces, etc.
The other concept that is really important to get across is infectious risk assessment, and scenario work is a good tool for that.Regards,
Irene Wilkinson
Manager, Infection Control Service
Communicable Disease Control Branch
SA Department of Health
11 Hindmarsh Square
Adelaide SA 5000http://www.sahealth.sa.gov.au/infectionprevention
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This e-mail may contain confidential information, which also may be legally privileged. Only the intended recipient(s) may access, use, distribute or copy this e-mail. If this e-mail is received in error, please inform the sender by return e-mail and delete the original. If there are doubts about the validity of this message, please contact the sender by telephone. It is the recipient’s responsibility to check the e-mail and any attached files for viruses.I agree Brett,
Transmission based precautions and correct application seems to be the biggest issue we have at present. Some Staff just do not seem to be able to grasp the basic principles. I find I am continually re-iterating and teaching in every instance. I have modified signs to provide more information to attending staff, developed a transmission based precautions folder with guidance and resources yet still this area remains problematic.
Liz Vanderlinde
Infection Control Officer
North West Private Hospital
Brickport Road, Burnie TAS 7320, Australia
T +61 2 6432 6000 F +61 2 6431 5766
E Liz.Vanderlinde@healthecare.com.au W | facebook | twitterHi John,
A group of us have just submitted a paper to a journal from a study we did exploring graduating nurses knowledge, intentions and beliefs around infection control. This study was conducted at 6 Australian universities late last year. There were a few things of interest, but the standout was the lack of knowledge of and correct application of transmission based precautions – given some clinical scenarios. This was very substandard.
That tells me that something is amiss when it comes to how we are delivering these messages to undergraduate nurses at least. It is possible that the same themes would apply to medical students.
Re the curriculum when I work, infection control measures are taught more formally very early on, including micro, but then subsequently integrated throughout individual units, including various clinical assessments. There is a particular focus on aseptic technique and hand hygiene. First year nurses are required to complete the HHA OLP. In the very last semester before they graduate (Year 3), we have introduced a new unit on emerging health issues. In this unit, antibiotic resistance is covered, alongside emerging infectious diseases and the various IPC measures. In covering antibiotic resistance, stewardship will be covered. One assessment item is a patient information leaflet – where students have to develop a patient information leaflet on C.difficile, influenza or antibiotic resistance. That is then peer marked and this forms the basis for their grade, for that one assessment item. Students are also required to undertake the HHA OLP again – we encourage the certificate is kept for their various new employers.
Thanks
BrettDear All
We are in the process of curriculum change and would be very interested in learning about other’s approach to this essential topic. [Needless to say, our College needs to develop a position on this I think! ]
Whilst I guess the basic topics are straightforward – Std and Tx based precautions, specific emphasis on 5 moments with practical training, aseptic technique learning and practical techniques, sterilisation and disinfection and environmental hygiene etc, I’m particularly interested in how people sequence the content and what activities are used. Are you for instance , training your students as peer HH or AT auditors? How does it couple in with training about microbiology and infection?
A related topic is AMS – that would also be of interest for people to share what they are doing please.
Best wishes
JohnDr John Ferguson
Director, Infection Prevention Service, Hunter New England Health
Locked Bag 1, Newcastle Mail Centre, NSW 2310
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 | john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.orgClick here to report this email as spam.
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Hi all,
Rachel makes some very valid points about the limitations of in vitro testing of these materials. What is needed are some good quality in vivo studies using sampling of curtains at various times after first hang.
I know from conversation with Dr Stephanie Dancer at the last ACIPC conference that she is not keen on the blanket use of these curtains throughout a hospital, since no-one has yet published a good cost-effectiveness study, and there are concerns (as pointed out previously) about the waste issue.
It would seem prudent to me in the current state of knowledge to limit the introduction of these curtains to those areas where we know that frequent changes of cloth curtains are causing bed block problems, such as in ED. One also needs to have in place a system for monitoring the hang date to make sure they are not left in place indefinitely! Rachel also makes a good point about who is going to monitor for the presence of soiling?
There has been limited introduction of these products in South Australia due to the concerns expressed below.
Irene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auHi all,
I would like to put out there some thoughts and observations in relation to disposable biocidal curtains from a personal perspective.
The biocidal curtains currently on the market have one property that has got nothing to do with Infection Prevention & Control, but a property that makes these items very appealing to organisations (and managers within them). That is, that they are light weight and relatively easy to change. This would seem to have a couple of distinct advantages therefore over traditional cloth curtains, that is;
* Reduced risk of injury during curtain change
* Likely increased compliance with a request to change
(I am aware that others have now commented on these benefits)There is then the infection prevention and control perspective. I would like to comment on this.
I do not believe that the product information and the available literature is as clear in relation to the Infection Prevention & Control properties as we might like it to be (or might think it to be). The testing that is applied to these curtains, as I understand it, is a ‘modified Kirby-Bauer test’. This test (again as I understand it) measures disinfectant or antiseptic susceptibility of various organisms on a modified agar plate. Bacteria are applied to the agar and, for the purposes of these tests, a square centimetre of the biocidal fabric is placed on the plate and inhibition zones are measured in millimetres. These measurements are taken with the use of ultra-violet light to increase the exposure rate and extrapolated results are taken from these findings. This may be a simplistic interpretation of this test and I would welcome comment from the more ‘microbiologically-minded’ subscribers to the list. My comments on this testing methodology for the efficacy of the curtains are the following;
* Testing does not include ‘real world’ data. The transferability and reliability of the modelling and results achieved from the modified Kirby-Bauer testing is not clear to me.
* Whilst a known quantity of a known pathogen is tested with this fabric, there is no capacity to understand if this actually relates to alternate inoculation methodologies. E.g. From multiple contaminated hand touching of the curtain on the leading edge through to faeces splattered onto fabric etc.
* Testing against agents such as non-enveloped viruses (e.g. norovirus) is not documented or reported on in the product literature. If there is no testing data, what action will need to be taken to ensure safety?
One company recommends that their biocidal curtains are changed after patients with known or suspected infectious agents, including MROs especially in the higher risk settings. Whist another company make no such recommendation. The cost of regular replacement will surely not be insubstantial in some settings, especially the more acute services. As mentioned, if the testing does not include a number of important pathogens then can it be reasonably assumed that the agents not tested for will be controlled or eliminated with the biocidal curtains in place?
It is accepted that the manufacturers clearly recommend that biocidal curtains should be changed if there is evidence of soiling. The question must be asked, though, who will validate this process? If curtains are left hanging for very prolonged periods (potentially substantially longer than standard cloth curtains), has the risk of this been established or even fully considered?
I am not suggesting that biocidal curtains represent a ‘less safe’ environment than cloth curtains; indeed this would appear patently untrue. I think, however, that a number of facilities and staff within them are seeing these curtains as the ‘holy-grail’ of a prevention/control measure. I would certainly suggest that there is a place for enhanced research and subsequent publication in peer reviewed literature to add to the body of current knowledge.
Just some thoughts!
Cheers
RachelRachel Thomson
Nurse Unit Manager
Infection Prevention & Control Unit
Royal Hobart Hospital
E: rachel.thomson@dhhs.tas.gov.auHi All,
Have a small issue – Disposable curtains/screens!
Would appreciate feedback from areas that are using the disposable curtain/screens in their facilities
The issue is around cost of linen vs disposable curtains/screens.
We have trialed & like what we have but those who watch the pennies are questioning their use.
Originally we brought them into our ED because the poor terminal cleaning staff were frantic with attending the cleaning ( which involves the replacement of curtains).
The NUM of ED was indicating at this particular incident -that there were three ambulances waiting to off load patients onto ED beds which were being held up by the terminal cleaning required.Amongst other actions taken regarding this issue in ED-was the implementation of the disposable curtains.
Now the question being asked is who else in other health areas has disposable curtains/screens & where are they ( ie high risk areas).
Much appreciate any assistance with this.
Thank you
Vicki Denyer
Clinical Nurse Consultant | Infection Prevention & Control Unit
Lismore Base Hospital
Tel 02 6620 2385 | vicki.denyer@ncahs.health.nsw.gov.au________________________________
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Hi Terry,
Sorry for a late reply. This organism is a normal water organism, non-fermentative (previously known as Ralstonia pauculus) and generally considered non-pathogenic, although it has been rarely reported in the literature as a cause of infection in severely immune-compromised patients. It has also been reported to cause a “pseudo-outbreak” via swabs moistened with tap water! (see J Clin Microbiol. 2010 July; 48(7): 2645-2647.)
I would suggest that you probably have a biofilm issue within the AERs, and this may even involve the filters themselves. Consultation with the manufacturer is highly recommended.
…I will be interested in Bill Rutala’s comments also, Cath.
Regards,
IreneIrene Wilkinson BSc(Hons) MPH MASM
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auHi Everyone,
Thanks for your responses. Cath, thanks for referring this on to Bill – I look forward to hearing what he has to contribute.
None of the patients have been affected by this organism. We are culturing it in very low numbers [<100cfu] from the Automated Flexible Endoscope Reprocessor [AER] only, however as it is being initially reported as a gram negative bacilli or a pseudomonas species, alarm bells have rung and we have asked for the organism to be identified so we can take appropriate action to protect our patients.
Unfortunately the GENCA (2010) guidelines do not have a flow chart to assist in the response to positive cultures of an AER, so the approach we have taken from a risk management perspective is to follow the recommendations for a contaminated endoscope and have consulted the microbiologists from the various pathology labs.
My original thoughts were that it could be arising from the filters or potentially be contaminating the fluid pathway of the AER, however the affected machines are different models [same brand], different disinfectant [for one] and the clients are not all using the same brands of filters. They are however, located in a similar geographical area.
My primary question is – given the organism has low pathogenicity, do we really need to be concerned if the count is <100cfu?
Thoughts anyone?
Regards
Terry McAuley
Sterilisation & Infection Prevention and Control Consultant
STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
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Hi Terry
Interesting question and interesting set of responses.I have sent it along to Bill Rutala to see his opinion. Will keep you posted on any reply.
Out of interest have you seen any illness among pts that could correlate with this org (I note the at risk group you mention)?
Regards
CathDr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty LtdAdjunct Professor
Griffith University, School of Nursing and Midwifery
http://www.infectioncontrolplus.com.au
[cid:image001.jpg@01CF2DBA.5F031C00][cid:image002.jpg@01CF2DBA.5F031C00][cid:image003.jpg@01CF2DBA.5F031C00]Hi Everyone,
I have had a recent spate where a number of my endoscopy procedure centre clients have reported culturing of “Pseudomonas species” or Gram negative bacilli after the monthly water testing of the Automated Endoscope Reprocessors.
Upon further investigation, the organism has been identified as Cupriavidis pauculus. This organism is often associated with ultra filtration systems and although it has low pathogenicity it is a risk to immunocompromised patients.
Despite repeated water line disinfections, filter changes, disinfectant dumps etc this bug keeps cropping up over and over again. We find that we have cleared it in the next test after filter changes etc etc but then a month later – we get a positive result again.
Whilst in low numbers, it is causing some concern regarding potential risks to patients. In all cases we are not growing the organism form the endoscopes.
I am wondering if anyone else has been experiencing the same issues?
If so – what did you do about it both in terms of managing the machines and the risks to patients?
If you have cultured this organism, did you manage to identify the cause of the problem?
Happy to chat offline.
Regards
Terry McAuley
Sterilisation & Infection Prevention and Control Consultant
STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
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Hi Michael,
The big problem with the economic argument on this is that the “savings” produced by preventing infection don’t actually accrue to the hospital budget. The most important savings measure is bed-days, so that for a typical hospital with high occupancy rates and a waiting list, this means release of bed-days to treat more patients and no actual dollar savings to the hospital. See the many publications by Nick Graves on this issue. Makes it very difficult as you say to mount a good economic argument for increasing the cost of consumables in the interest of preventing infection. The best argument is from the point of view of patient safety and quality of care. Penalties can work, but often also lead to ‘gaming’ of the system.regards,
Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________I will chip in as well. The biggest issue I have had over the years, and it still applies today, is the economic ‘bean-counter’ argument where the cost of consumables vs the cost of reusable is a tangible budget line, whereas the costs associated with prevention of infections is not. So when we talk about moving to disposable tourniquets, for example, everyone agrees that the infection control principles are good, but the ‘bean-counter’ mentality sees how much it will cost vs what reusable tourniquets ‘cost’, and it doesn’t get approved. Budget lines seem pretty much fixed in the ‘bean-counter’ mentality, and when a department manager sees an increase in expenditure but cannot easily see the savings in THEIR budget, then they stop supporting this even if they like the principle. I have seen it many times.
What is needed, I believe, similar to what we need in Australia for safety devices in sharps, is some form of mandatory requirement or penalties if you don’t use them. Currently there is very little from a penalty perspective to make administrators work very hard to prevent infections (like a financial penalty), although these seem to be more commonly increasing. A major change in funding methodology and accountability for infections will, I think, lead to greater use of disposables. The US health system is what I see as an example of this, flawed and damaged as it is.
Another problem is actual evidence related to infection reduction for specific disposables (eg tourniquets). Who is to say to giving all the medical staff disposable ties would have more impact on MRSA acquisition rates? Evidence related to bacterial reduction does not automatically equate with infection risk reduction; we all know that. The difficulty in saying definitely that doing x will result in y will always make the ‘bean-counter’ mentality the most prevalent, I think.
Just my (cynical) views as another ‘oldie. 🙂
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email—–Original Message—–
Thanks Irene and Terrie
Whilst I appreciate Terrie’s position coming from his role with a provider of reusable waste equipment my question was more specifically about equipment used on patients for clinical care so things like BP cuffs, ECG leads and tourniquets. The various responses are interesting and please keep them coming as debate and expression are good for us as is an appreciation for the past (and yes I qualify and feel “oldie” as well 🙂 Cheers CathRegards
CathDr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty LtdAdjunct Professor
Griffith University, School of Nursing and Midwifery
http://www.infectioncontrolplus.com.au—–Original Message—–
Hi all,
as a fellow “oldie” I agree with Terry’s assessment of the trends over the years. I also support the final point about the issues involved in the decision making process. What has always puzzled me is how to accurately measure the environmental impact of either disposable or re-usable items?Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________Hi Cath,
I had not heard of a movement back to single use items so I will be interested to hear members’ responses on this topic. For oldies like me it has been interesting to see the disposable/reusable “cycle” over the decades.* in the 60’s we reused needles, glass syringes, gowns, etc, to reduce procurement costs;
* in the 70’s the cost of labour to process reusables (and modern technology enabling economic production of disposables) moved us to disposables;
* In the 80’s and 90’s waste disposal costs together with environmental impact of disposables, caused many to move to reusables again;
* Now with staff shortages, in-house processing of reusables is being re-examined (NB. processing by external contractors can still be economical, e.g. reprocessing single-use medical devices saves USA hospitals $300m annually.
As you point out, there have been relatively few evidence-based articles implicating disease transmission with either protocol.
The decision to use disposables or reusables must be evidence-based encompassing patient and staff safety, labour costs, procurement costs, and environmental impact. I look forward to members’ commentsBest regards, Terry
Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph/Fx (NZ): +64 7 856 4042
Mob (NZ): +64 274 365 140
E: tg@gandassoc.com
“This email (including any attachments) is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are reminded that any dissemination, distribution or copying of this email or attachments is prohibited. If you have received this email in error, please notify me immediately by return email or telephone and destroy the original message. Thank you.”Happy new year all
As you may know there’s a subtle movement in Australia towards more widespread adoption of single-use items such as venepuncture tourniquets, lower limb surgical tourniquets, BP cuffs and ECG leads. Tom Gottlieb recently did some elegant research on venepuncture tourniquets and AT ACIPC 2013 Karen Vickery presented new perspectives on biofilm on reusable equipment. Single-use items have been adopted widely in the US for some years and recommendations to that effect are included in many Standards published by relevant professional associations eg AORN.
Whilst appreciating that demonstrating causality between reusable equipment and transmission of colonising organisms or infection is difficult either is biologically plausible. There are also issues of non-cleaning, lack of clarity about who’s role it actually is to clean reusable equipment, how frequently they need to be cleaned or reprocessed etc. These issues have plagued us for at least 3 decades that I know of and likely longer. I’m wondering what others in Australia and beyond think about single-use pt care items
So my questions are:
1. Has any ACIPC colleague successfully built a business case to convert their facility to single-use pt equipment? If so who was involved in that process?;
2. Which pieces of pt equipment do folks think are most in need of single-use alternative options?;
3. Other than price, storage, supply and environmental/waste issues and lack of detailed science what other factors would need to be addressed to help convince you or your organisation’s decision makers to invest in specific single-use equipment?.
I’d be grateful for any discussion here or as PMs on the email address below. If anyone is interested in my further work around this issue please email me.
Regards
CathDr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty Ltd
Cath@infectioncontrolplus.com.auAdjunct Professor
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Hi all,
as a fellow “oldie” I agree with Terry’s assessment of the trends over the years. I also support the final point about the issues involved in the decision making process. What has always puzzled me is how to accurately measure the environmental impact of either disposable or re-usable items?Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________Hi Cath,
I had not heard of a movement back to single use items so I will be interested to hear members responses on this topic. For oldies like me it has been interesting to see the disposable/reusable cycle over the decades.in the 60s we reused needles, glass syringes, gowns, etc, to reduce procurement costs;
in the 70s the cost of labour to process reusables (and modern technology enabling economic production of disposables) moved us to disposables;
In the 80s and 90s waste disposal costs together with environmental impact of disposables, caused many to move to reusables again;
Now with staff shortages, in-house processing of reusables is being re-examined (NB. processing by external contractors can still be economical, e.g. reprocessing single-use medical devices saves USA hospitals $300m annually.
As you point out, there have been relatively few evidence-based articles implicating disease transmission with either protocol.
The decision to use disposables or reusables must be evidence-based encompassing patient and staff safety, labour costs, procurement costs, and environmental impact. I look forward to members commentsBest regards, Terry
Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph/Fx (NZ): +64 7 856 4042
Mob (NZ): +64 274 365 140
E: tg@gandassoc.com
“This email (including any attachments) is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are reminded that any dissemination, distribution or copying of this email or attachments is prohibited. If you have received this email in error, please notify me immediately by return email or telephone and destroy the original message. Thank you.”Happy new year all
As you may know theres a subtle movement in Australia towards more widespread adoption of single-use items such as venepuncture tourniquets, lower limb surgical tourniquets, BP cuffs and ECG leads. Tom Gottlieb recently did some elegant research on venepuncture tourniquets and AT ACIPC 2013 Karen Vickery presented new perspectives on biofilm on reusable equipment. Single-use items have been adopted widely in the US for some years and recommendations to that effect are included in many Standards published by relevant professional associations eg AORN.
Whilst appreciating that demonstrating causality between reusable equipment and transmission of colonising organisms or infection is difficult either is biologically plausible. There are also issues of non-cleaning, lack of clarity about whos role it actually is to clean reusable equipment, how frequently they need to be cleaned or reprocessed etc. These issues have plagued us for at least 3 decades that I know of and likely longer. Im wondering what others in Australia and beyond think about single-use pt care items
So my questions are:
1. Has any ACIPC colleague successfully built a business case to convert their facility to single-use pt equipment? If so who was involved in that process?;
2. Which pieces of pt equipment do folks think are most in need of single-use alternative options?;
3. Other than price, storage, supply and environmental/waste issues and lack of detailed science what other factors would need to be addressed to help convince you or your organisations decision makers to invest in specific single-use equipment?.
Id be grateful for any discussion here or as PMs on the email address below. If anyone is interested in my further work around this issue please email me.
Regards
CathDr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty Ltd
Cath@infectioncontrolplus.com.auAdjunct Professor
Griffith University, School of Nursing and Midwifery
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Marija,
Another important consideration would be how the air conditioning system is designed, as presumably if this is a modular system, the walls can be removed or moved in future? This would have an impact on the direction of air flow, etc.
Irene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auDear all,
We would like a review a modular theatre/OR wall system is working for your unit. I am on a steering group reviewing how to upgrade our 40 year old operating theatre suite. We’re interested in how the wall system is coping with every day impacts including scratches, cleaning products and the joints between the panels.
Any assistance would be greatly appreciated.
Kind Regards
Marija Juraja |Clinical Service Coordinator (CICP) -Infection Prevention & Control Unit|
Division of Acute Care and Clinical Support
The Queen Elizabeth Hospital | Central Adelaide Local Health Network
Level 8 Tower Building | 28 Woodville Road, WOODVILLE SOUTH 5011
t: +61 8 8222 7588| p: 47757| f: +61 8 8222 6461 | DX: 465432 |e:marija.juraja@health.sa.gov.au
Care Excellence Collaboration Integrity
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Dear Penny,
SA Health has developed a full suite of resources on aseptic technique which you are welcome to use. Unfortunately the on-line learning package is only available to SA Health staff, however, I believe that arrangements are being worked out for other states to be able to use the OLP in the near future.
The resources are available here:
http://www.health.sa.gov.au/INFECTIONCONTROL/Default.aspx?tabid=143Irene Wilkinson
Manager, Infection Control Service
Communicable Disease Control Branch
SA Department of Health & Ageing
11 Hindmarsh Square
Adelaide SA 5000Tel: (08) 7425 7170
Fax: (08) 8226 2594
http://www.health.sa.gov.au/infectioncontrol
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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Birchmore, Penny
Sent: 03 December 2013 10:57
To: AICALIST@AICALIST.ORG.AU
Subject: ANTT (Aseptic Non Touch Technique) EducationDear All,
As part of the implementation process of ANTT at Melbourne Health, we are looking for resources for our training/education program.
We are wanting a robust theoretical base for our competency based program.
Does anyone have any resources/packages/ideas or suggestions they are happy to share??Thank you
Penny Birchmore
Penny Birchmore / ANTT Project Nurse, Infection Prevention & Surveillance Service The Royal Melbourne Hospital City Campus | 2nd Floor MPH Building Grattan Street, Parkville Victoria 3050
T: + 61 3 9342 8325 | F: +61 3 9342 8484 | Pager: 28005 | penny.birchmore@mh.org.auMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Hi Glenys,
Personally I believe the NHSN definitions are overly complex. I can understand the reason for distinguishing superficial infections from deep/organ space, but really what is the purpose of distinguishing deep from “organ space”? The likely causes/sources of infection and hence preventive measures would be similar.
Regards,
IreneIrene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auHi John,
While there is no muscle there is fascia and if involved you would proceed with using the deep definition to see if you meet the other criteria. From your description it seems in your cases you would meet b plus 1 signs of infection confirming it was a deep infection.
The definition seems fairly straight forward to me and I have found it very easy to use over the years. It is a definition for surveillance purposes not clinical management.
By definition an organ space infection does not include the wound, hence “infection deep to the deep fascia a deep (or organ space infection)” is not the correct application of the organ space definition.
Vac dressings can be used on lots of wounds including superficial sternal wounds (see below). The foam is cut and contoured to fit the size of the tissue defect, and covered with an adhesive drape and connected through the evacuation tube to the vacuum pump. There is no exposure of the wound bed/surface using these devices.
From memory there is usually an percutaneous suture in closure of a sternal wound.
Bapat V et al. Experience with Vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use. J Card Surg. 2008 May-Jun;23(3):227-33Department of Cardiothoracic Surgery, St Thomas’ Hospital, London, UK. vnbapat@yahoo.com
Dezfuli B et al, Treatment of Sternal Wound Infection With Vacuum-assisted Closure. Wounds. 2013;25(2)Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Thanks Glenys
However, there is no muscle overlaying the sternum and the deep fascia is just above the periosteum of the sternum.
For the most part there is just skin and subcut tissue in front of the sternum. These tissues overlying the sternum are very thin in most people.
And so it is nonsensical to distinguish superficial from deep based on this definition in my viewI don’t think that most surgeons put a closure layer beneath the skin once the sternum is wired- it is impossible. Effectively, then, opening or dehiscence of the incision will expose the fascia. Similarly, I cannot see that application of a vac can be done to a ‘superficial’ wound as the fascia will be exposed in these sort of wounds.
I could cope if the definition specified in this case that infection deep to the deep fascia a deep (or organ space infection); however that is not what it says.We are long overdue for a better NHSN SSI definition…., esp for sternal wounds
John
[cid:image002.jpg@01CEB910.B1B99D30]
Dr John Ferguson
Director, Infection Prevention & Control, Hunter New England Health
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 | john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org[cid:image003.jpg@01CEB90F.65088BF0]
Hi John,
Whether or not these wounds are superficial or deep depends on the first part of the definition as to what tissue is involved. This question has to be answered before progressing to the rest of the definition.
Superficial – Infection occurs within 30 days after any NHSN operative procedure and involves only skin and subcutaneous tissue of the incision
Deep – Infection occurs within 30 or 90 days after the NHSN operative procedure and involves deep soft tissues of the incision (e.g., fascial and muscle layers)
If only skin and subcutaneous tissue are involved it meets the superficial definition as from your description c below is met and, I’m assuming that the patient had at least 1 of the sign or symptom below.
patient has at least 1 of the following:
a. purulent drainage from the superficial incision
b. organsims isolated from an aseptically-obtained culture of fluid or tissue from the superficial incision
c. superficial incision that is deliberately opened by a surgeon and is culture-positive or not cultured
and
patient has at least one of the following signs or symptoms of infection: pain or tenderness; localized swelling; redness; or heat. A culture negative finding does not meet this criterion
d. diagnosis of superficial incisional SSI by the surgeon or attending physician
If deep soft tissues (e.g., fascial and muscle layers) are involved it will meet the deep definition as from your description b below has been met and I’m assuming that the patient has at least 1 of the sign or symptom below.
patient has at least one of the following:
a. purulent drainage from the deep incision
b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon and is culture- positive or not cultured
and
patient has at least one of the following signs or symptoms: fever (>38C); localized pain or tenderness. A culture-negative finding does not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or by histopathologic examination or imaging test.
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
Hence in the first instance you need to know what level the surgeon has opened these wounds too as VACs can be used on superficial or deep would infections.
Just on organ space infections – these wounds as described would not be considered an organ space infection as such infections exclude the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure (i.e. the incisional wound is not involved at all). In this surgical setting an organ space infection would be something like osteomyelitis of the sternum without surgical incision/wound involvement.
I use a definition checklist (i.e. it either meets or does not meet the criteria) when training staff in the interpretation of the definitions for surveillance purposes.
Can send a copy if you like.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Dear All
Would appreciate advice on interpretation of the definition (below)
In two sternotomy cases, there has been prolonged ooze post op (several days) and the surgeon concerned has opened the wound on the ward and then instituted vac dressings
The cases required prolonged nursing management but did not come to formal debridement or removal of sternal wires etc. CT scans did not show retrosternal collections (ie not organ space infection)In my view, this constitutes a ‘deep’ wound infection. What would others say?
Our other surgeons would have usually taken such cases to theatre and performed open debridementin one case the culture grew Serratia
in the other, culture was no growth; in that case, the determination rests then on whether we had ‘purulent drainage’ observed from the ‘deep incision’
it does beg the question as to how one gauges from what level the drainage is coming fron and also whether one should use an objective measure for what is purulent etc!
criterion b under superficial is also problematic – how does one ever get ‘aseptically-obtained’ samples from a superficial incision? wound swabs presumably not ok but I would guess are usedWould be very interested to know of how people teach surveillance staff to apply the NHSN definition, esp for sternotomies , where essentially the superficial wound is extremely close to the deep sternal structure , and also for prosthetic joints where similar problems of distinguishing the depth of infection arise
thanks
JohnDr John Ferguson
Director, Infection Prevention & Control, Hunter New England Health
Locked Bag 1, Newcastle Mail Centre, NSW 2310
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 | john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org
[cid:image001.jpg@01CEB86A.85790C70][cid:image002.png@01CEB86A.85790C70][cid:image003.png@01CEB86A.85790C70]
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Hi Rebecca,
I will be addressing this topic at the upcoming APIC conference in October. The presentation should be made available shortly afterwards on the APIC website.
Your summary of the current status of guidelines regarding microbiological air sampling of theatres is correct. As far as I can find, there are no more recent guidelines, and still a lot of debate. There is not a great deal of science on which to base recommendations, but I intend to cover the theoretical risks of airborne contamination and the difficulties in interpreting sampling results.
There is a strong argument that if the newly installed air ventilation system passes all the necessary engineering checks for leaks, particle counts etc. then microbiological testing is maybe not necessary. However, I am pre-empting my talk here, so Ill leave it at that for now.Regards,
IreneIrene Wilkinson
Manager, Infection Control Service
SA Department of Health & Ageing
Irene.wilkinson@health.sa.gov.auDear All
Can anyone advise of your current practices for the requirement to perform microbiological air sampling following construction of or major refurbishment of operating rooms. The WA policy is based on the 2002 Hoffman paper and I am not aware of any more recent extensive publications on this subject.
A commentary in JHI in 2005 questioned the value of microbiological sampling (Jowitt / Morris), and the Aust HFG recommend it is performed on commissioning but give no acceptable cfu counts. The 2005 Loddon/Mallee text, give various counts for fungi and bacteria and HB 260 does not mention nor do the Australian Infection Control Guidelines.If anyone can shed some light on the way forward in 2013 it would be appreciated.
Kind Regards
Rebecca
Rebecca McCann Program Manager
Healthcare Associated Infection Unit (HAIU)
Communicable Disease Control Directorate Department of Health
Grace Vaughan House
227 Stubbs Terrace
SHENTON PARK WA 6008
T:08 9388 4859 M:0439 920 819 F:08 9388 4888
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Thank you Deb for the clarification, I am much relieved!
And I acknowledge the potential exceptions you highlight below.I’ll let others more knowledgeable respond to your specific question, but are there not suitable safety devices that could be used instead of a syringe?
Regards,
Irene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auThank you Irene for your response.
You are correct in saying that as a ‘general rule’ blood cultures should not be taken out of IV lines.
The following patient scenarios may clarify when the ‘general rules’ do not apply, requiring blood cultures to be taken from IV lines:
1. Brand new, aseptically inserted vascular devices can be used to sample from and may be done so whilst the patient is still draped for insertion.
2. If the invasive device is suspected to be the source of infection, then comparison cultures between the line and the peripheral stab can be used to confirm this (using time to positivity studies).
3. Where peripheral puncture fails, or is contraindicated, in the presence of an invasive device it is the only port to sample from.
4. PICC lines are occasionally inserted essentially because all other means of access is unavailable.
Because we know the above scenarios do occur, we are seeking advice for safe transference of blood from syringe to blood culture bottle.Many thanks
Kind regardsDeb Rhodes
Infection Prevention Project Nurse
Infection Prevention & Healthcare Epidemiology Unit
m 0429418495
p 4066
t 03 90763139 e D.Rhodes@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia[cid:706185101@25072013-24C6]
Alfred Health incorporates The Alfred, Caulfield Hospital and Sandringham Hospital
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Hi all,
This posting troubles me because as a general rule blood for culture should not be taken through IV lines. This can give a false positive result, since most IV lines become colonised with biofilm-producing organisms such as staphlylococci and yeasts within a fairly short time of insertion. This does not necessarily mean the patient has a bloodstream infection with these organisms. It is always preferable to take a separate draw from a peripheral vein for diagnosis of bloodstream infection.
Irene Wilkinson
Manager, Infection Control Service
SA Health
Irene.wilkinson@health.sa.gov.auHello All
Our organisation uses wide necked blood culture sampling bottles. In the case of obtaining blood from PICC lines or
Hickman lines, a sterile male luer transfer needle and transfer adaptor is used to engage the sampling bottle directly to
the hub of the device. We find there is enough length with these devices to ensure the bottle remains upright for accuracy
of sampling.There are some situations however where clinicians have no other option but to draw blood for blood cultures
using a syringe.Do any organisations have a sterile, female luer transfer needle or are they using any devices which will allow for
the safe, needle free transference of blood from a syringe into blood culture bottles?We would be delighted to hear from anyone with information regarding this.
Many thanks
Kind regardsDeb Rhodes
Infection Prevention Project Nurse
Infection Prevention & Healthcare Epidemiology Unit
m 0429418495
p 4066
t 03 90763139 e D.Rhodes@alfred.org.auAlfred Health
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia[cid:171170323@24072013-24B1]
Alfred Health incorporates The Alfred, Caulfield Hospital and Sandringham Hospital
http://www.alfredhealth.org.auCONFIDENTIALITY NOTICE: This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error, please notify us by return email and delete all copies in your system. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking any action in reliance on the contents of this information is strictly prohibited and may be unlawful. Alfred Health is not liable for the proper and complete transmission of the information contained in this communication or for any delay in its receipt.
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