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Dear All,
Wow it is great to see so many folk buying into a discussion about hand hygiene and HHA!
So to answer a few issues:
1. Brian yes, there are now clear Australian data showing an link between improved HH compliance (HHC) and reduced Australian SAB rates this was presented this year at ECCMID and has been submitted to Lancet Infectious Diseases (revised publication addressing reviewers comments now in preparation submission next week). In summary from an analysis of the 132 largest Australian hospitals (ie. 77% national beddays; [15.3 M of the 19.9 M nationally in 2016-17]) over the 8 years of the National Hand hygiene Initiative – for every 10% improvement in HHC nationally, there was an associated 15% decrease in HA-SAB rates. This change was independent of time ie. the change (delta) in HHC correlated with the delta in SAB rates. This is the first study on such a massive national scale that shows such an association all previous studies have been smaller (see Grayson ML, Russo PL, Cruickshank M, Bear JL et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. Medical Journal of Australia 2011195:615-9) or based on single hospital or State-based data. Brian I am happy to send you the ECCMID presentation, but please keep it to yourself until our publication is released let me know.
2. As a number of you have noted, HH auditing is time-consuming, but use of mobile devices and the HHCApp reduces the time burden by 50%; plus, more importantly, the value of direct auditing is in the educational role that auditors should be playing in immediately correcting poor HHC. The days of simply auditing should be gone. Obviously the current HHC data are almost certainly an over estimate since they do not control for night or weekend shifts; may be associated with a Hawthorne Effect (we estimate that to be <7% based on our data) and multiple other possible confounders but the Australian data has been collected in the same standard manner for at least 8 years, so is comparable year-to-year. Anyone who has sat with a sick relative overnight knows that the stated rates may not always apply, but the current system is standardised. The opinions of Mary-Lou McLaws and others, are noted, but what other approach do you suggest? We (and others) have looked at electronic monitoring systems but they are extremely expensive, do not allow for risk stratification according to the HH Moment being measured (e.g. Moment 2 vs Moment 5) and do not provide the educational benefits that on-the-spot human auditors provide.
3. I totally agree with John Ferguson that medical HHC is a really key issue that we need to improve on. The fact that some examiners in the FRACP exams still belittle candidates who perform HH between short-cases is pathetic and needs to be dealt with. We will be focusing on the Colleges this year. It is a credit to the RACS that they are the only College in the world to require that all surgical exam candidates must be credentialed in HHC before they can sit their Part 1 surgical exams.
4. Finally Glenys isnt it about time you declared your conflict of interest? I recall you berating Lars Ostergaard when, at the end of his sabbatical at the Alfred when he fed back that HHC rates were very poor and much worse than in Denmark (this was around the time HHA was just getting established so 10 years ago) you stated that HH had nothing to do with disease transmission or SAB rates!
A lot of hard work has gone into the National Hand Hygiene Initiative by a lot of committed HCWs over many years it is not perfect, but is better than any other national program. It also allows us to benchmark an important national infection control intervention against similar data from many other countries, which is a rather rare phenomenon in healthcare.
Kind regardsLindsay
Prof. M. Lindsay Grayson
MB BS, MD, MS, FRACP, FAFPHM, FRCP, FRCP (Edin), FIDSA
Director, Infectious Diseases & Microbiology, Austin Health
Director, Hand Hygiene Australia
Department of Medicine, University of Melbourne
Studley Rd., Heidelberg, Melbourne, VIC, 3084
Australia
Tel: +61-3 -9496-6676; FAX: +61-3-9496-6677From: 'Allen Cheng' via Ozbug [mailto:ozbug@asid.net.au]
Sent: Friday, 22 June 2018 1:17 PM
To: Dale Fisher
Cc: Chris Mansell; Glenys Harrington; John Ferguson; ozbug@asid.net.au; AICA Infexion Connexion
Subject: Re: [ozbug] Hand hygiene debate in the UK Parliment – 15/5/2018Wouldn't this suggest that we should de-link process from outcome? That is, measure the activity of the HH program (eg wards visited etc) and use independent "secret shoppers" to assess compliance?
If be more suspicious of wards reporting very high compliance esp if done by ward (link) nurses.
A.
On Fri, 22 Jun 2018, 13:05 Dale Fisher, <mdcfda@nus.edu.sg> wrote:
I think its easy (oh so easy) to find flaws in HH measures today. But do reflect on why HH auditing was invented and that is because there was a time when ABHR was not easily available and no one undertook hand hygiene. We know that moving from 10 to 30% is of enormous value compared to 30 to 50% or 70 to 90% .diminishing gains. There have been many other major gains in IPC processes such as environmental cleaning, devices and infrastructure design.Personally I feel HH audits have changed their role into more of a reminder or a tool to talk with management (and actually whether its up or down doesnt matter). Its about a conversation to direct HAI interventions and actually caring.
For the record; hospitals in Singapore sit around 65-85% HH compliance reported. Independent covert audits we have contracted knock these down about 20% (give or take).
We need to keep audits but understand their value and why we do them today ..with a view to life before them (not good)Dale Fisher
SingaporeFrom: Chris Mansell [mailto:Chris.Mansell@waikatodhb.health.nz]
Sent: Friday, June 22, 2018 10:32 AM
To: ‘Glenys Harrington’ <infexion@ozemail.com.au>; ‘John Ferguson’ <John.Ferguson@hnehealth.nsw.gov.au>; ozbug@asid.net.au
Cc: AICA Infexion Connexion <AICALIST@AICALIST.ORG.AU>
Subject: RE: [ozbug] Hand hygiene debate in the UK Parliment – 15/5/2018Im not sure if Im rising to a good internet trolling here
Thank you Glenys for the references on recent audit validation very interesting.
These are the historical, somewhat shakey, studies used to support introduction of the NZ programme in 2012:
Johnson P, Martin R, Grayson M. L et al. Efficacy of an alcohol/chlorhexidine Hand Hygiene
programme in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus
aureus (SA) infection. Medical Journal of Australia 2005; 183: 509-514Grayson ML, Jarvie LJ, Martin R, Jodoin ME, McMullan C, Gregory RHC, Bellis K, Cunnington
K, Wilson FL, Quin D, and Kelly A-M, on behalf of the Victorian Quality Council Hand Hygiene
Study Group and Victorian Quality Council Hand Hygiene Statewide Roll-out Group. Significant
reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates
associated with a multi-site, Hand Hygiene culture-change programme and subsequent
successful statewide rollout. Medical Journal of Australia 2008; 188:633-40Grayson ML, Russo PL, Cruickshank M, Bear JL et al. Outcomes from the first 2 years of the
Australian National Hand Hygiene Initiative. Medical Journal of Australia 2011195:615-9Do bear in mind that the 5 moments and the standardised auditing tools are intended as a process indicator which correlates with biological and ecological pressure, to reduce effective Reproductive Number. As such, they deserve respect for driving behavioural and operational improvements, no matter how rationally people question their direct validity and effectiveness for specific scenarios.
Anecdatally, it seems that the compliance rate recorded by our auditors, including Hawthorne effect, do correspond well to patient protection. In our hospital, small outbreaks have mostly occurred on wards with HH rates < 60%, while few have occurred elsewhere and we average around 80% overall which may not meet targets yet seems biologically fairly successful. The compliance target is very rigorous and good control of cross transmission can be achieved with rates under 90% . Our rates of detection for multiresistant MRSA (corresponding more or less to EMRSA-15 and AUS/ST239) have drifted down since 2012 while rates of Fluclox/Fusidic only non multi resistant MRSA (more or less community acquired ST5) have risen. See PLOS One Apr 2013 V8 (4) e62020 for earlier NZ epidemiology. Likewise, traditionally hospital associated ESBL K. pneumoniae rates are stable, while the more community associated ESBL E. coli rates have increased about 3 fold over 5 years. Waikato data: http://lab.waikatodhb.health.nz/assets/QCItems/MDRO-Trends-Waikato-Hospital-2013-to-2018-web-report.pdf
We are satisfied that Hand Hygiene 5 moments is beneficial and that current audit methods are well calibrated, providing actionable information.
However, further improvements would of course be appreciated.
Chris Mansell
Dr Chris Mansell MB,ChB FRCPA | Clinical Microbiologist | Waikato Hospital | 021 833 783
From: Glenys Harrington [mailto:infexion@ozemail.com.au]
Sent: Friday, 22 June 2018 14:24
To: ‘John Ferguson’; ozbug@asid.net.au
Cc: AICA Infexion Connexion
Subject: RE: [ozbug] Hand hygiene debate in the UK Parliment – 15/5/2018Hi John,
Many thanks for responding.
To continue putting $$ (mostly infection control personnel resources) into direct HH observations in the setting of gross overestimations of compliance rates should be evidence enough to review current practices.
There is a significant amount of information out there that challenges the accuracy of direct observational auditing of HH compliance, some of which has been undertaken in your own state of NSW see below.
While strides have been made by HHA since its establishment it is time to review the following given the information that is currently before use:
a) why do we continue to collect and report flawed data
b) why are we not reducing some of the current direct observation (infection control personnel /liaison nurses) auditing requirements until more accurate methods are investigated and,
c) why we are not looking at alternatives methods ( is see suggestions below – electronic devices/methods in combination with smaller observational audits).
In light of the available evidence (below) we should also be openly transparent and at this point in time when reporting direct observation compliance rates in Australia include a statement that cautions the reader that current research indicates the rates are likely to be significantly artificially inflated rather than implying to managers, CEOs and the general public that they are accurate.
Recent literature of interest
Australia – Yen Lee Angela Kwok et al. Automated hand hygiene auditing with and without an intervention. American Journal of Infection Control 44 (2016) 1475-80
* HHA rates (Hand Hygiene Australia human audits) for June 2014 were 85% and 87% on the medical and surgical wards, respectively. These rates were 55 percentage points (PPs) and 38 PPs higher than covert automation rates for June 2014 on the medical and surgical ward at 30% and 49%, respectively. During the intervention phase, average compliance did not change on the medical ward from their covert rate, whereas the surgical ward improved compared with the covert phase by 11 PPs to 60%. On average, compliance during the intervention without being refreshed did not change on the medical ward, whereas the average rate on the surgical ward declined by 9 PPs.
Australia – Mary-Louise et al. Hand hygiene compliance rates: Fact or fiction? AJIC online 17th May 2018
Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter.
The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates.
Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians ability to hyperrespond to produce habitual compliance.
Systematic review – Kingston L et al. Hand hygiene-related clinical trials reported since 2010: a systematic review. Journal of Hospital Infection 92 (2016) 309-320
We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.
Editorial – Hand hygiene compliance: are we kidding ourselves? Editorial, Journal of Hospital Infection 92 (2016) 307-308
It is clear that monitoring hand hygiene compliance using direct observation is flawed and that electronic devices/methods in combination with smaller observational audits using appropriately trained staff would enable a better assessment Hence, in an era of multi-resistant Gram-negative bacteria, it is now time to take stock and consider that we have spent a number of years performing research on hand hygiene with little evidence that any particular strategy works. Perhaps future research should be focused not on campaigns to improve hand hygiene at all costs, but on understanding when hand hygiene is most beneficial, setting reasonable, achievable targets, and then monitoring using validated, reproducible methods.
Observational study – Scheithauer S et al. Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study. Journal of Hospital Infection 97 (2017) 11-16
Calculated compliance was inversely associated with nurses workload. Hand-rub activities (HRA)/patient-day (PD), observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.
The use of liaison nurses to undertake direct observation of HH compliance audits is not a common practice across Australia and Im not aware of any information that using a liaison nurse is any more accurate that an infection control professional? Happy to be corrected.
Ill cross posting my response with the Australasian College of infection Prevention and Control (ACIPC) list server in order to keep infection control personnel in on the discussions.
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auFrom: John Ferguson [mailto:John.Ferguson@hnehealth.nsw.gov.au]
Sent: Friday, 22 June 2018 9:45 AM
To: ozbug@asid.net.au
Subject: Re: [ozbug] Hand hygiene debate in the UK Parliment – 15/5/2018Hi Glenys
Im not sure Id agree that the current Australian HH audit system is broke and parliamentary records are not necessarily representative of what is really going on ! We should remember what little we had before HHA came into existence. In fact the load on infection control services has been minimised by training auditors who are link nurses etc. We now have such a brace of auditors that the main problem is keeping them credentialed. Our audits go across a large number of facilities each time and work pretty well like clockwork. Across Oz we have invested a lot of work in getting things to where they are and arguably there have been measurable gains in terms of SAB reduction etc. I think we should focus not on revolution but rather tinkering with the existing system.
A huge issue to me is that we medicos are still largely allowed to operate in a parallel universe, with no real accountability system ensuring that we (in NSW at least) have even completed 5 moments training or shock/horror been competency assessed for HH, PPE or aseptic technique. Aside from the College of Surgeons, it seems that the other colleges are dodging and weaving still and that is where ACIPC and ASID should be pushing +++. For instance our medical advanced trainees still have no explicit expectation put on them by the RACP concerning expectations of inf control practice during exams etc. We allow doctors to get about in all sorts of gear (suits, coats etc) or theatre scrubs and no-one wants to say boo. Why cant we adopt a bare below elbow standard nationally? Can we hear more about the Cognitive Institutes recent aust. pilot into Vanderbilt style accountability systems please? Royal Melb Hosp has been part of that pilot.
Other possible improvements:
a) At one of our sites, weve had the experience of a well credentialed external auditor conducting most of the HH audits for the past two audits. We have seen compliance there fall considerably indicating to me that all locations should adopt an approach to auditing whereby auditors are always drawn from a different ward or hospital (proper independent auditing).
b) We know also that the initial audit figures from a session are more indicative of actual practice and so, we should not allow for auditing at any site to go on for more than say 30 mins max.
c) We should ensure that audits occur more frequently than thrice yearly and across all shifts with at least monthly feedback of data to cadres and managers
d) Integrating HH auditing with AT audits
e) More careful operational research what is working , what is not, how valid are results, what effects are improvements in HH having, why are medicos not getting engaged with the system? etc
Best wishes
JohnDr John Ferguson MBBS DTM&H FRACP FRCPA
Director, Infection Prevention Service | HNE Local Health District
John Hunter Hospital, Locked Bag 1, Newcastle Mail Centre, NSW 2310, Australia
T: 61 2 49214444 | F: 61 2 49214440 | M: +61(0)428 885573 (Speed Dial 67607) | Tw @mdjkf
Error! Filename not specified.
From: Glenys Harrington <infexion@ozemail.com.au>
Sent: Wednesday, 20 June 2018 9:28 AM
To: ozbug@asid.net.au
Subject: [ozbug] Hand hygiene debate in the UK Parliment – 15/5/2018Dear All,
There was a debate in the UK parliament, Westminster Hall on 15/5/2018 in relation to hand hygiene compliance.
The parliament was told that actual hand hygiene compliance is only 18% – 44% in the UK and that direct observation is grossly overestimating HH compliance rates (Hawthorn effect).
The discussion has implications for direct observation of hand hygiene compliance programs in Australian healthcare settings.
It is time to review our direct observation HH compliance strategies and the significant infection control resources committed to such programs across Australia.
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.au
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Further to Matthias’ email… His point #16 is correct – namely that
neither Infection Control nor Infectious Diseases know anything about
eWater and have never been asked to assess it, let alone approve it!!
Until this email I had never heard of eWater.Needless to say, we are currently investigating how Austin Health
“approved eWater”, but it was not via any clinical department. I will
report back since it may be a lesson for others.Thanks Matthias
Kind regards
Lindsay
Prof. M. Lindsay Grayson
Infectious Diseases Department,
Austin Health
Department of Medicine, University of Melbourne
Studley Rd., Heidelberg, VIC 3084
Australia________________________________
Dear Colleagues,
The topic of the eWater System appeared on both the ACIPC and OzBug
e-mail lists (I overlooked the ACIPC one initially) and I thought it
would be worth writing a somewhat more detailed joint reply to both
lists.I have previously posted (to ACIPC) on what seemed a similar technology,
the ActiveIon device.I have looked at some of the available information concerning the eWater
System, and even though I cannot make any final conclusions, I have a
number of questions and issues of concern that I would like to share. If
I were to look at purchasing the device, these would be some of the
points that I would look at more closely.(1) The description is that the system performs electrolysis of an NaCl
solution and creates two solutions, one a (probably weak) bleach (NaOCl)
and/or hypochlorous acid (HOCl) solution (not sure which one
predominates), the other a sodium hydroxide (NaOH) solution. The bleach
solution — according to the description — is microbicidal and can be
used for disinfection, including disinfection in the food industry, in
hospitals, even hand antisepsis. The NaOH solution — according to the
description — is for cleaning.(2) The question comes: What would be the difference between using the
eWater system and just buying bleach and/or hypochlorous acid itself,
which are cheap standard chemicals that are easily available?(3) Has the system been tested by a manufacturer-independent (!)
disinfectant testing laboratory with relevant expertise? Experience
tells us that one cannot solely rely on manufacturer-provided test
reports or manufacturer claims when it comes to disinfectants —
preferable would be at least two independent test reports from
experienced reputable labs.(4) Has the system been tested by any of the available standardised
testing protocols for surface disinfection (or other types of
application, depending on the intended use)? There are, for example, US
ASTM standards and European EN standards. The EN standard for surface
disinfection is EN 13697, and such tests are typically done in
variations (a) with or without organic load (“dirty conditions”) and (b)
with or without mechanical action (simulating the wiping).(5) If, for example, antimicrobial activity would fail in the presence
of organic load, then a prior cleaning step would become highly
critical. Organic load is, of course, an issue in the food industry,
where one of the advertising targets lies.(6) FYI, disinfectant testing and assessment is usually done in two
steps, step 1 is testing in suspension — like the MBC (minimum
bactericidal concentration) for antibiotics – and step 2 is testing
under simulated practice conditions, e.g. surface disinfection on a
carrier.(7) Has any testing employed experimental controls that — in terms of
biological plausibility — leave no other conclusions than what the
machine produced killed the microorganisms and not (!) some other part
of the application? (In the ActiveIon example, the microbial reduction
achieved by one testing lab was similar to what one would expect from
applying plain inactive water and wiping, but such a control was
omitted).(8) Is there a way to make sure that the disinfectant concentrations
coming out of the machine are kept consistent and in an antimicrobially
active range to fulfill their purpose? Meaning how are concentrations
monitored and ensured that there is active disinfectant? Is there a
testing method provided to measure the concentrations in daily use (in
analogy to checking fridge temperatures in labs on a daily basis as part
of quality control)? Apparently, electrodes age over time and may
deliver electrolysis less consistently. Is there experience with
stability of not only disinfectant concentration but also microbicidal
activity over the intended period of machine usage (I presume years)?
Also, how long are the prepared solutions stable after electrolysis and
before application?(9) The company address given on the website is an Australian one, but
it is unclear to me if they are a distributor or the manufacturer. Some
of the documentation appears to be from Japan; this may indicate that
the Australian address may be a distributor.(10) I saw two “research” publications on the website, both looked like
research papers, but none had proper bibliographic information (journal
name, year, volume, etc.). (I found one of these subsequently, with
journal information, by putting the title into PubMed).(11) A table on the website showing microbial test results (citing an
article published in Japanese) misspelled quite a number of bacterial
names. If someone claiming to have microbiological expertise is unable
to spell some of the most common bacterial names, this should ring alarm
bells.(12) On the eWater website, there are three linked documents from RMIT
University (origin: School of Civil Engineering). One is a brief
Executive Summary, another a more comprehensive multi-page document,
another what appears to be a conference poster. The Executive Summary
appears to focus on cost, environmental and social factors, the bigger
document has “report final” in its file name but has oblique “draft”
written over the pages and no authors specified. The microbiology part
is dubious. All three are written in a very positive tone, raising the
question whether they might be industry-sponsored.(13) The claim that the system can “sterilise” medical instruments
appears unsubstantiated. From a solution like the one described, one
would expect at best (!) high-level disinfection, but not sterilisation.
Even claims for high-level disinfection would have to be substantiated
by standardised testing, and it should be specified what types of
instruments can be treated and under which conditions.(14) It is proposed to use the electrolysed water for hand hygiene, but
it is unclear to me how it should be useful for that purpose. NaOCl
(bleach) is genuinely unsuitable (!) for hand hygiene, because in higher
concentrations it would be damaging to hands and in lower concentrations
it would take too long to kill microorganisms (alcohol hand rubs produce
several log reduction in about 30 sec). Again, results from standardised
tests would be needed.(15) The main target is apparently the food industry, but it is also
promoted for hospitals. Even if the product were “only” intended for the
food industry, one would still expect that the system should fulfill
basic claims concerning antimicrobial efficacy. Both industries are
critical in terms of preventing infections.(16) The company advertises with an endorsement from Austin Health. That
would raise the question whether Austin’s Infection Control Department
and/or Lindsay Grayson’s group has seen and/or endorsed this, or whether
the company only liaised with scientifically untrained personnel, such
as the housekeeping or kitchen department. The latter would be quite
inappropriate. (We had an occasion here where a manufacturer tried to
market a new product by circumventing the Infection Control Committee
and went straight to Housekeeping).I think that this system should be properly investigated by an
institution or authority with the competency and clout to do this before
it is used in the healthcare and food industry.Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387
kkh
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