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Dear Colleagues,
To use a famous quote:
“Absence of evidence is not evidence of absence”.
http://en.wikipedia.org/wiki/Argument_from_ignorance
and another one: “Those who cannot remember the past are condemned to repeat it” (George Santayana).
What I am trying to say is that the question of whether or not to wear theatre clothing, and in which circumstances, is — in my opinion — more complex than to say “there is no evidence for it” or vice versa, “there is evidence for doing it in a particular way”.
Some of it boils down to what we want to accept as evidence — is it only evidence from randomized clinical trials with surgical infection rates as the outcome (for which there are none in theatre clothing — so we would not find any evidence), or is it evidence from microbiology, historical/anecdotal sources, combined with “what makes sense”? If we were to accept only high-quality evidence from RCTs, we would have no basis for many everyday clinical decisions that otherwise make perfect sense (think of the famous parachute article in the 2003 Christmas edition of BMJ). In the absence of good-quality evidence from clinical trials, some answers may come from other sources and include scientific reasoning, common sense and sociological issues (e.g. institutional identity and public perception, as pointed out by Paul Smollen).
It is for some of these reasons that some of the analyses in the HIS document (Woodhead et al. 2002) — while it is overall a reasonable document and a laudable approach to query the issues — lack a little depth to fully address these issues (they also point out social and/or theatre discipline issues).
Things started in the 19th century, around Lister’s time. Senior surgeons often took pride in how dirty, blood- and pus-splattered their gowns were, because this was viewed as a status symbol. (Not sure, is wearing scrubs in cafeterias also a kind of status symbol?). In the late 19th and early 20th century, the principle of aseptic surgery was introduced (including scrubs, gowns, sterile field, etc.) and then refined during the first half of the 20th century. Note that by about the 1970s, the infection rates for clean surgery (classified as clean) were already quite similar to what they are today. Advancements came mostly from the other categories (clean-contaminated and higher).
The microbiological rationale for wearing dedicated operating theatre clothing, i.e. scrubs, comes from the fact that when freshly-laundered clothing is put on, this clothing acquires the wearer’s (and to a lesser extent the environment’s) microorganisms, and this bacterial burden increases over the time of wearing. This is thought to be in principle very similar for street clothing and scrubs, and what happens is that over time, the microorganisms on the clothing reach a saturated state and then the wearer disperses these microorganisms into the environment around her/him, although this also depends on how tightly woven the garments are (scrubs are more tightly woven, so lesser shedding). This is called the “cloud phenomenon”, and someone who has published on this in recent times is Robert (“Bob”) Sherertz from the USA. The acquisition and dispersal of microorganisms includes pathogens like Staph. aureus (also MRSA) in those who are colonised. That means, what the wearing of fresh scrub suits effectively does is to set the “clock” of microorganism acquisition and dispersal back to zero each time a new suit is put on. The consequence is that if there is an institutional scrub-wearing policy, then the institution has some control over this microorganism acquisition and dispersal, whereas if people can wear street clothes or re-use old scrubs, then there is no institutional control over this biological process. (People may come in with several-days-old street clothing or just put the scrubs in the locker for re-use if the process is not controlled). Much of this research dates back to about the 1950s and 1960s, before the advent of evidence-based medicine, and therefore information in the very recent literature is scarce. (I need to credit my colleague Andreas Widmer from Switzerland for bringing my attention to this microbiological rationale — a quote from Andreas is “what’s the point of having clean HEPA-filtered OT air when the clothing makes the bacteria airborne?”).
A publication by Bob Sherertz is here:
Bischoff WE, Tucker BK, Wallis ML, Reboussin BA, Pfaller MA, Hayden FG, Sherertz RJ. Preventing the airborne spread of Staphylococcus aureus by persons with the common cold: effect of surgical scrubs, gowns, and masks. Infect Control Hosp Epidemiol. 2007 Oct;28(10):1148-54.
http://www.ncbi.nlm.nih.gov/pubmed/17828691While the above provides a clear rationale (I can’t call it evidence) for wearing dedicated scrubs in OT and for having an institutional OT attire policy, the rationale for changing when leaving OT and for putting on fresh scrubs when reentering, or alternatively for putting on cover gowns, is less clear. The microbial contamination between scrubs dedicated to the OT and scrubs worn outside the OT is generally not very different from each other. However, one study from the 1980s found that the microbial burden on scrubs was less when covergowns were worn outside the OT or when fresh scrubs were put on while reentering, while there was more contamination when no covergowns were worn, or when scrubs were just put in lockers and worn again after a lunch break:
Copp G, Mailhot CB, Zalar M, Slezak L, Copp AJ. Covergowns and the control of operating room contamination. Nurs Res. 1986 Sep-Oct;35(5):263-8.
http://www.ncbi.nlm.nih.gov/pubmed/3529043Also to consider is the image of professionality and the professional image of healthcare staff on patients and the general public (see Paul Smollen’s comment).
Another issue to consider is the inadvertent contamination of scrubs with blood and body fluids (staff may have individually different perception as to when they regard scrubs as contaminated) and any potential infection risk to food/drink consumption areas, although I am not aware of any good literature on this.
Another interesting article is here:
Wright SN, Gerry JS, Busowski MT, Klochko AY, McNulty SG, Brown SA, Sieger BE, Ken Michaels P, Wallace MR. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012 Dec;33(12):1238-41.
http://www.ncbi.nlm.nih.gov/pubmed/23143362This is a recent case cluster of G. bronchialis sternal wound infections after cardiac surgery in the USA that was traced to contaminated scrub suits by a nurse anaesthetist. This was traced back (most likely) to home laundering of the scrub suits (a practice that is apparently still done at some institutions in the USA) with a badly-maintained, contaminated washing machine. That means, contaminated scrub suits definitely have the potential to cause surgical site infections.
Again, I am not claiming to have conclusive evidence here, but the above may be some food for thought.
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 1387An “oldie but a goodie” is the Hospital Infectioin Society working party report on “behaviours and rituals in the operating theatre” this was published in the journal of hospital infection quite a number of years ago now.
http://www.his.org.uk/_db/_documents/Rituals-02.pdf The working party reviewed all of the available evidence at the time and made recommendations based on the level of evidence available. Theatre attire, scrubs, overgowns & overshoes are addressed in this document.Overgowns are not necessary outside the operating theatre. Scrubs must be changed as soon as there is any blood/body fluid contamination regardless of whether staff are remaining in the OT suite or leaving to go to the cafe.
I recommend a quick literature search of Pubmed for the latest literature/evidence on this subject.
Fiona Randall
CNC Infection Prevention & Control
Wesley Mission Brisbane.On Fri, Mar 1, 2013 at 2:40 PM, Paul Smollen <Paul.Smollen@cec.health.nsw.gov.au> wrote:
Toni,I do enjoy this chestnut. While it is a public perception, facilities and us at the Ministry receive multiple complaints from visitors about this issues. One of the complaints we get is that the public see them in the gowns in the cafe and are worried they are going off to operate on their family member. This alone could convince your OT staff against the practice.
The problems lies with no valid evidence. This comment may open a can of worms….. but I find this should be a two way street and if OT staff want to walk around a hospital and outside and do all normal activities in their scrubs, then they should allow people to walk into an OT in street clothes. I really see no difference. While we are concerned with levels of evidence about scrubs outside an OT what level of evidence is there about wearing scrubs inside an OT? The scrubs are usually kept on open shelves in open change rooms with toilets and showers nearby.
I do know of facilities that have a lunch ordering system with their cafe and the food is delivered there. This may be an option you could explore.
Good luck with it all.
Paul Smollen
Project Manager, Healthcare Associated Infections (HAI)
Clinical Excellence Commission | Level 14/227 Elizabeth Street, Sydney NSW 2000
T: (02) 9269 5586 |F: (02) 9269 5599 | E: Paul.Smollen@cec.health.nsw.gov.au
http://www.cec.health.nsw.gov.auDear All,
The issue of where you can and cannot wear operating theatre attire (blues) has arisen at our facilities – again.
I would be interested to know if your facilities/organisations allow theatre staff to eat and drink in the on-site cafeteria if they have clean blues that are covered.
Food is not supplied to the OT; staff are permitted to collect food from the on-site cafeteria if in clean blues that are covered; there is a tea room but it is said that it can be over crowded at peak times.
The public perseption (and complaints received) says that they should not be allowed to eat and drink there.
What valid evidence is there and what do others do or say to back up that they should not eat and drink in on-site cafeterias (if at all).
Look forward t your comments.
Regards, Toni.Toni Schouten CICP
Clinica Quality Manager
Sydney Local Health District
toni.schouten@sswahs.nsw.gov.au_____________________________________________________________________
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James,
Thank you. With regard to C. difficile and in healthcare, the situation is fairly clear and handwashing is recommended if a patient is specifically known to be infected. (Difficult to deduce a similar situation in the food industry).
With regard to non-enveloped viruses, a few years ago I have compared in some detail the published log reduction factors (as a marker for pathogen elimination) of handwashing versus regular/standard formulations of alcohol-based hand rubs, and the result was that there is not much difference, i.e. the two perform very similarly against these viruses.
To recapitulate, one of the main advantages of ABHRs is that in most situations they are far superior to handwashing in eliminating pathogens from hands. When hands are contaminated with “usual” pathogens, a handwash typically achieves a 1-2 log (factor 10-100) reduction (the 100 is already very optimistic), while ABHRs typically achieve somewhere between a 2-4 log reduction (factor 100-10000). Handwashing with antiseptic soaps/detergents is usually in between the two, but falls short of achieving the reduction of well-formulated handrubs.
However, virucidal hand rubs do achieve better reduction factors against non-enveloped viruses than washing. There are several such products on the market in Europe, and I believe some may be available in the US, but they may not yet be on the market in Australia. I have some articles, but I am currently away from work, and can send you some when I am back in early February.
I can’t comment much on the other requirements in the food industry, such as the possibility of frequent contamination of hands with organic matter.
Sorry, I did not understand the part of your sentence that says “it appears it is simply coherence of the message vis–vis hand hygiene and healthcare workers which seems to override”.
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
________________________________Hi Andrea,
Thank you for the feedback. Apologies for the incorrect word use, ie virus and C diff.
I believe the ASID/AICA position on the matter is that gloves should be worn, if not worn, or if hands become soiled, then use soap (microbial or otherwise) and water. (ASID/AICA position statement – Infection control guidelines for patients with Clostridium difficile infection in healthcare settings 2011).
Am I right in saying that you recommend a good reference point for the overlap between food and healthcare hand hygiene guidelines would be the veterinary industry?
Kind regards,
James Casey
Business Development
ManagerTealwash Pty Ltd
a member of the Transplumb group.Mobile +61 438 175 504
Phone +61 3 8336 1899 ext 3
Email jcasey@tealwash.com.au
72b Barrie Road, Tullamarine 3043,
VIC, Australia.Hi James,
Thanks for the comments.
Clostridium difficile is not a virus…..very important distinction from Norovirus.
it is recommended staff use an antimicrobial Handwashing product after contact with patients with CDAD (Clostridium difficile associated diarrhoea), not social handwash or soap and water.
Given that many animals can become infected with C. difficile perhaps you could look at what is recommended in veterinary practice?Regards Andrea Menzies
Andrea Menzies
RN | Infection Prevention and Control | Health Directorate
Building 10, Level 4 | The Canberra Hospital | Garran ACT 2605The very first requirement in a hospital is that it should do the sick no harm.
Florence NightingaleCare | Excellence | Collaboration | Integrity
Hi All,
I work for a company with significant overlap in both the food and medical industries. The regulations/recommendations/overall leanings are certainly clear with regards to each industry individually. The Food Industry subscribes to soap and warm water washing (see AUSNZ Food Standard 3.2.2 Division 4-1 and 4-2, as well as 3.2.3 Division 4-1) and the Medical to alcohol based sanitiser (WHO, CDC, HHA, NHMRC etc). What is less clear however is when they overlap. To my knowledge I do not know of any intersecting guidelines (happy to be pointed in the right direction!).
As far as the Science goes, the inconsistencies between the two are a reflection perhaps of the differing routes of infection, and the prominence of different outbreaks in each industry. As Cath noted the FDA has a good summary of the reasoning for this but basically it comes down to the fact that pathogens in the food industry (in terms of human transmission) are more likely to be transmitted via the faecal-oral route as opposed to the person-to-person route seen in the medical industry. For this reason alone notable viruses such as Clostridium Difficile and Norovirus are prevalent in the food industry and as such, soap and water hand washing are the better alternative due to the documented inadequacy of alcohol sanitisers in dealing with the two.
Further to this, the increased risk of hands being physically soiled in the food service industry due to foodstuffs etc compels the mechanical removal of physical contaminants, ie soap and water.
For me it would come down to a balance of applicability. Whether you think the kitchens food activities outweigh their exposure to the hospital setting or vice-versa.
I hope Ive given a fair and balanced response, very happy to provide references. I look forward to your feedback 🙂
Kind regards,
James Casey
Business Development
Manager
Tealwash Pty Ltd
a member of the Transplumb group.Mobile +61 438 175 504
Phone +61 3 8336 1899 ext 3
Email jcasey@tealwash.com.au
72b Barrie Road, Tullamarine 3043,
VIC, Australia.Hi Cath
I am not sure I can place my hand on my heart and say that our Australian / New Zealand Food Safety Standards (http://www.foodstandards.gov.au/) are actually fully based on evidence and supported by evidence, but they are certainly well accepted within the food industry and by the food industry regulators.
Here is an example from NSW about food safe chemicals, which includes hand sanitisers http://www.foodauthority.nsw.gov.au/industry/food-business-issues/chemicals-suitability/
Cheers
MichaelMichael Wishart
CNC Infection Control
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 emailHi Michael
Could you please provide a link of title of those food safety recommendations Michael. Im keen to see what science they are based on.
Cheers
CathCathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.auHi Cath
Food safety recommendations preclude use of non-food safe chemicals in the food processing environment, which precludes use of most alcohol based hand hygiene products and some antiseptic products. I do believe there are some waterless hand hygiene products (not sure if some of these should be considered alcohol based, though) that are approved as food safe, but most of those alcohol based hand hygiene products routinely in use in healthcare have not been approved as food safe. Thus, the use of alcohol based hand hygiene products within certain parts of food services with healthcare facilities is problematic, which is why I think this is a good question, and I believe the responses have indicated this.
In regard to mentioning of brand names, yes, we generally try to recommend avoiding use of brand names in discussions where possible, but this creates some work for both myself as the moderator and the list subscribers who are replying. Rather than bog the list down in administrative emails and such, I have preferred to weigh up the issue of posting of actual product names with the benefits of open discussion. For example, in this instance, my belief was it was useful to see which actual products are being used in what aspects of food service delivery (eg ward delivery vs food production), as this was conducive to the conversation. This approach had been supported by previous ACIPC / AICA executives, although like all things, this is open to review with further comments from the membership.
It is always useful to examine what we are discussing, how we are discussing it, and what benefit and risk these discussions may have, so I thank you for your comments. More discussion is always welcomed!
Cheers
Michael Wishart
Infexion Connexion AdministratorMichael Wishart
CNC Infection Control
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 emailHi Marlize
Im curious about the question and the responses. As I understand it there have been no scientific reports or official Australian public policy directives that suggest differentiating between what is available in public areas, in the wards where staff perform hand hygiene before feeding patients and/or in kitchens or food prep areas. I checked the WHO Guidelines from 2009 and they also appear to be silent on the issue.
Given that one of the basic tenets to improve hand hygiene compliance is standardisation I would think it wise if you introduced or continued to use a neutral liquid soap identical to that used in the settings mentioned above. The key points are making sure kitchen staff understand the importance of HH as part of food hygiene, that they perform it when needed (including when on the ward if potentially exposed) and that their technique and wearing of gloves is performed in such a way that the skin on their hands is maintained. It would be an education rather than a product issue I think.
As always I am surprised to see brand names mentioned here in the forum given its policies and conditions around promotion etc it would be more ethical to stick to using generic terms but perhaps the moderator can advise. Also my experience would indicate that if you raised the issue of HH for kitchen staff your current supplier of HH product would no doubt be able to provide you with data and information regarding suitability of their product in that setting.
Good luck and thanks for making me curious 😉
CathCathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.auDear All,
We are currently looking for a alcohol based hand sanitiser to use in our Food Service Department. I was wondering what the practices are out there, and what product you are using in your Food Service Departments and on your food delivering trolleys?
Thank you and regards
Marlize Senekal
Infection Prevention and Control Coordinator
St. Andrew’s War Memorial Hospital
457 Wickham Terrace, Spring Hill
Brisbane
Ph. 07-3834 4444
Ext. 4328, Pg. 0328_________________________________________________________________
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Dear All,
Two small points. It is unclear to me (genuine lack of knowledge) whether Clostridium difficile transmission plays a significant role in the food industry — it certainly does in healthcare. C. difficile populations consist of two parts, the (easy to kill) vegetative forms, and the spores (hard to kill). Although this certainly varies, stools from acutely-infected patients have been reported to contain 10:1 vegetative forms:spores. Second, with regard to noroviruses (and other non-enveloped ones), there is insufficient evidence to tell whether either alcohol-based handrubs in standard formulations or handwashing is better. However, there are now specifically-formulated virucidal ABHRs, and these are better than handwashing against norovirus.
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
________________________________Great points James. Thank you for the thoughtful discussion and considerations. V interesting. Also reminds me of the importance of unwell kitchen staff absenting themselves from work for 48hrs post symptoms in the event of V&D type illness.
You gotta love the diversity and debate around infection prevention and control.
Cheers
CathCathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.auHi All,
I work for a company with significant overlap in both the food and medical industries. The regulations/recommendations/overall leanings are certainly clear with regards to each industry individually. The Food Industry subscribes to soap and warm water washing (see AUSNZ Food Standard 3.2.2 Division 4-1 and 4-2, as well as 3.2.3 Division 4-1) and the Medical to alcohol based sanitiser (WHO, CDC, HHA, NHMRC etc). What is less clear however is when they overlap. To my knowledge I do not know of any intersecting guidelines (happy to be pointed in the right direction!).
As far as the Science goes, the inconsistencies between the two are a reflection perhaps of the differing routes of infection, and the prominence of different outbreaks in each industry. As Cath noted the FDA has a good summary of the reasoning for this but basically it comes down to the fact that pathogens in the food industry (in terms of human transmission) are more likely to be transmitted via the faecal-oral route as opposed to the person-to-person route seen in the medical industry. For this reason alone notable viruses such as Clostridium Difficile and Norovirus are prevalent in the food industry and as such, soap and water hand washing are the better alternative due to the documented inadequacy of alcohol sanitisers in dealing with the two.
Further to this, the increased risk of hands being physically soiled in the food service industry due to foodstuffs etc compels the mechanical removal of physical contaminants, ie soap and water.
For me it would come down to a balance of applicability. Whether you think the kitchens food activities outweigh their exposure to the hospital setting or vice-versa.
I hope Ive given a fair and balanced response, very happy to provide references. I look forward to your feedback 🙂
Kind regards,
James Casey
Business Development
Manager
Tealwash Pty Ltd
a member of the Transplumb group.Mobile +61 438 175 504
Phone +61 3 8336 1899 ext 3
Email jcasey@tealwash.com.au
72b Barrie Road, Tullamarine 3043,
VIC, Australia.Hi Cath
I am not sure I can place my hand on my heart and say that our Australian / New Zealand Food Safety Standards (http://www.foodstandards.gov.au/) are actually fully based on evidence and supported by evidence, but they are certainly well accepted within the food industry and by the food industry regulators.
Here is an example from NSW about food safe chemicals, which includes hand sanitisers http://www.foodauthority.nsw.gov.au/industry/food-business-issues/chemicals-suitability/
Cheers
MichaelMichael Wishart
CNC Infection Control
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 emailHi Michael
Could you please provide a link of title of those food safety recommendations Michael. Im keen to see what science they are based on.
Cheers
CathCathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.auHi Cath
Food safety recommendations preclude use of non-food safe chemicals in the food processing environment, which precludes use of most alcohol based hand hygiene products and some antiseptic products. I do believe there are some waterless hand hygiene products (not sure if some of these should be considered alcohol based, though) that are approved as food safe, but most of those alcohol based hand hygiene products routinely in use in healthcare have not been approved as food safe. Thus, the use of alcohol based hand hygiene products within certain parts of food services with healthcare facilities is problematic, which is why I think this is a good question, and I believe the responses have indicated this.
In regard to mentioning of brand names, yes, we generally try to recommend avoiding use of brand names in discussions where possible, but this creates some work for both myself as the moderator and the list subscribers who are replying. Rather than bog the list down in administrative emails and such, I have preferred to weigh up the issue of posting of actual product names with the benefits of open discussion. For example, in this instance, my belief was it was useful to see which actual products are being used in what aspects of food service delivery (eg ward delivery vs food production), as this was conducive to the conversation. This approach had been supported by previous ACIPC / AICA executives, although like all things, this is open to review with further comments from the membership.
It is always useful to examine what we are discussing, how we are discussing it, and what benefit and risk these discussions may have, so I thank you for your comments. More discussion is always welcomed!
Cheers
Michael Wishart
Infexion Connexion AdministratorMichael Wishart
CNC Infection Control
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 emailHi Marlize
Im curious about the question and the responses. As I understand it there have been no scientific reports or official Australian public policy directives that suggest differentiating between what is available in public areas, in the wards where staff perform hand hygiene before feeding patients and/or in kitchens or food prep areas. I checked the WHO Guidelines from 2009 and they also appear to be silent on the issue.
Given that one of the basic tenets to improve hand hygiene compliance is standardisation I would think it wise if you introduced or continued to use a neutral liquid soap identical to that used in the settings mentioned above. The key points are making sure kitchen staff understand the importance of HH as part of food hygiene, that they perform it when needed (including when on the ward if potentially exposed) and that their technique and wearing of gloves is performed in such a way that the skin on their hands is maintained. It would be an education rather than a product issue I think.
As always I am surprised to see brand names mentioned here in the forum given its policies and conditions around promotion etc it would be more ethical to stick to using generic terms but perhaps the moderator can advise. Also my experience would indicate that if you raised the issue of HH for kitchen staff your current supplier of HH product would no doubt be able to provide you with data and information regarding suitability of their product in that setting.
Good luck and thanks for making me curious 😉
CathCathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.auDear All,
We are currently looking for a alcohol based hand sanitiser to use in our Food Service Department. I was wondering what the practices are out there, and what product you are using in your Food Service Departments and on your food delivering trolleys?
Thank you and regards
Marlize Senekal
Infection Prevention and Control Coordinator
St. Andrew’s War Memorial Hospital
457 Wickham Terrace, Spring Hill
Brisbane
Ph. 07-3834 4444
Ext. 4328, Pg. 0328_________________________________________________________________
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________________________________
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P.S. Sorry, I meant “choose” and “EN 12791” (instead of 81). Typed too quickly.
—
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 1387Dear Annette,
I assume you are referring to alcohol hand rub in terms of surgical hand antisepsis (“surgical scrubbing”), not to alcohol hand rub beteen patients, such as in the 5 Moments. Correct?
There is no requirement for a surgical hand wash between alcohol-based surgical hand antisepsis procedures. The only requirement for a soap/detergent (plus water) based hand wash in terms of surgical hand antisepsis is when the hands are dirty/soiled before alcohol-based surgical hand antisepsis. (See WHO Hand Hygiene Guidelines 2009, pages 54-60). Such a situation may arise, for example, before alcohol hand antisepsis for the first procedure of the day when staff come into OT from outside. In some institutions it is therefore standard practice (in terms of unifying/standardising OT procedures) to do a hand wash (followed by towel drying) — including cleaning under fingernails — before doing alcohol hand antisepsis for the first procedure.
The film/residue left after alcohol hand rubbing depends very much on the product that is used, and on user preference as to when they feel it gets too sticky for them. Some products leave a lot of sticky residue on hands, and the very good, top products leave very little to no sticky residue (film) and can be used for hand antisepsis consecutively for quite a number of procedures. Because there is no Australian standard for alcohol-based surgical hand antisepsis, and because US standards have not been specifically tailored towards alcohol-based surgical hand rubs, it is probably a good move to hoose a product that fulfills European standard EN 12781 (see also WHO guideline).
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 1387Dear all,
We would like to know if anyone can inform us please, on the recommended number of alcohol hand rubs you can utilise, before another full surgical hand wash is required when working in theatres.We have previously been informed for the alcohol rubs to be fully effective, that they cannot be utilised all day as they eventually leave a film on the skin. The intermittent washing of hands with soap and water is therefore deemed necessary to remove the film before continuing with the use of the alcohol hand rub.
We look forward to your response and thank you for your time.
Kind regards,
Annette Kennedy
DDON
Skin & Cancer Foundation Australia Day Care Procedure Centre
7 Ashley Lane Westmead NSW 2145Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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kkh
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Dear Annette,
I assume you are referring to alcohol hand rub in terms of surgical hand antisepsis (“surgical scrubbing”), not to alcohol hand rub beteen patients, such as in the 5 Moments. Correct?
There is no requirement for a surgical hand wash between alcohol-based surgical hand antisepsis procedures. The only requirement for a soap/detergent (plus water) based hand wash in terms of surgical hand antisepsis is when the hands are dirty/soiled before alcohol-based surgical hand antisepsis. (See WHO Hand Hygiene Guidelines 2009, pages 54-60). Such a situation may arise, for example, before alcohol hand antisepsis for the first procedure of the day when staff come into OT from outside. In some institutions it is therefore standard practice (in terms of unifying/standardising OT procedures) to do a hand wash (followed by towel drying) — including cleaning under fingernails — before doing alcohol hand antisepsis for the first procedure.
The film/residue left after alcohol hand rubbing depends very much on the product that is used, and on user preference as to when they feel it gets too sticky for them. Some products leave a lot of sticky residue on hands, and the very good, top products leave very little to no sticky residue (film) and can be used for hand antisepsis consecutively for quite a number of procedures. Because there is no Australian standard for alcohol-based surgical hand antisepsis, and because US standards have not been specifically tailored towards alcohol-based surgical hand rubs, it is probably a good move to hoose a product that fulfills European standard EN 12781 (see also WHO guideline).
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 1387Dear all,
We would like to know if anyone can inform us please, on the recommended number of alcohol hand rubs you can utilise, before another full surgical hand wash is required when working in theatres.We have previously been informed for the alcohol rubs to be fully effective, that they cannot be utilised all day as they eventually leave a film on the skin. The intermittent washing of hands with soap and water is therefore deemed necessary to remove the film before continuing with the use of the alcohol hand rub.
We look forward to your response and thank you for your time.
Kind regards,
Annette Kennedy
DDON
Skin & Cancer Foundation Australia Day Care Procedure Centre
7 Ashley Lane Westmead NSW 2145Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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Matthew,
This depends what kind of evidence you are looking for, and what the evidence is supposed to be for. For the change into scrub suits before entering the ICU, or for using a dedicated change room?
Much of the evidence in terms of various clothing requirements in various hospital areas is historical evidence and derived from microbiological data and from what makes biological sense in terms of pathogen transmission. That branch of research goes back to about the 1950s or 1960s, although several professional bodies have their recommendations, and there are newer pieces, e.g.:
http://www.ncbi.nlm.nih.gov/pubmed/17828691
http://www.ncbi.nlm.nih.gov/pubmed/3529043
You won’t find any randomised clinical trials in that area (if so, I would be surprised).
The microbiological rationale and biological plausibility for dedicated clothing for certain areas comes from the fact that when freshly-laundered clothing is put on, this clothing acquires the wearer’s (and to a lesser extent the environment’s) microorganisms, and this bacterial burden increases over the time of wearing. This is thought to be similar for street clothing and scrubs, and what happens is that over time the wearer disperses these microorganisms into the environment around her or him, although this also depends on how tightly woven the garments are (scrubs are more tightly woven, so lesser shedding). This is called the “cloud phenomenon”. The acquisition and dispersal of microorganisms includes pathogens like Staph. aureus in those who are colonised. That means, what the wearing of fresh scrubs effectively does is it sets the “clock” of microorganism acquisition and dispersal effectively back to zero each time a new suit is put on. The issue is that if institutional scrub-wearing is set up, and the change into fresh scrubs is mandated, the institution has some control over this microorganism acquisition and dispersal, whereas if people can wear street clothes or re-use old scrubs, then there is no institutional control over this biological process. (People may come in with several-days-old street clothing if the process is not controlled).
What the change rooms effectively do is to provide convenience and uniformity in the sense of having an area where to change and providing a stocked supply of fresh scrubs.
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—–Original Message—–
I’m wanting to know of any hospitals with a policy that requires all staff to change into ‘scrubs’ via a dedicated change room prior to entering the intensive care unit, similar to how theatre staff change into ‘scrubs’ prior to entering an operating theatre? If so, is the policy supported by evidence.
Many thanks
Matthew Richards
Clinical Nurse Consultant
Infection Prevention and Surveillance Service Melbourne Health
T: 9342 8325 F: 9342 8484 E: matthew.richards@mh.org.auMessages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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———————————————————————————
The information contained in this e-mail and the attachments (if any) may be privileged and confidential and is intended solely for the named addressee. If you are not the intended recipient, please do not print, retain copy, disseminate, distribute, or use this e-mail or any part thereof. Please notify the sender immediately by replying to this e-mail and delete all copies of this e-mail and the attachments.Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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P.S. My understanding is that hexachlorophene is an historical antiseptic that is now obsolete. The spectrum of activity is narrower and the overall efficacy less than chlorhexidine, and it was found neurotoxic when used on neonates; this was reported in the early 1970s.
—
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 1387Hello
We have been using 3% hexachlorophene body wash as part of the topical decolonisation therapy for selected MRSA carriers who meet a specific for over 20 years. The supply is no longer available. Suggested alternatives are 1% Triclosan or Chlorhexidene. I wanted to get a feel on what others are using around Australia so hoping you can share the information. It is difficult to measure success but if you have done so it would be great to hear about it.
Regards
Rosie
Rosie Lee
RN. BSc. CICP
Coordinator – Infection Prevention & Management
SMH Service – Royal Perth HospitalPh + 61 8 9224 2805 Fax + 61 8 9224 1989
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Hi All,
We are just in the process of looking whether octenidine might be a suitable option for MRSA decolonisation, including premature neonates.
I understand octenidine is not available in Australia. (It has similar antimicrobial efficacy but greater tissue compatibility and lesser side effects than chlorhexidine).
Among the other options mentioned in the other e-mails, chlorhexidine seems more suitable than triclosan or benzalkonium chloride. (For neonates, our current practice is to dilute chlorhexidine from 4% to 0.4% for that purpose).
See:
Krishna BV, Gibb AP. Use of octenidine dihydrochloride in meticillin-resistant Staphylococcus aureus decolonisation regimens: a literature review. J Hosp Infect. 2010 Mar;74(3):199-203. Epub 2010 Jan 8.
http://www.ncbi.nlm.nih.gov/pubmed/20060619Abstract
Decolonisation of patients colonised with meticillin-resistant Staphylococcus aureus (MRSA) is one of the recommended methods for controlling MRSA in hospitals but there is a limited choice of agents that can be used. Octenidine dihydrochloride is a relatively new antiseptic that has been used for MRSA decolonisation in some countries. On reviewing available literature on its use for MRSA decolonisation, only four observational studies were found. All of these were small studies, which differed in study design. MRSA decolonisation rates of 6-75% have been reported. Patients with wound colonisation were included in these studies but it was not clear if the hair was treated in two of these. Octenidine appears to be as effective as chlorhexidine for MRSA decolonisation with fewer adverse effects, but large randomised trials incorporating octenidine as a skin disinfectant for MRSA decolonisation need to be undertaken to confirm its usefulness in clinical settings.Also, it appears that there is a protocol available for octenidine for MRSA decolonisation of neonates from the UK Neonatal Network:
http://www.neonatal.org.uk/documents/4839.pdf
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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of TERRI CRIPPS
Sent: Wednesday, 07 November, 2012 11:14 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Topical Antiseptic agent used for decolonising or as suppresive therapy for MRSA carriersHi Rosie,
This is what we use with children who have MRSA:Suitable body washes are either 1% Triclosan (PhisoHex) or a chlorhexidine based wash like Microshield TM 2 or Microshield TM4 (2% chlorhexidine gluconate or 4% chlorhexidine gluconate wash respectively). If however the child has eczema, then a Oilatum Plus* (Benzalkonium chloride 6% w/w, Triclosan 2% w/w, light liquid paraffin 52.5% w/w) should be used instead.
Good luck.
Terri Cripps | Clinical Nurse Consultant Infection Control | Sydney Childrens Hospital
‘: (02) 9382 1876 | fax: (02) 9382 2084 | : terri.cripps@sesiahs.health.nsw.gov.au| “:www.sch.edu.au| page: 47140[Description: Description: http://www.chw.edu.au/site/signature/schn.jpg%5D
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Jayne OConnor
Sent: Wednesday, 7 November 2012 2:01 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Topical Antiseptic agent used for decolonising or as suppresive therapy for MRSA carriersHi Rosie,
Our facilities policy is to use triclosan 1% for all our MRO patients. I have used chlorhexidene wash as part of a decolonisation protocol too.
Kind regards
Jayne
Jayne OConnor RN, BSc. Infection control
CNC IPC
Sydney Adventist Hospital
185 fox valley rd
Wahroonga
NSW 2076Tel: (02) 9487 9433
Mob: 0406 752685________________________________
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Lee, Rosie
Sent: Wednesday, 7 November 2012 1:06 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Topical Antiseptic agent used for decolonising or as suppresive therapy for MRSA carriersHello
We have been using 3% hexachlorophene body wash as part of the topical decolonisation therapy for selected MRSA carriers who meet a specific for over 20 years. The supply is no longer available. Suggested alternatives are 1% Triclosan or Chlorhexidene. I wanted to get a feel on what others are using around Australia so hoping you can share the information. It is difficult to measure success but if you have done so it would be great to hear about it.
Regards
Rosie
Rosie Lee
RN. BSc. CICP
Coordinator Infection Prevention & Management
SMH Service – Royal Perth HospitalPh + 61 8 9224 2805 Fax + 61 8 9224 1989
Email: rosie.lee@health.wa.gov.au
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Dear Ruth,
According to my reading of the literature, the (rough) ranking in terms of antimicrobial efficacy would go (from least to most effective):
Plain nonantimicrobial liquid soap < antiseptic soap/detergent with triclosan < dto with chlorhexidine < alcohol hand rubs
(This is referring to ward-based hand hygiene, not surgical scrubbing).
There appears a sense in the literature that for most wards for regular use, antiseptic addition to soap is probably not necessary, but it may have a benefit for critical areas (ICUs etc.). Some antiseptic additives (e.g. chlorhexidine rarely) can be associated with allergies.
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 1387Dear All,
I was wondering if any of you have up to date information on what is the best (most effective) solution with which to wash one's hands? Special Care Nursery was wondering if Microshield's Triclosan was still considered effective?
RegardsRuth Dalrymple
Infection Control Coordinator
Hurstville Private Hospital
37 Gloucester Rd, Hurstville, NSW 2220, Australia
T +61 2 9579 7780 F +61 2 9579 7466
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Dear Mary-Rose,
My recommendation would be to go for a liquid hand rub instead of a gel. Liquid hand rubs are usually microbiologically more effective and usually do not leave as much sticky, unpleasant residue on hands.
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—–Original Message—–
Hello Mary-Rose,
Avaguard (3M), Sunny Wipes, DB Health, Aquium Gel (Ego) also supply small individual containers of alcohol-based hand rub with a carabiner or method to fix them to belts.
Kind regards,
Jennifer.
Jennifer Gillott
NSW Coordinator | National Hand Hygiene Initiative
Clinical Excellence Commission
Level 14, 227 Elizabeth Street, SydneyLocked Bag A4162, Sydney South NSW 1235
Tel 02 9269 5537 | Fax 02 9269 5599 | Mob 0448 269 870 | jennifer.gillott@cec.health.nsw.gov.au
http://www.cec.health.nsw.gov.au
http://www.hha.org.au3M used to have small individual bottles (and I presume they still do)
Janet
ICU Best Practice Project Officer
ICCMU / Ministry of Health
Sydney
AustraliaOn 9 October 2012 08:41, Tara Stanway wrote:
Morning Mary-Rose
We use deb Cutan, they have a 50 ml bottle with holder. There web address is http://www.debgroup.com or email: sales@deb.com.au.
I hope this will help.
Thanks
TaraTara Stanway
A/ CN Infection Prevention and Control
Cape York Hospital and Health Service
Ph: 07 4082 3662
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Hi Lynley,
Not purporting to be able to answer your question in its entirety, but this is potentially serious. I am not aware of any formal guidelines or standards, but by applying principles I would say that (a) a maternity unit is fortunately not a high-risk area for mould infections, but (b) but the amount of mould spores in the air from a ceiling with macroscopically visible mould growth must be very (!) high.
I was once at a conference in an interesting infection control case presentation where the speaker presented a case of mould growth in a haem-onc unit on a false wall or ceiling (you know that kind of wall with a plasterboard where something is behind). It was found that this was due to a water pipe breakage behind that false wall, and only fixing the leakage and cleaning up everything behind the false wall was able to fix the problem.
So my prime suspect would be a water pipe leakage or other type of water seepage or other constant moisture source behind the bathroom tiles or behind a false wall. Plumbing alone may not fix this; the entire room/wall/ceiling may have to be checked and redone.
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
________________________________Hi Team,
Just wondering if anyone has had mould growing across the entire ceiling (almost, anyway) in a shared bathroom in the Maternity Unit.
If so I have three queries:* How did you get rid of the mould?
* Did you in fact close the area until the issue was solved?
* Are their standards I can use as supporting material to either close the area or at least support the cost of fixing the problem?Thank you for your help.
Kind regards,
LynleyLynley King
Acting Clinical Nurse Specialist
Infection Control
Alice Springs HospitalMessages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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Sue,
Out of interest, do you happen to know the reference for the OHS regulations, and what they specifically say about food consumption in ward areas?
I agree it is a sad state that one should need evidence or even a “risk management framework” (what a mouthful) for what should normally come with common sense.
Has anyone tried “evidence reversal” — actually in my opinion the right and scientifically correct way to place the onus for evidence in such situations — to say, here are the OHS regulations and here is what common sense and microbiological principles tell you, and now YOU show me the evidence that breaking the rules is NOT associated with an increased risk?
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 1387Hi Helen,
It is such a shame that you can only argue a point of common sense with evidence.
I agree the ‘evidence’ is poor in this area but OHS (Workplace Health and Safety) provides the opportunity for employers and employees to review real and possible risks of eating in the work area. The Australian Infection Control Guidelines do not address this issue specifically but do provide you with a risk management framework to use for developing your position on this for your organisation.
Some of the risks to be considered include – vermin, food/drink contamination, odour, spills that can create slip and trip hazards, professionalism, hand hygiene, cleaning (increased requirements), disease/infection transmission.
Options to consider – provision of a designated place to consume food/drinks, staffing allocation sufficient to cover breaks, governance of decisions made, consultation with those affected.Good luck,
SueSue Greig
Senior Project Officer
Australian Commission on Safety and Quality in Health Care
GPO Box 5480 Sydney NSW 2001 | Level 7, 1 Oxford Street, Darlinghurst NSW 2010
( direct (02) 9126 3565 | ( switchboard (02) 9126 3600 | 6 (02) 9126 3613 |
Email sue.greig@safetyandquality.gov.au | http://www.safetyandquality.gov.auHelen Scott <Helen.Scott@HEALTHSCOPE.COM.AU>
Sent by: ACIPC Infexion Connexion <AICALIST@AICALIST.ORG.AU>31/07/2012 08:56 AM
Please respond to
ACIPC Infexion Connexion <AICALIST@AICALIST.ORG.AU>To
cc
Subject
Has anyone got anymore information on this please? I’d like to provide evidence and documentation to follow up my concerns about the same thing.
Thanks,
Helen.Helen Scott
Clinical Nurse Specialist |
Infection Control |
Anaesthetics & Recovery
Nepean Private Hospital
Kingswood, NSW.
Tel 02 4732 7333 | helen.scott@healthscope.com.auPlease consider the environment before printing this message
>>> On 10/07/2012 at 12:57 pm, in message <BF9F17B8E99F2345A43563B49B8F2AA3186031928A@EHEXVS01.eh.local>, “Breen, Jennifer (MH)” <Jennifer.Breen@EASTERNHEALTH.ORG.AU> wrote:
Hi All,We are having some issues with staff consuming food in their ward area, particularly at the staff base and in the corridors. We have located articles about transmission of Hepatitis A but are hoping to source articles to provide further evidence . Our current hospital guidelines are fairly general in this area and pertain more to an outbreak of gastro .
Kind Regards
Jenny Breen
Clinical Nurse Consultant
Infection Control
Maroondah Hospital
Tel: 98713175 Pager 0111
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Barbara,
I know my opinion may not be popular, perhaps “politically incorrect”, but this appears to be a classical case where the onus to provide evidence should be with those who want to change standard, internationally accepted practice. Standard practice is to have footwear that can be easily cleaned or disinfected and is confined to the theatre area.
The question should be: “If anyone would like to change practice and wear outside footwear in operating theatres, then please show me the evidence that wearing outside footwear is NOT associated with an increase in infection rates as opposed to wearing easy-to-clean footwear confined to theatres”.
I am almost certain that some of the US AORN papers and recommendations would have some details on this, as they are usually quite detailed.
It is also a matter of common sense. Outside footwear may have been worn in mud, bring in dirt, etc., and is uncontrolled in that regard, whereas footwear confined to the theatre area has never left it.
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 1387Hi All,
I have been asked to provide evidence regarding the wearing of outside footwear in the operating theatres. A couple of surgeons at our facility have expressed concern that outside footwear is a risk and I am unable find very little evidence to convince them otherwise. Most references do recommend closed in footwear that can be easily cleaned, but this seems to be more OS&E related, rather than infection prevention and control.The same surgeons don’t seem to think that wearing scrubs outside the complex or the hospital is a risk though!
Does anyone have any thoughts on this one?
Thanks
BarbaraBarbara Elliott I Coordinator Infection Prevention & Control I St John of God Subiaco Hospital
Level 3, 12 Salvado Road SUBIACO WA 6008
P: 08 9382 6871 F: 08 9382 6785 M: 0413706384 E: barbara.elliott@sjog.org.au
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Dear Rachel,
I have not yet specifically looked at the specifics of endoscope testing, so unfortunately I do not have immediate information that would help you.
Just doing the cross-posting bit that Rachel requested in my reply: Any input from OzBug members?
What I would look at is if there are any testing standards for endoscope reprocessing, such as ASTM or EN (I think Australia does not have its own set of standards). Then to ask endoscope manufacturers what they recommend and whether they know of any testing standards. Then to reapproach the wipe manufacturers if they have any manufacturer-independent (!) test results from reputable labs that would indicate that such standards are met.
If you have difficulties finding the info, I can ask some of my European colleagues what they know.
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 1387Hi all,
I also value the questions and comments from our ID colleagues on this matter. The need for rigorous and critical consideration of newer technologies is so important and the right questions so clearly need to be asked!
On another matter which is largely unrelated but I would value any comments that either Lindsay, Matthias or any other ASID member might be willing to make relates to a sporicidal wipe system for disinfection of non-lumened scopes, which uses a patented chlorine dioxide agents (Tristel). These wipes are currently being promoted by a company in Australia and adopted by some centres. I harbour grave concerns in relation to this product and its use. Would it be possible to have this request cross-posted to the asid-ozbug members as I wonder what view is held in this community in relation to this product? Specifically, I wonder if there is comment that any ID person might make on the use of a sporicidal agent applied by a “wipe” rather than through an automated system and the apparent absence or any validation for a clean/disinfection process?
I look forward to some possible replies/responses
Kind regards
RachelRachel Thomson
Nurse Unit Manager
Infection Prevention & Control Unit
Royal Hobart Hospital
E: rachel.thomson@dhhs.tas.gov.au________________________________
Thanks Matthias for further identifying the many gaps in the eWater system and their “research”.
It is alarming to note that Austin Health’s approval was not sought (from its clinical departments) as the company often quotes its use there in marketing its product.
I have declined their request to allow my organisation’s letterhead to be used by them for the informal random swabs they’d conducted in our catering department.
As mentioned to the rep then, there will obviously be a microbial count reduction noted in the swab results (post-eWater) as we are not dealing with plain water but either hypochlorous acid/hydrochloric acid or caustic soda (depending on which tap the “water” is from).
That plus vigorous scrubbing of the surfaces to be swabbed when eWater was applied.
I think with the discussion points raised, there is an obvious lack of supporting evidence to pursue a trial at this stage.
Thanks Matthias and Lindsay for your feedback.
Kind regards,
GeraldGerald Chan
Coordinator Infection ControlSt John of God Murdoch Hospital
100 Murdoch Drive
MURDOCH. WA 6150P: 9366 1552
M: 0405 495 906 (7804)
F: 9311 4685E: Gerald.Chan@sjog.org.au
W: http://www.sjog.org.au/murdoch[Murdoch]
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>>> “GRAYSON, Lindsay” <Lindsay.GRAYSON@AUSTIN.ORG.AU> 26/06/2012 12:44 PM >>>
Dear All,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[cid:image001.gif@01CD53AA.386DFB50]kkh
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Hi Tim,
Alcohol-based products (in appropriate concentrations) are effectively “auto-sterile” except for bacterial spores. That is why they have to be filtered (a standard procedure) but not sterilised in a classical sense (such as autoclaving). For a product like the Solu IV sticks one would (I think) therefore have to postulate that the plastic sticks and swabs would have to be radiation-sterilised (a standard procedure for plasticware like syringes) and the CHG-ALC solution filtered separately and then combined under sterile conditions (although I am not familiar with the details of such pharmaceutical manufacturing processes). The problem with the SoluMed response was that they were not forthcoming with relevant information (e.g. whether above had been done) and the person that I corresponded with did not have the slightest clue about the underlying concepts of sterility.
I will have to dig in my old e-mails to find this.
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 1387Hi Matthias,
This has come up often about the fact that swabsticks are not “sterile”. I get asked about it alot.
The inability to heat treat for sterilisation with IPA is obviously a combustable issue. 😉
However, the sterilisation process also has some destabilisation of the CHG (from what I have heard only).
I am unawwre of ANY other product on the market at the moment that is completely sterilised for use (that contains CHG and IPA)If you are happy, would you mind forwarding me the correspondence with SoluMed as I would like to also investigate this.
Regards,
Tim..Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant | Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, University of NSW
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel 02 8738 3603 | Fax 02 8738 3551 | Mob 0409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au
[cid:963553402@15062012-1708][cid:963553402@15062012-170F]________________________________
Dear Tim, dear Colleagues,The use of 2% CHG with isopropanol versus 0.5 or 1% makes perfect biological and microbiological sense, but there are currently no data available from clinical trials (i.e. outcomes-based research) having compared the higher versus the lower concentration.
I wonder about the Solu IV swabsticks that are being mentioned. Earlier, in 2008, someone mentioned that they are not labelled as sterile. I looked into this a little further and contacted the Canadian headquarters, and they also stated that they are not sterile in a strict sense. It became obvious that the person from the headquarters who I was corresponding with had absolutely not the slightest clue about the concepts of sterility.
It is well known that alcohol products need to be filtered in the process of production, in order to exclude bacterial spores. This is a well-established standard process, and most companies just simply do it. A recent article in ICHE highlighted problems with alcohol pads where this apparently had not been done:
http://www.ncbi.nlm.nih.gov/pubmed/22669227
For items like the single-use swabsticks (soeaked with alcohol) that are packaged, I would assume (but I don’t know for certain) that the plastic sticks would have to be irradiated for sterility separately in the production process and the alcohol filtered (as stated above).
At the time, I ended up not following through with the correspondence (somewhat frustrated by the Canadian response), but I wonder if anyone from this list has looked at this issue (?).
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 1387Robert,
We have done so and do so for EVERY IV device, not just PIVs.
2% CHG in 70% IPA – its all evidence based and there is plenty of literature to support it as well.
We previously used 0.5% CHG in 70% IPA.
We use Solu-IV swabsticks (tinted for insertion and clear for maintenance) and the large wipes.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant | Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, University of NSW
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel 02 8738 3603 | Fax 02 8738 3551 | Mob 0409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au
[cid:075230600@15062012-16D7][cid:075230600@15062012-16DE]________________________________
Good morning
I would like to know from those facilities who currently uses 70% Isopropyl alcohol v/v in 0.5% to 1% Chlorhexidine, and are moving towards or have now changed to using 2% Chlorhexidine in alcohol specifically for insertion of an Peripheral IVC.
I am aware of the current recommendations surrounding this but would like others comments on this matter.
regards
Robert RobinsonClinical Nurse Consultant | Infection Control
Blacktown/Mt. Druitt Hospitals
Tel 02 9881 8994 | Mob 0408 923 789 | robert.robinson@swahs.health.nsw.gov.au[http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-Health-Western-Sydney-LHD.jpg]
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