[Michael Wishart]

Hi Lyn

Apart from the possible air disruption / bacterial dispersion issues, there has been some discussion in the past about the speed and efficiency of electric hand driers in clinical areas. You would need to ensure you were not setting up your staff for longer drying times (or even worse, less adequate drying because it takes too long), and also increased skin care issues for staff due to excessive drying of the skin. If you do decide to support electric hand dryers in clinical areas, I would really encourage you to propose a solid trial phase and review the impact on both hand hygiene practices (are staff discouraged from hand hygiene with soap and water because of the dryers?) and also impact on staff skin integrity.

Good luck with whichever decision is made.

Cheers
Michael

Michael 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 email

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Maree Sommerville
Sent: Thursday, 13 June 2013 9:33 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Mechanical Hand dryers at clinical staff sinks

Dear Lyn,
Our neonatal unit considered hand dryers as an option to paper towels a couple of years ago.
The 2 issues that we raised were uncontrolled air dispersal and the noise factor (and they are so noisy. Imagine hearing the hum of dryers all day.)
To choose a dryer in a clinical setting would very much depend on that setting.
In our neonatal nursery, the hand basins are within the ward, we have carpeted floors, and the dryers potentially could disperse hand bacteria and, depending on design, could disperse bacteria lurking in the carpet.
My organisation adopted a paper recycling process for the paper towels.
Hand dryers are relegated to public areas and not clinical ones.

The NSW hand hygiene policy directive states no hand dryers.
http://www0.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_058.pdf

A study funded by Dyson (hand dryer company) supports their claims that their product is superior to other hand dryers however they are noisy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017747/

HHA have a sample hand hygiene procedure that includes the possibility of using a hand dryer
http://www.hha.org.au/UserFiles/file/Manual/Generic%20Hand%20Hygiene%20Guidelines_final%20_4_.pdf

I wish you the best in making a final decision.

Maree Sommerville
Infection Control Coordinator
Mercy Hospital for Women
________________________________
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Lyn A. Golden
Sent: Wednesday, 12 June 2013 4:34 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Mechanical Hand dryers at clinical staff sinks

Has anybody had any experience with installation of hand dryers (warm blowing air) in clinical areas?
We are building a new facility, the question has been raised can we install hand dryers instead of paper towel in clinical areas at the hand washing sinks?

Does anyone have any thoughts on this?

Lyn

Infection Prevention and Control Manager

Echuca Regional Health
17 Francis Street
Echuca 3564

Phone: 54855340
Fax: 54855390
E-mail: lgolden@erh.org.au

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[Michael Wishart]

Hi Rita and Lesley

There is no doubt that MROs have been cultured from just about every surface in a healthcare environment: clothes, pens, lanyards, keyboards, etc. That does not mean we need necessarily to be concerned about banning everything. It is more about awareness of what you touch, and what the risk is of transferring organisms in such a way that will potentially cause an infection or colonisation. I recall a response to an article that grew MROs from lanyards stating we should ban them for this reason which argued it depends what your hand hygiene is like: do you perform correct hand hygiene after fingering your lanyard before contact with patients? We cant get rid of the bugs in the environment easily, so we need to look at other ways we can minimise transmission, like hand hygiene practices.

I think we should encourage staff to take responsibility for their personal effects, including clothing, but the most important thing is to reinforce the need for excellent hand hygiene practices.

My personal opinion, anyway.

Cheers
Michael
Michael 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
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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Lesley MASON
Sent: Thursday, 6 June 2013 10:37 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Re pouches carried by nurses on a shift

Hi All, Lesley here standing in for Debra Vesey.

Ummmm, and what about those lanyards too, particularly the ones with all the badges and pins (form groups that we support with donations) attached?

I often wonder if these are incubation and infection transport devices –

Lesley Mason
Acting Clinical Nurse Consultant
Infection Control & Sterilising Services
Metro North Health and Hospital Services
Caboolture Hospital

Phone 5433 8024

>>> Tain Gardiner <Tain.Gardiner@NT.GOV.AU> 6/6/2013 10:18 am >>>
Morning everyone
We have the same issue across the board, we have recently incorporated into our uniform policy that these pouches are to be treated like the uniform and be laundered daily.
I doubt that happens, but it is in writing.

Tain Gardiner
Royal Darwin Hospital

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Rita Roy
Sent: Thursday, 6 June 2013 7:57 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re pouches carried by nurses on a shift

Dear colleagues,
Many nurses carry pouches (or bumbags for want of a better word) which hold their scissors, pens, tape,and even a mobile phone during a shift. I feel that these bumbags are a source of infection and the nurses should not be carrying these around. However I have faced stiff opposition when trying to stop this practice. Have you had a similar experience in your hospitals and what are your thoughts on this?
Rita

CNC Infection Control | Hornsby & Ku-ring-gai Health Service
Palmerston Road,
Tel 02 9477 9232 | Pager 52533|
rroy@nsccahs.health.nsw.gov.au
http://www.health.nsw.gov.au

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[Michael Wishart]

Hi Lynley

If this was only about amputation of infected limbs and digits which were then discarded, it would be less concerning. But safe surgery protocols now require us to mark every site and side for every surgical procedure that has laterality (except mucous membrane areas, basically). So your professional athletes having joint surgery, your women having breast surgery, the diabetic patient having foot amputation for chronic infection: they all need the correct site marked. We obviously want to do everything we can to reduce risks of infection in all of our patients.

That is what the question is aimed at: what is the risk, and what should we do to minimise such risk?
Apologies if this sounds dictatorial, but I feel we need to focus on why we are discussing this.

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3326 3523
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

________________________________________

Hi All,

I would still prefer to mark the leg then have the wrong one amputated.
Happens more often then you might think!

Just a thought.

And if the leg is being amputated what is the risk of infection following surgery?
And as the leg is being amputated (usually due ti infection) isn’t the site left at increased risk anyway?

Just curious.

Lynley

ICP
Alice Springs Hospital
CAHN

Sent from mikala, the iPad!

On 05/06/2013, at 11:56, Michael Wishart wrote:

> Hi Irene
>
> Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.
>
> http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440
>
> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx
>
> Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.
>
> So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.
>
> Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.
>
> At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).
>
> More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?
>
> Cheers
> Michael
>
> Michael 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 email
>
>
>
> —–Original Message—–
> From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
> Sent: Wednesday, 5 June 2013 12:03 PM
> To: AICALIST@AICALIST.ORG.AU
> Subject: Re: Pens for marking skin prior to surgery
>
> Hi all,
>
> Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
> Th

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[Michael Wishart]

Hi Irene

Good question, some aspects of which has already been discussed in the literature, but with conflicting opinions.

http://www.medpagetoday.com/MeetingCoverage/ICAAC-IDSA/11440

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/130.aspx

Some of those referred studies seem to indicate different brands will act differently. The most interest finding I saw was that in one study, MRSA remained on all types of felt tips tested.

So, the question remains: is it possible to transfer microorganisms via felt tip pens? Without doing a full study on whichever brand of felt tip pen we chose, I would be reluctant to say a definite yes for all different marking pens.

Should we rely solely on antiseptic skin prep prior to the procedure? I think would much depend on where the site was marked… I have seen limbs marked prior to surgery well below where the area was be prepped with antiseptic.

At the very least, the body of the marking pens should be wiped over between uses to avoid transfer of MRO’s onto the hands of whoever handles it, as these pens have direct contact with patients. Carrying a marking pen for the purpose of limb marking in one’s pocket ‘until it runs dry’ seems to be asking for problems (and not just from staining of the pockets from ink!).

More discussion on this would be appreciated. I recognise that sterile marking pens have been used within the sterile field for a long time, but should we use these same disposable sterile markers for pre-operative limb marking as required for safe-site surgery protocols?

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside,Qld4032
t: (07) 3326 3068 | f: (07) 3607 2226
e:Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Wilkinson, Irene (Health)
Sent: Wednesday, 5 June 2013 12:03 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Pens for marking skin prior to surgery

Hi all,

Is there any evidence that texta markers are a vehicle for transmission of microorganisms?
The solvents used in them would have fairly powerful antibacterial action. Isn’t the skin then well prepped before the incision is made?

Regards.

Irene Wilkinson
Manager, Infection Control Service
Communicable Disease Control Branch
SA Health
Irene.wilkinson@health.sa.gov.au

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michele.Cullen@HEALTH.VIC.GOV.AU
Sent: 04 June 2013 3:40
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Pens for marking skin prior to surgery

Dear Michael

Single use sterile pens for skin marking have been available for over thirty years.
Likewise reusable pens/inkwells and ink have been available and can be washed and sterilized between uses.

Regards

(Embedded (Embedded image moved to file: pic15046.jpg)
image moved
to file:
pic12667.jpg)

Michele Cullen
Infection Control Consultant | Communicable Disease Prevention and
Control | Public Health
Department of Health | 50 Lonsdale Street, Melbourne, Victoria,
3000
p. 03 9096 5094 | f. 1300 651 170
e. michele.cullen@health.vic.gov.au

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Hi all

What do other facilities use for marking skin prior to surgery? We currently use a reusable felt tip permanent marker that doesnt appear to be cleaned in any way between each patient. This occurs prior to the surgical procedure outside of the operating room, so does not need to enter the sterile field.

Our questions revolve around whether we should source disposable pens, or try to clean the markers between each patient use. This raises the
question: how do you clean a felt tip??

We did note some interesting discussions on possible cross-contamination using marking pens (eg
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5
(4)/Pages/130.aspx ).

Any comments?

Thanks
Michael

Michael 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 email

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[Michael Wishart]

Please direct any brand name related responses to Jo Dewey at Jo.Dewey@healthscope.com.au.

My apologies for allowing this message with brand names of various endoscope reprocessors from being sent to the list.

Please remember to avoid using brand names on this list as possible, in this instance refer to the process (eg peracetic acid), rather than a brand name if replying to the list.

Thanks
Michael Wishart
ACIPC Infexion Connexion Administrator

Michael 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
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Hi

We are looking at upgrading our scope sterilizers at the moment and I would like to know what sterilizers you are all using and how you are finding them. We are using the steris system at the moment but have looked at the solumed and the new steris.

Just have to get some feedback to take back to my DON and GM.

Kind Regards

Jo Dewey
Infection Control Co-ordinator
Peninsula Private Hospital
Jo.Dewey@healthscope.com.au
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[Michael Wishart]

[Further information shared from asid-ozbug Moderator]
Further information (particularly regarding requirements to notify and where to refer for testing) will be available from your state/territory public health units.

This information from CDNA and PHLN provides details of testing (pneumonia with recent travel to China, although testing may be considered in milder cases) and infection control policies (airborne/contact until further information is available about transmission).
Allen Cheng

H7N9 Influenza
Important information for Clinicians and Laboratories

Summary: As of 7 April, 2013, 21 cases of H7N9 influenza have been reported in China, including 6 deaths. Although the environmental source has not yet been definitively determined, some of the confirmed cases have been associated with contact with chickens or poultry or an animal wet market environment.
In patients with acute pneumonia or pneumonitis with a history of travel to China within 7 days of illness onset, or contact with known confirmed or probable cases, the following is recommended:
1. Place the patient in a single room with negative pressure air-handling, or a single room from which the air does not circulate to other areas, and implement standard and transmission-based precautions (contact and airborne), including the use of personal protective equipment (PPE).
2. Investigate and manage the patient as for community acquired pneumonia. Appropriate specimens should also be collected for influenza PCR testing.
3. Arrange testing of any suspected or probable cases (see case definition) in accordance with the instructions below. Notify any suspected, probable or confirmed cases promptly to your local public health authorities.
What is the H7N9 influenza?
Influenza (A)H7 viruses are a group of influenza viruses that normally circulate among birds. H7N9 is a reassortant derived from three different avian influenza viruses. This strain is distinct from the H1N1/09 (that caused the 2009 pandemic in humans) and H5N1 influenza. H7N9 that is genetically similar to that detected in infected humans has been detected in pigeon and poultry samples collected at a live animal market in Shanghai. Unlike other influenza strains, including highly pathogenic avian influenza H5N1, this new virus is hard to detect in poultry because this novel virus causes little to no signs of disease in animals.
Although there is no evidence of human-to-human transmission of H7N9 to date, sequence analysis indicates the virus has properties to infect mammalian cells; therefore, the potential for avian-human and human-human transmission exists but requires further investigation. Sequences previously associated with high virulence of A(H7) in humans (PB2 gene) have been detected in isolates in the current outbreak.
What is the current situation?
See WHO website on the current situation, including epidemiological updates, Q&A and guidance documents:
Disease Outbreak News http://www.who.int/csr/don/en/index.html
Influenza at the Human-Animal Interface http://www.who.int/influenza/human_animal_interface/en/

A total of 21 cases have been reported from China, including six deaths. To date cases have been reported from four eastern provinces of China (Shanghai, Anhui, Jiangsu and Zhejiang).
There continues to be no evidence of human-to-human transmission with medical observation of over 530 contacts ongoing. In Jiangsu, investigation is ongoing into a contact of an earlier confirmed case who developed symptoms of illness.
The incubation period is not precisely known.
There is currently no vaccine available for H7N9 influenza. Laboratory testing conducted in China has shown that the influenza A(H7N9) viruses are sensitive to neuraminidase inhibitors (oseltamivir and zanamivir). When these drugs are given early in the course of illness, they have been found to be effective against seasonal influenza virus and influenza A(H5N1) virus infection. However, at this time, there is no experience with the use of these drugs for the treatment of H7N9 infection.
From 1996 to 2012, human infections with H7 influenza viruses (H7N2, H7N3, and H7N7) were reported in Netherlands, Italy, Canada, USA, Mexico and the United Kingdom. Most of these infections occurred in association with poultry outbreaks.

What are the symptoms?
H7N9 was initially identified in patients with severe pneumonia and/or Acute Respiratory Distress Syndrome (ARDS) but 3 recent cases have been mild. Symptoms include fever 38C, cough and shortness of breath. However, information is still limited about the full spectrum of disease that infection with influenza A(H7N9) virus might cause.
Symptoms and signs of A(H7) infections during previous outbreaks mainly resulted in conjunctivitis and mild upper respiratory symptoms, with the exception of one death, which occurred in the Netherlands.
Are health workers at risk from H7N9 influenza?
The routes of transmission to humans of the H7N9 influenza have not yet been fully determined, but there is currently no evidence that this strain can spread from human to human. Infection control recommendations in this document for suspected, probable and confirmed cases aim to provide the highest level of protection for health care workers, given the current limited state of knowledge.
Has WHO recommended any travel or trade restrictions related to this new virus?
The number of cases identified in China is very low. WHO does not advise the application of any travel measures with respect to visitors to China nor to persons leaving China. There is no evidence to link the current cases with any Chinese products. WHO advises against any restrictions to trade at this time.
Who do I test for H7N9 influenza?
Testing should be considered for:
1. Individuals with acute pneumonia or pneumonitis and history of travel to, or residence in China within the previous 7 days.
2. Individuals with acute pneumonia or pneumonitis and history of contact with those in point 1 above.
3. Health care workers with acute pneumonia, who have been caring for patients with severe acute respiratory infections, particularly patients requiring intensive care, without regard to place of residence or history of travel.
How do I test for H7N9?
Where H7N9 infection is suspected, samples should be referred to the jurisdictional PHLN laboratory for testing. Specimens can be handled and transported routinely. They should be clearly identified as requiring urgent testing for influenza A/H7N9, and separated from non-urgent specimens. The reference laboratory should be notified.
Collect combined nose and throat swabs (usually from adults) or nasopharyngeal aspirates (usually from children) and place in viral transport medium. Sputum is strongly recommended wherever possible. Bronchoalveolar samples and lung biopsy should also be sent if available.
Gloves, gown, surgical mask and eye protection should be worn as a minimum when collecting samples from patients. For invasive samples (nasopharyngeal aspirates, BAL and other samples where aerosols may be produced) a P2 respirator mask is recommended. If a negative pressure room is unavailable, the patient should be placed in a single room with the door closed.
Testing for other infectious causes can be undertaken at the referring laboratory using PC2 precautions, processing of samples in a biosafety cabinet and use of PPE including a surgical mask and eye protection. Routine tests for acute pneumonia should be performed where indicated, including bacterial culture, serology, urinary antigen testing and tests for influenza viruses.
The laboratory carrying out the influenza testing should immediately refer all unsubtypeable or presumptive H7 influenza A virus to one of the National Influenza Centres or the WHOCC in Melbourne.
Laboratory staff should handle specimens under enhanced PC2 conditions, with handling of open samples in a biosafety cabinet and the use of gloves, gowns, masks and eye protection. PC3 conditions are required for virus culture.
What are the recommended isolation and PPE recommendations for patients in hospital?
While further information is accumulating, current recommendations are for airborne transmission precautions for suspected, probable or confirmed cases.
These recommendations on isolation and PPE for probable and confirmed cases take a deliberately cautious approach by recommending measures that aim to control the transmission of pathogens that can be spread by the airborne route. These measures are detailed in NHMRC: Australian Guidelines for the Prevention and Control of Infection in Healthcare 2010 (particularly section B2.4).
In summary, transmission-based precautions for probable and confirmed cases should include:
Placement of confirmed and probable cases in a negative pressure room if available, or in a single room from which the air does not circulate to other areas
Airborne transmission precautions, including routine use of a P2 respirator, disposable gown, gloves, and eye protection when entering a patient care area
Standard and contact precautions, including close attention to hand hygiene
If a single or negative pressure room is not available (eg in primary care settings), or if transfer of the confirmed or probable case outside the negative pressure room is necessary, asking the patient to wear a surgical face mask, if tolerated, while they are being transferred and to follow respiratory hygiene and cough etiquette.
Triage areas should have signs asking that patients with severe respiratory tract infections with a recent history of travel to China should make themselves known so that appropriate arrangements can be made.

Case Definitions

1. Suspected case (under investigation)*
A person with an acute febrile respiratory infection with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (e.g. pneumonia, pneumonitis or Acute Respiratory Distress Syndrome (ARDS))
AND
With one or more of the following exposures during the 7 days prior to the onset of symptoms:
Travel to a country where human cases of H7N9 influenza have recently been reported, especially if there was recent direct or close contact with animals (e.g. wild birds, poultry or pigs).
Close contact with a laboratory-confirmed case.
2. Probable Case
A person fitting the definition of a Suspected Case but with no possibility of laboratory confirmation for H7N9 influenza, either because the patient or samples are not available for testing AND
Not already explained by any other infection or aetiology, including all clinically indicated tests for community acquired pneumonia according to local management guidelines.
3. Confirmed Case
A person with laboratory confirmation of infection with H7N9 influenza at a WHO National Influenza Centre.

* Although most of the cases to date have presented with a severe acute respiratory illness, mild cases have been reported. If doctors are concerned about patients presenting with milder illness, they should discuss this with the local public health authorities.
Currently, China (excluding Hong Kong) is the only country that has recently reported human cases of H7N9 influenza.
Close contacts include:
Any person who provided care for the patient or who had other similarly close physical contact while not wearing appropriate PPE in the 7 days before symptom onset; this includes health care workers or family members.
Any person who stayed in the same household as a probable or confirmed case while the case was symptomatic.

Advice for contacts of cases
Contacts of cases should be directed to the local public health unit for advice.
Advice for travellers to China
At this time, it is advisable that travellers to China keep away from sick and dead poultry and livestock and avoid visiting live animal markets.
Advice for returned travellers
At this time, if returned travellers meet the exposure criteria for the case definition but have a less severe respiratory illness, advice regarding further management should be sought from the local public health unit
Other useful links
UN Food and Agriculture Organization of the United Nations (FAO) http://www.fao.org/news/story/en/item/173655/icode/

—
Allen Cheng
Associate Professor in Infectious Diseases Epidemiology
Department of Epidemiology and Preventive Medicine
Monash University

Infectious Diseases Physician
Alfred Hospital

Honorary Principal Research Fellow
Menzies School of Health Research

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[Michael Wishart]

[Further information on H7N9 Influenza Moderator]

Update from Gary Lum, Office of Health Protection today

* The number of confirmed cases has increased to 21, including 6 fatalities (WHO update 7 April).
* Cases have now been detected across the disease spectrum from mild (3 cases) through to deaths. Median age of all cases is 59 years (range 487).
* There continues to be no evidence of human-to-human transmission (based on active surveillance of 530 close contacts)
* Cases have been clustered in the central eastern provinces around Shanghai/Nanjing (9 Shanghai; 2 Anhui;7 Jiangning and 3 Zhejiang)
* H7N9 virus has been detected in pigeon and chicken and environmental samples collected at three separate market places in Shanghai and in quail samples (Hangzhou Farmers market).
A more complete document for clinicians (including testing and infection control recommendations) is being worked on and will be disseminated widely today or tomorrow.
Allen

Allen Cheng
Associate Professor in Infectious Diseases Epidemiology
Department of Epidemiology and Preventive Medicine
Monash University

Infectious Diseases Physician
Alfred Hospital

Honorary Principal Research Fellow
Menzies School of Health Research

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[Michael Wishart]

Hi Helen

Not entirely sure what you mean by ‘aside from the obvious’, but this technical article may help answer your questions.

http://www.woundsinternational.com/pdf/content_195.pdf

Cheers
Michael

Michael 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
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Hi all,

Does anyone have any evidence based/referenced information on the impact of MRSA on a healing wound please?

I specifically want to know the exact reasons WHY is slows down the healing (aside from the obvious).

Thanks,
Helen.

Helen Scott
Infection Control Co-ordinator |
Staff Educator |
Nepean Private Hospital
Kingswood, NSW.
Tel 02 4725 8758 | helen.scott@healthscope.com.au
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[Michael Wishart]

Hi Marie

I think your facility and operating theatre staff need to review their management of blood and body fluid exposures during procedures, based on a risk assessment. First aid for simple needlesticks is, as far as I am aware, potentially of little value in decreasing the risk of infection post needlestick (there is some debate about this). I don’t think there is much evidence to say that either a soap and water or an antiseptic wash is any better for this.

However, what you do need to ensure is that any punctures of gloves and skin are managed to minimise the risk of bleeding into a patient. Therefore, you should not be saying it is ‘impractical’ to allow a scrub nurse or proceduralist to change gloves and manage any needlestick wounds, as exposing a patient to their blood would be considered unacceptable in a court of law unless it was a life- and-death emergency (eg open cardiac massage)

Splashes to mucous membranes do require immediate first aid, and any delay in rinsing mucous membranes after a splash could increase the chances of seroconversion to a blood-borne virus. Unless the scrub nurse or proceduralist is immediately risking the patient’s life by taking time to have their mucous membranes rinsed, occupational health & safety legislation would require your facility to have a process for minimising risks form such exposures. Unless there was a process to allow staff who had splashes to mucous membranes rapid access to copious rinsing, your facility could be found in breach of its duty of care to the staff.

My thoughts would be to consider these risks, and discuss them with the surgical teams involved. Just to say it is ‘impractical’ would not, in my view, be considered acceptable in managing these risks. The days when healthcare workers risk their own health and safety just ‘because’ are gone, and facilities need to be mindful of the potential legal consequences of not managing these risks well.

These are my personal thoughts as an experienced occupational health nurse and infection control practitioner. Sometimes we need to remind staff of the risk to them personally as well as to their whole workplace in order to effect a change to the culture.

Cheers
Michael

Michael 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
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Hi

I have been informed that our hospital blood and body fluid exposure policy has not been followed since 2005, regarding first aid, as it is impractical for scrubbed theatre staff to rinse the affected site with soap and water (or normal saline for mucous membrane exposures). Current practice involves pouring betadine on the site.

Has anyone else encountered a similar problem? And have you any ideas how I could manage this?

Many thanks

Marie Daws
Infection Control Coordinator

Hospital & Day Surgery
SPORTSMED*SA
32 Payneham Road
Stepney SA 5069

T: (08) 8130 1100
F: (08) 8130 1101
E: marie.daws@sportsmed.com.au
W: http://www.sportsmed.com.au

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[Michael Wishart]

Hi Rachel

I did do a workshop in conjunction with the University of Queensland in regard to HIV test counselling (http://www.som.uq.edu.au/about/academic-disciplines/general-practice/hiv-hcv-education-projects/our-courses.aspx), but in practice most of our staff who require pre-test counselling post-exposure are seen by our ICU medical staff, and I provide post-test counselling. Source patients for exposures are mostly provided pre-test counselling (probably a very loose use of the term counselling here!) by senior ward staff or hospital co-ordinators, who have no formal HIV pre-test counselling training, but follow a scripted sheet, and can call upon ICU medical officers for any assistance in this.

It is my understanding this is a common scenario in the larger Queensland private hospitals.

Cheers
Michael

Michael 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
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Hi all,

In our organisation the responsibility for management of Occupational Exposures resides with Workplace Health & Wellbeing. There are some changes occurring in Tasmania relating to the legislative framework around HIV testing, including rescinding of the Tasmanian HIV/AIDS Preventative Measures Act. This has provided our organisation with an opportunity to consider the approach taken in other jurisdictions and organisations.

The following question is posted on behalf of the Medical Director Workplace Health & Wellbeing in Tasmania

The question I would like answered is below:

I am interested to know what training your Occupational Exposure Coordinators have in pre and post-test counselling following an occupational exposure and who provides the training?

Thanking you in advance for your replies.

Kind regards
Rachel

Rachel Thomson

Nurse Unit Manager
Infection Prevention & Control Unit
Royal Hobart Hospital
E: rachel.thomson@dhhs.tas.gov.au

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[Michael Wishart]

Hi Claire

I, too, agree with Matthias, but I do not think your comparison with IV access is correct. Giving a sub-cut or IM injection has a much lesser risk of infective complications than any direct access to the blood stream (such as IV access or phlebotomy, for example). In my own practice I currently still use alcohol swabs prior to IM vaccination as it is quick, cheap and not worth the potential infective risk (which is yet to be well quantified as pointed out by Matthias).

If patients are self-injecting (either sub-cut or IM), then the risk from auto-inoculation with their own flora may be even lower (viz self-catheterisation guidelines), so I would have no issues with teaching patients not to swab their own skin prior to a simple injection (as long as they were not directly injecting into a vein or device, though). The evidence supporting this is also pretty scant, though.

Cheers
Michael

Michael 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
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I completely agree with you Matthias.

With injections into IV ports we are now encouraged to “scrub the hub” for 30 seconds with either isopropyl alchol or alcoholic chlrohexidine etc!

Yet for the skin, which is nice and warm and moist – capable of supporting much higher microbe counts than a dry cool rubber bung, we use nothing…bizarre!!!

Best regards, Claire

Professor Claire Rickard RN PhD

c.rickard@griffith.edu.au | +61 7 3735 6460 | Skype: clairexm1 | Twitter: IVAD_Research | Intravascular Access Device Research Group | NHMRC Centre of Research Excellence in Nursing | Centre for Health Practice Innovation | Griffith Health Institute | Griffith University

Visiting Scholar: Royal Brisbane & Women’s Hospital | Princess Alexandra Hospital | The Prince Charles Hospital

P.S. Research frequently takes me off campus. Please contact Jenny Chan, School Secretary 3735 5406 or j.chan@griffith.edu.au with any urgent enquiries.

On 25 March 2013 11:29, Matthias Maiwald (KKH) <matthias.maiwald@kkh.com.sg> wrote:
Dear Franciska,

Not sure about clexane and insulin (s.c. injections), but I have looked in some detail into the current Australian recommendations concerning vaccinations. Most vaccinations are i.m. injections, which are biologically quite different from s.c. injections and also from venipuncture. The official recommendation by the Australian Immunisation Handbook is not to swab (so if you follow that, you are following official recommendations), and only to swab if the injection area is visibly dirty, but the problem is that these recommendation are severely misguided and intellectually flawed.

(1) Much of it is based on a short 2001 article in the MJA, examining a few hundred s.c. injections and venipunctures, and concluding that swabbing for ANY type of injection is not necessary, including i.m. injections. There are two fatal flaws with this assumption. (a) The article did not examine even a single i.m. injection and made conclusions pertaining to these (which is inconsistent with the principles of evidence-based medicine, which the article purported to adhere to), and (b) the natural infection rate after i.m. injections is very low, estimated to be in the range of 1:5000 to 1:10000 or less (which is reassuring), but if you study a smaller population than is needed to capture the natural incidence of an event, then you cannot make conclusions that the intervention has no effect on the occurrence of the event.

(2) The recommendation to swab only if visibly soiled is not justified either, because microorganisms are invisible, and implementing this as a cutoff between swabbing and non-swabbing is arbitrary without a scientific base or evidence base. Imagine you sit in front of a patient with a darker skin colour and want to give an injection. When would you be confident that the skin is NOT visibly dirty?

In summary, if you don’t swab, you are consistent with the guidelines, but the guidelines are seriously flawed (at least you won’t be responsible then). It is certainly reassuring that the natural infection rate is very low, and statistically you are unlikely (but it is possible) to see any adverse event. It is clear that i.m. injections and other types of injections are biologically and clinically different and bear a different infection risk. Also, the deeper an injection is, the more complicated infections can get (examples on the complicated end are joint injections, corticosteroid injections, or more complicated injections).

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 All,

There is still an ongoing debate whether we should use an alcohol swab before administering clexane, vaccines and insulin. Any ideas please?
I know the latest practice in regards administering clexane is to “not swab”.

I just want to advise my team from a infection control point of view with facts to stand on.

Kind Regards

Franciska Ferreira
INFECTION PREVENTION & CONTROL /WOUND MANAGEMENT CONSULTANT
Burnside War Memorial Hospital
120 Kensington Road, Toorak Gardens, SA 5056
t: 08 8202 7222 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au

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kkh

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[Michael Wishart]

Hi Delma

What I was quoting is the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010) which has a table on page 206 (Table C2.1) of risk categorisation for staff, which is based on a NSW Health policy PD 2007_006 (not sure if this has since been revised). I merely was using this as a platform for discussion rather than definitive policy, but as the national standard I would consider this a minimum standard to be considered. Yes, it is important to follow state based legislation that is applicable to your facility.

I do understand most would have completed the national vaccination schedule, which includes Hepatitis B vaccine, and have evidence available for that but what if the prospective student had not been vaccinated due to parental concern or simply missed opportunity? Do we exclude them from patient contact? Sign a waiver?

Cheers
Michael

Michael 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 email

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Makejev, Delma
Sent: Wednesday, 13 March 2013 12:19 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Immunisation guidelines for work experience students

Michael and Marie,
Each states has differing requirements for staff vaccination requirements, hence if the student was attending a NNSW health facility and having contact with patients they are considered category A not B as Michael has stated which I presume is Queensland requirements.
For school work experience in our Local Health District we ask that student show evidence of all vaccinations as per the Australian childhood vaccination schedule. Therefore they should be able to provide dTpa as adolescent, hep B x2 as adolescent or early childhood schedule, MMR x2 as infant, varicella x1 as Adolescent. Places to obtain records are ACIR register apply through Medicare for record or Baby health record book, Local GP record of vaccination or school based vaccination record.

Regards
Delma

Delma Makejev
Clinical Nurse Specialist | Staff Clinic, Infection Control Unit
Lismore Base Hospital
Tel 02 6620 2516 | Delma.Makejev@ncahs.health.nsw.gov.au

Staff Clinic open for appointments Monday to Friday

[Description: Description: http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-Health-Northern-NSW-LHD.jpg%5D

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Wednesday, 13 March 2013 12:16 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: [ACIPC_Infexion_Connexion] Immunisation guidelines for work experience students

Hi Marie

I think this is both a legal and a moral question, myself. Legally, you have to ensure you meet a reasonable duty of care for these work experience students whilst they are in your facility. As the current Australia guidelines do not require mandatory Hepatitis B vaccinations for these types of contacts in healthcare (see pg 206), you could avoid the need to collect this information. However, as they would be having some patient contact, they would be considered category B, and you should seek information about MMR, pertussis, varicella and influenza status.

My personal view for Hep B would be based on what the facility has decided for staff regarding Hep B vaccination. Is it offered to all groups regardless of risk of exposure? Is it recommended that all staff, or only specific groups, are aware of their status in regard to Hep B? Based on these I would then treat work experience students as staff and ask them to provide evidence accordingly.

Just my thoughts, anyway.

Cheers
Michael

Michael 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 email

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Maree Sommerville
Sent: Wednesday, 13 March 2013 8:36 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Immunisation guidelines for work experience students

Dear colleagues,
I would like to know what immunisation guidelines other health services specify for work experience students.
Our work experience students are required to complete an immunisation questionnaire similar to clinical staff. I am currently reviewing this. Their role is mostly observational but may change 1 or 2 nappies, cuddle a baby, take vital signs or palpate an abdomen. .
Most of these year 10 students are fully immunised as per NIP but some are not.
Do any services decline an application for work experience based on the students immunisation history?
In relation to Hepatitis B vaccination: should the same expectations apply to these students when they are unlikely to handle blood or body fluids? Or should we take the view that, by the very fact they are in a health care service, places them at risk of exposure.

Thankyou
Maree Sommerville
Infection Control Coordinator
Mercy Hospital for Women

163 Studley Road
Heidelberg 3084
Phone: 8458 4759
Mob: 0408 789 798
Fax: 8458 4751

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[Michael Wishart]

Hi Marie

I think this is both a legal and a moral question, myself. Legally, you have to ensure you meet a reasonable duty of care for these work experience students whilst they are in your facility. As the current Australia guidelines do not require mandatory Hepatitis B vaccinations for these types of contacts in healthcare (see pg 206), you could avoid the need to collect this information. However, as they would be having some patient contact, they would be considered category B, and you should seek information about MMR, pertussis, varicella and influenza status.

My personal view for Hep B would be based on what the facility has decided for staff regarding Hep B vaccination. Is it offered to all groups regardless of risk of exposure? Is it recommended that all staff, or only specific groups, are aware of their status in regard to Hep B? Based on these I would then treat work experience students as staff and ask them to provide evidence accordingly.

Just my thoughts, anyway.

Cheers
Michael

Michael 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 email

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Maree Sommerville
Sent: Wednesday, 13 March 2013 8:36 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Immunisation guidelines for work experience students

Dear colleagues,
I would like to know what immunisation guidelines other health services specify for work experience students.
Our work experience students are required to complete an immunisation questionnaire similar to clinical staff. I am currently reviewing this. Their role is mostly observational but may change 1 or 2 nappies, cuddle a baby, take vital signs or palpate an abdomen. .
Most of these year 10 students are fully immunised as per NIP but some are not.
Do any services decline an application for work experience based on the students immunisation history?
In relation to Hepatitis B vaccination: should the same expectations apply to these students when they are unlikely to handle blood or body fluids? Or should we take the view that, by the very fact they are in a health care service, places them at risk of exposure.

Thankyou
Maree Sommerville
Infection Control Coordinator
Mercy Hospital for Women

163 Studley Road
Heidelberg 3084
Phone: 8458 4759
Mob: 0408 789 798
Fax: 8458 4751

DISCLAIMER This email and any files transmitted with it

may be confidential and intended solely for the use of the

individual or entity to whom they are addressed. If you have

received this email in error please notify the sender immediately

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been cleared by Mercy Health’s virus protection systems, recipients

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[Michael Wishart]

Hi Franciska

The only issues I have had with water baths and maternity are in regard to cleaning the baths after use, and the use of spas or baths with plumbing under the bath that returns water to the bath. Each time the bath is used it needs to be fully cleaned before the next patient uses it. With a spa, if the plumbing retains fluid (and other stuff…) after you empty the bath, when it is turned on again this fluid (and other stuff) can be pumped back into the bath. Thus any bath with plumbing which retains fluid and can be pumped back into the bath needs to be flushed with an appropriate cleaner (eg spa cleaning product) after every use (even if the spa jets are not used). I had previously recommended that baths with spa capability in maternity units were replaced by plain baths because of the difficulties in ensuring compliance with this.

Aside from the above, items used in the bath by patients (eg supports) need also to be cleaned between uses. You need to ensure there is a clear process and responsibility for cleaning both the bath and any other items used in the bath between each patient. This includes any reusable gloves or other reusable protective equipment staff may wear that may be splashed with fluid.

Cheers
Michael

Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside,Qld4032
t: (07) 3326 3068 | f: (07) 3607 2226
e:Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

—–Original Message—–

Hi Everyone,

I’m a new subscriber and just would like to test my email.

I have a question for you all, I’m keen to know what issues, if any, you might have with providing baths for labour and delivery from an infection control or risk management perspective?

Kind Regards

Franciska Ferreira
INFECTION PREVENTION & CONTROL /WOUND MANAGEMENT CONSULTANT Burnside War Memorial Hospital
120 Kensington Road, Toorak Gardens, SA 5056
t: 08 8202 7222 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au

This email is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this email is strictly prohibited. If you receive this email in error, could you please notify us by return email and delete it and any attachments from your system. Even though this message is scanned no representation is made that this email or any attachments are free of viruses or other defects. Virus scanning is recommended and is the responsibility of the recipient.

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[Michael Wishart]

Hi Terry

We looked at storage of human skin recently, as we were using a fridge that was used to store lab specimens. Provided you have a temperature monitored and maintained fridge with appropriate alarms and checks, and provided the tissue is labelled with name and date of collection / expiry, and sealed into its own container, we couldn’t find any guidelines that specified what else could be storied in the fridge with it.

We have changed our practice here, though, and now store these tissues in a blood fridge, as that has is attached to a monitored alarm system. Whereas the pathology fridge just beeps to itself in the pathology room where no one can hear it.

If anyone has actual tissue storage guidelines that specify more clearly where these tissues can be stored I would be interested as well.

Cheers
Michael

Michael 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 email

Hi everyone,

I have recently come across a practice of storing human tissue i.e. skin in the same fridge as drugs.

I was wondering if anyone could point me to the reference where it clearly states that this is not an acceptable practice? A quick internet search hasn’t been helpful.

Thanks in anticipation.

Regards
Terry McAuley
Sterilisation & Infection Control Consultant
STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
VIC Australia 3802

CONFIDENTIAL COMMUNICATION: The information contained in this message may contain confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or duplication of this transmission is strictly prohibited. If you have received this communication in error, please notify us by telephone or email immediately and return the original message to us or destroy all printed and electronic copies. Nothing in this transmission constitutes an agreement of any kind unless otherwise expressly indicated.

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