[Michael Wishart]

Hi Kylie

I have not seen any recommendations for only purchasing stainless steel trolleys for mobile computers. We recently purchased mobile computer trolleys for all clinical areas that are polypropylene and purpose designed for computer use. We have attached detergent cleaning wipes to all of these trolleys, and ensured they are compatible with our environmental disinfectant if that may be required.

The most important issue would be routine cleaning of any equipment, as per the attached CHRISP guidance.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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UNCLASSIFIED
Good Morning all,

Just wondering if anyone has any information/references on requirements e.g. design/specifications for trolleys used for laptops at bedsides/clinical area’s?

Do they need to be stainless steel (because I have been told they cost around $1000 each)?

Regards,

Kylie Long

Flight Lieutenant
Infection Prevention and Control
Garrison Health Operations
Directorate of Health Service Delivery
Joint Health Command
Department of Defence

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[Michael Wishart]

It has been brought to my attention that there is not a complete contact number for this position in the previous emails.

The full job specification includes a contact phone number.

https://smartjobs.qld.gov.au/jobtools/b_fileupload.proc_download?in_file_id13342484&in_servicecodeCUSTOMSEARCH&in_organid14904&in_sessionid0&in_hash_key02F2A84C68AD56DF33E85477F536A5A7

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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This position below has had an extended closing date as below.

Thanks
Michael

Hello Michael

Just to let you know that the closing date for our position has been extended until this Friday [1st August 2014] if this is able to be communicated to your group.

Thanks
Juliana Buys

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

[http://www.interactivejam.com.au/images/ACIPC-conference.jpg]

[Posted on behalf of Juliana Buys Moderator]

Interested in joining the nursing team at the Lady Cliento Childrens Hospital (LCCH), the new tertiary paediatric hospital for Queensland? Opening in late 2014, the LCCH will bring together the staff and services of the existing Royal Childrens and Mater Childrens hospitals into a new facility located in South Brisbane.

We have an opportunity for an experienced Clinical Nurse Consultant, Infection Control to join what will be a proactive and dynamic nursing team. This position will commence at the Royal Childrens Hospital within the Infection Management and Prevention team and will then transition to the LCCH.

A role description and details on how to apply are available on the Smartjobs website http://www.smartjobs.qld.gov.au – simply search for reference number H14CHQ. The vacancy closes on Friday 25th July.

If youd like to hear more about this great opportunity, contact Juliana Buys on 0417 278

______________________________________________________________________
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[Michael Wishart]

This position below has had an extended closing date as below.

Thanks
Michael

Hello Michael

Just to let you know that the closing date for our position has been extended until this Friday [1st August 2014] if this is able to be communicated to your group.

Thanks
Juliana Buys

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

[http://www.interactivejam.com.au/images/ACIPC-conference.jpg]

[Posted on behalf of Juliana Buys Moderator]

Interested in joining the nursing team at the Lady Cliento Childrens Hospital (LCCH), the new tertiary paediatric hospital for Queensland? Opening in late 2014, the LCCH will bring together the staff and services of the existing Royal Childrens and Mater Childrens hospitals into a new facility located in South Brisbane.

We have an opportunity for an experienced Clinical Nurse Consultant, Infection Control to join what will be a proactive and dynamic nursing team. This position will commence at the Royal Childrens Hospital within the Infection Management and Prevention team and will then transition to the LCCH.

A role description and details on how to apply are available on the Smartjobs website http://www.smartjobs.qld.gov.au – simply search for reference number H14CHQ. The vacancy closes on Friday 25th July.

If youd like to hear more about this great opportunity, contact Juliana Buys on 0417 278

______________________________________________________________________
For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the svha.org.au domain (or any other domain of St Vincents Health Australia Limited or any of its related bodies corporate) (an SVHA Email Address) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.

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For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the svha.org.au domain (or any other domain of St Vincents Health Australia Limited or any of its related bodies corporate) (an SVHA Email Address) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.
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[Michael Wishart]

This is partly a design /construction issue. It is cheaper to design smaller shower spaces that require a shower curtain than a larger space that doesn’t need one. If the architects can get away with smaller shower spaces, they will, as it is an economic issue.

I would suggest that this will be an ongoing issue.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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Hi Christine,

We use them in our ensuites, including our newly opened building and also have a changing regime for them. They are then laundered in a commercial laundry.

In relation to removing them the objections that have been raised to me include:
The bathroom, toilet, IV pump, other equipment etc will get wet if they are not there.
The ensuites are not big enough to put in a nib wall / solid screen and still allow nursing access for assistance in the shower.
Required for privacy if someone opens the door inadvertently

Kind regards,

Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
185 Fox Valley Road, Wahroonga, NSW, 2076

Hi,

Shower Curtains – replaced after each admission and routinely entire hospital 3 monthly regardless.

Hotel Services would love to remove all together – any thoughts on their use and need in ensuites????

Regards,

Christine Lawson | Nursing Admin

Quality & Risk Manager I Infection Control Coordinator I Education Coordinator
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]

UNCLASSIFIED
Good morning

I would be interested in other people’s thoughts or if there is any policy concerning the use of shower curtains in health care facilities.

Also what cleaning and replacement currently occurs in health care facilities for shower curtains?

Regards

Melissa McEwan RN, BN, Grad Cert Health Management, Quality and Leadership & Infect Control
Quality Manager
Contractor to Defence
Wagga Wagga
02 69338338
Private mobile 0428 753783
melissa.mcewan@defence.gov.au

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[Michael Wishart]

I have to comment that I originally posted this study in wonderment: have we all completely now given up on teaching HCW’s to practise hand hygiene before touching patients? Have we lost already? And this will be the result?

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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Maybe we should go with the chest bump and keeps hands out of it all together. With a bit of singing along the way we can turn our facilities into an episode of Scrubs! Anyone want to do a research project on it?

Cheers Matt

Matt Mason RN, CICP, BNSci, M Rural Health, M Advanced Practice (IC)
Lecturer School of Nursing & Midwifery
Faculty of Science, Health, Education and Engineering University of the Sunshine Coast
University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Queensland, 4558 Australia.
CRICOS Provider No: 01595D
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________________________________

Hi Michael,
I can see consultants fist-bumping if they wear their trousers low! Seriously, the research was well conducted and well-written and actually got space in our NZ newspaper – I’ve never had press like that with any of my papers!

Best regards, Terry

Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph/Fx (NZ): +64 7 856 4042
Mob (NZ): +64 274 365 140
E: terry@terrygrimmond.com
[Twitter_logo_blue]: @terrygrimmond
W: http://terrygrimmond.com
[cid:image002.gif@01CFABE3.55EAF0A0]
“This email (including any attachments) is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are reminded that any dissemination, distribution or copying of this email or attachments is prohibited. If you have received this email in error, please notify me immediately by return email or telephone and destroy the original message. Thank you.”

We saw a call before to ban handshaking in healthcare as a way to reduce transmission of organisms. Now a study suggest ‘fist bumping’ is the best greeting to replace a hand shake. Can we all see our consultants fist pumping their patients each morning? 🙂

http://www.infectioncontroltoday.com/news/2014/07/fist-bumping-beats-germspreading-handshake-study-reports.aspx

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
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[Michael Wishart]

Hi Sony

The regulatory body in Australia that issues clinical product and medication alerts in the TGA (Therapeutic Goods Administration). They have an email alert subscription service that was recently posted on this list.

http://www.tga.gov.au/newsroom/subscribe.htm

Hope this is what you are asking for.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Sony SO
Sent: Monday, 28 July 2014 8:48 PM
To: AICALIST@AICALIST.ORG.AU
Subject: safety alert related to medical devices, disinfectants and antiseptic with infectious hazards

Dear All,

We would like to know, in Australia, which government agent/department is responsible for the captioned issue.

This issue is raised because we would like to monitor the captioned issue (not only just for Aus. products but also other products i.e. global monitoring), and to notify our management and local users timely, if incident occurs.

Yours sincerely,

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection, HONG KONG SAR, CHINA

http://www.chp.gov.hk/tc/cindex.html

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk
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For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the svha.org.au domain (or any other domain of St Vincents Health Australia Limited or any of its related bodies corporate) (an SVHA Email Address) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.
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[Michael Wishart]

Moderator note: Some subscribers have noted the link to the ICHE article cited below is for subscription login only.

Here is a link to the free preview of the article (not the entire article):
http://www.jstor.org/stable/10.1086/676422
Cheers
Michael Wishart
ACIPC Infexion Connexion Administrator

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Joe-Anne Bendall
Sent: Thursday, 10 July 2014 8:10 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Bare below the elbows etc. and the RACP exams – do you have a policy?

Craig,
We have a hand hygiene policy/procedure that is waiting for approval it has Bare Below the Elbow included and it mentions MUST a lot!

This article may be interesting about white coats

Infection Control and Hospital Epidemiology

June 2014, Volume 35, Issue 6

740742

Healthcare Worker Perception of Bare Below the Elbows: Readiness for Change?

James Pellerin, MD; Gonzalo Bearman, MD, MPH; Jonathan Sorah, BS; Kakotan Sanogo, MS; Michael Stevens, MD, MPH; Michael B. Edmond, MD, MPH, MPA

Thanks

Joe-Anne Bendall
(Monday/Thursday/Friday)
Joe-anne Bendall | Clinical Nurse Consultant Infection Prevention and Control
Sydney Hospital and Sydney Eye Hospital
8 Macquarie St
SYDNEY NSW 2000
| ph +61 2 9382 7199 |page 22070 via switch 9382 7111| 7 Fax 93827510 |
Mobile 0418984255 | Joe-anne.Bendall@SESIAHS.HEALTH.NSW.GOV.AU

(Tuesday/Wednesday)
HAI Project Officer | Clinical Nurse Consultant Infection Prevention and Control
Clinical Governance Unit
Phone: 93827621
Mobile: 0434323222

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Craig Boutlis
Sent: Wednesday, 9 July 2014 7:28 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Bare below the elbows etc. and the RACP exams – do you have a policy?

Hi,

Hundreds of nervous medical registrars are about to fan out all over Australia for their Royal Australasian College of Physicians exams from July 25 to August 3, as they do every year. In hot pursuit will be about 150 “National Exam Panel” (NEP) members, of whom I am one. If you are wondering, it definitely is “all beer and skittles”.

Some of you can relax…I ditched my tie years ago, my jacket is left hanging on a chair, sleeves are rolled up, my pedometer has a watch, and there is no lanyard to be seen. For many others though, it is all about the grandest suit and tie they can conjure. Of interest, it’s amazing to see how easily those ties flop on to patients when candidates lean forward, but I digress.

I take it as a given that you all practice the 5 moments and cleaning of reusable equipment between patients. Do any of you in public (or some larger private) hospitals have a dress code (eg, BBE) that we NEPs and exam candidates must respect? Further, is it guidance (“should”) or actual policy (“must”)? Feel free to send on to me.

Best wishes,

Craig

Craig Boutlis

Department Head, Infectious Diseases | IMACS
LMB 8808, SCMC, NSW, 2521
Tel. 02 4222 5898 | craig.boutlis@sesiahs.health.nsw.gov.au

[http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-Health-Illawarra-Shoalhaven-LHD.jpg]

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[Michael Wishart]

They use a workbench here in the anaesthetic bay, or the anaesthetic trolley if inserting an IV in the theatre. Not the patient’s body or bed/table. I have never seen an anaesthetist wipe down the workbench in the anaesthetic bay; it is done by nurses/orderlies as part of the end of procedure clean between patients.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

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Thanks Michael,

I agree with your points. Do anaesthetists at your workplace use a trolley? Do they wipe it between patients or does this fall to the anaesthetic nurses? I’m curious to see what practices are used vs organisational policy.

Regards,

Jane Bryant, RN
Acting Infection Control Consultant
Royal Victorian Eye & Ear Hospital
32 Gisborne Street, East Melbourne, 3002, VIC
[Description: Description: Description: Home]

Hi Jane

I think the question should not be ‘how common?’ but ‘is this reasonable and safe?’

In my opinion, it is not a safe practice, either for the patient (who can move and upset all of the equipment which includes sharps) or the staff member (again, who can be exposed to sharps if the patient moves). Purists would argue you should never use the bed/patient for setting up an aseptic field, but I think it is more a safety issue myself.

How hard is it to use a trolley or workbench, then wipe it between patients??

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

[http://www.interactivejam.com.au/images/ACIPC-conference.jpg]

Sure Fiona,

Using the patient’s chest/abdo (covered by a blanket) to place equipment on instead of using a trolley. I know this is not best practice and I am trying to get an indication on how common this practice is elsewhere.

Regards,

Jane Bryant, RN
Acting Infection Control Consultant
Royal Victorian Eye & Ear Hospital
32 Gisborne Street, East Melbourne, 3002, VIC
[Description: Description: Description: Home]

Hi Jane,

I don’t quite understand what you mean by using the patient as a ‘workbench’, can you please clarify?

Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
185 Fox Valley Road, Wahroonga, NSW, 2076

Hi,

I’m interested to hear what practices are occurring in other organisations in regard to anaesthetists cannulating patients pre op. I’ve heard arguments for and against using the patient as ‘the workbench’ vs using a trolley. The appeal of using the patients is that there is no cross over. I believe this can be achieved positioning a trolley correctly, but would like to hear what other places are doing.

Regards,

Jane Bryant, RN
Acting Infection Control Consultant
Royal Victorian Eye & Ear Hospital
32 Gisborne Street, East Melbourne, 3002, VIC
[Description: Description: Description: Home]

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For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the “svha.org.au” domain (or any other domain of St Vincent’s Health Australia Limited or any of its related bodies corporate) (an “SVHA Email Address”) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.
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For the purposes of protecting the integrity and security of the SVHA network and the information held on it, all emails to and from any email address on the “svha.org.au” domain (or any other domain of St Vincent’s Health Australia Limited or any of its related bodies corporate) (an “SVHA Email Address”) will pass through and be scanned by the Symantec.cloud anti virus and anti spam filter service. These services may be provided by Symantec from locations outside of Australia and, if so, this will involve any email you send to or receive from an SVHA Email Address being sent to and scanned in those locations.
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[Michael Wishart]

Hi Jane

I think the question should not be ‘how common?’ but ‘is this reasonable and safe?’

In my opinion, it is not a safe practice, either for the patient (who can move and upset all of the equipment which includes sharps) or the staff member (again, who can be exposed to sharps if the patient moves). Purists would argue you should never use the bed/patient for setting up an aseptic field, but I think it is more a safety issue myself.

How hard is it to use a trolley or workbench, then wipe it between patients??

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

[http://www.interactivejam.com.au/images/ACIPC-conference.jpg]

Sure Fiona,

Using the patient’s chest/abdo (covered by a blanket) to place equipment on instead of using a trolley. I know this is not best practice and I am trying to get an indication on how common this practice is elsewhere.

Regards,

Jane Bryant, RN
Acting Infection Control Consultant
Royal Victorian Eye & Ear Hospital
32 Gisborne Street, East Melbourne, 3002, VIC
[Description: Description: Description: Home]

Hi Jane,

I don’t quite understand what you mean by using the patient as a ‘workbench’, can you please clarify?

Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
185 Fox Valley Road, Wahroonga, NSW, 2076

Hi,

I’m interested to hear what practices are occurring in other organisations in regard to anaesthetists cannulating patients pre op. I’ve heard arguments for and against using the patient as ‘the workbench’ vs using a trolley. The appeal of using the patients is that there is no cross over. I believe this can be achieved positioning a trolley correctly, but would like to hear what other places are doing.

Regards,

Jane Bryant, RN
Acting Infection Control Consultant
Royal Victorian Eye & Ear Hospital
32 Gisborne Street, East Melbourne, 3002, VIC
[Description: Description: Description: Home]

______________________________________________________________________
Attention:
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If you are not the intended recipient, any use, disclosure or copying of this e-mail is unauthorised.

If you have received this message in error, please contact the sender.

This footnote also confirms that this email message has been checked for the presence of computer viruses.

The Royal Victorian Eye and Ear Hospital however does not warrant the message is free of viruses.

It is recommended as a prudent business practice the recipient perform a virus scan of any message received.
______________________________________________________________________
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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_____________________________________________________________________
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[Michael Wishart]

Hi Sony

In terms of HCW safety this is not that much different from knowing (or suspecting) a patient has HIV infection or another infectious disease (even meningococcal infection), and whether staff should protect themselves appropriately. As an employer, I think your duty of care to staff will dictate you must have procedures in place to protect staff, therefore requiring HCW’s to perform CPR without appropriate PPE would not be appropriate. But, if staff make a personal choice to perform CPR without appropriate protection, then they should be supported by the organisation. With MERS, one of the differences will be that if staff come into unprotected contact with MERS cases, they should then be considered contacts, and may need to be treated accordingly (eg exclusion from direct patient contact for a period of time).

I personally think we can have administrative guidelines in place (eg staff must wear appropriate PPE when performing CPR), but recognise that some staff many make a personal choice in order to improve patient outcomes that may put their own safety at risk. Organisations should respect this (eg not penalising HCWS’s who chose to do this), whilst not forcing them to put their personal safety at risk.

I hope that makes sense. Good question to raise.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
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Dear All,

In infection control perspective, we recommend HCWs to wear appropriate PPE before to perform CPR, in particular patient is on isolation precaution for MERS. On the other hand, CPR may not be commenced “promptly” because HCWs need time to wear PPE. So, some guys say, infection control practices would delay the “CPR 10 seconds” requirements.

How to balance the captioned controversial issue.

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk
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[Michael Wishart]

Hi Glenys

Agreed. The main problem is that the only formulations of chlorhexidine and alcohol that are tinted red (both 0.5% and 2% chlorhexidine content) available in Australia are all from the same manufacturer and all only licensed by TGA for hard surface disinfection. The red tint is a specific requirements for some surgeons to enable them to easily visualise where the skin has been prepped.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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5th May 2014
[5may2014_top]

Hi Michael,

Until companies have their products correctly registered with the TGA (inclusive of the purpose of use and labelling) users (i.e. hospitals/surgeons) assume liability for any injuries resulting from any “off-label use”.

As it is difficult to find any recommendations or publications supporting the use of >0.5% chlorhexidine and Alcohol for surgical skin preparation at this point in time hospitals would be wise to undertake an “offline risk assessment” and have it endorsed by their Infection Control committee before proceeding.

Regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

[Description: ICC Diagram ICCversion]

Hi Matthias

I believe the labelling of the solution in question is more about TGA licensing than the actual formulation of the solution. That has been discussed here previously on this list. The manufacturer of that product has never explicitly stated you cannot use this solution for skin antisepsis, only that it is not current licensed for this use. A vexing issue indeed.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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5th May 2014
[5may2014_top]

Hi Glenys,

Thank you very much for these additional points.

I would like to add a few points for clarification.

It is indeed the case that the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be automatically inferred to surgical skin preparation. Apart from the IHI document that you cited (apparently specifying 2%; I have not yet seen the document), there does not seem to be a widely specified CHG percentage (supported by data) to be added to the alcohol that is available in guidelines.

The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for surgical skin preparation that the combination of 1% iodine and 70% alcohol (i.e. two antiseptics) performs better than a combination of 0.5% CHG and 70% alcohol (i.e. two antiseptics). Note that the type of iodine and the alcohol types have not been specified in that study. These results seem congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC versus CHG+ALC).

The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two antiseptics) performs better than 10% povidone-iodine alone (i.e. only one antiseptic). For anyone who has followed the microbiological literature on antiseptics (which spans many decades), the outcome of this trial was hardly surprising, because this is a massively unequal comparison: two antiseptics against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it indeed looks like the scientific part of the Darouiche trial is solid (as you state).

The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol is any inferior to 2% CHG with alcohol (or vice versa).

I have not suggested to use alcohol alone for surgical skin preparation; the combinations of either CHG+ALC or PVI+ALC have clear benefits of being combination antiseptics with enhanced activity. What I was suggesting is that people should get less hung up about the role of CHG in the CHG+ALC combination. The microbiological properties of skin antiseptics have been studied for over 100 years (e.g. Harrington and Walker. Boston Medical and Surgical Journal. 1903; 148: 548-52), and a wealth of information particularly came from studies done in the 1970s and 1980s. From this branch of the literature, the microbiological properties of the various skin antiseptics are well defined. Alcohols are known to be far superior in their immediate antimicrobial activity than either CHG or PVI. While evidence from clinical trials is clearly the best evidence, this evidence CANNOT be assessed in isolation, and it is necessary — while assessing evidence — to have a holistic picture with taking the necessary scientific background (in this case: microbiological background) and the principles of biological plausibility into account. That this was not commonly done in evidence assessments for skin antisepsis — and people focussed blindly on clinical trial outcomes — is presumably the reason for the massive, large-scale medical literature error that we described in our PLoS One (2012) article and subsequently commented upon further in our recent J Antimicrob Chemother (2014) article.

The advice “Do not use to disinfect surfaces likely to come in contact with broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you mention presumably simply means that alcohol-containing antiseptics are unsuitable to be used on wounds (also mucous membranes).

The range of CHG concentrations that I have seen in CHG+ALC combinations for surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one particular manufacturer. The 4% CHG concentration would be typical of aqueous CHG antiseptics (as John Ferguson states).

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 Matthias,

To access IHI information – you just need to register and then you can get access to information such as the How to Guides – it’s free.

We should clarify for those following this thread that the CDC reference to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol…………….” is referring to skin preparation for intravascular devices not surgical (preoperative) skin preparation – extract from guidelines below.

Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

* “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives [82, 83]. Category IA”

While there may be supportive evidence for >0.5% chlorhexidine and alcohol preparations for the prevention of catheter-related bloodstream infections we shouldn’t assume that this will necessarily be the case for reducing surgical site infections(SSIs). Hence until we see the studies that clearly demonstrate that alcohol alone is better that CHG and alcohol, Iodine and alcohol, CHG alone or Iodine alone for surgical (preoperative) skin preparation to prevent surgical site infections we should be cautious about what we suggest people focus on.

This recent publication from St Vincent’s Hospital, Melbourne may be of interest to those considering a 0.5% CHG and alcohol preparation for surgical (preoperative) skin preparation

The study showed that patients who received skin prep with 0.5% chlorhexidine and alcohol prior to orthopaedic surgical procedures were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.

Carroll K. et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection, Volume 20, Issue 2, pages 130-135, February 2014

* “The study was performed over an 18-month period (January 2011 to June 2012) and included 964 patients undergoing prosthetic hip or knee replacement surgery

* In the multivariable logistic regression analysis patients who received skin prep with 0.5% chlorhexidine and alcohol were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.

* The authors acknowledge findings may reflect surgeon preference and experience and that skin prep requires more evaluation/RCT”.

*
Thanks for forwarding the ProPublica scandal publication, very interesting reading.

I see the US company concerned settled with the US Dept of Justice avoiding criminal charges for allegations of fraud against the government and the product is now approved by the FDA as outlined in a US Department of Justice Press Release titled “CareFusion to Pay the Government $40.1 Million to Resolve Allegations That Include More Than $11 Million in Kickbacks to One Doctor” on Thursday, January 9, 2014:

* ” The settlement resolves allegations that, under agreements entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses and recommends standardized health care performance measures and practices. The government contends that the purpose of those payments was to induce Denham to recommend, promote and arrange for the purchase of ChloraPrep by health care providers. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.

* “This settlement also resolves allegations that, during the period between September 2009 and August 2011, CareFusion knowingly promoted the sale of ChloraPrep for uses that were not approved by the Food and Drug Administration, some of which were not medically accepted indications, and made unsubstantiated representations about the appropriate uses of ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
http://www.justice.gov/opa/pr/2014/January/14-civ-021.html
http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdf

In addition the product concerned has also been registered with the TGA in Australia and is on the ARTG list for use as “Sterile tinted antiseptic applied to patient’s skin prior to invasive medical procedures”.

https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbidebs/PublicHTML/pdfStore.nsf&docidD9C1698728A822FDCA257CA5003CC3EC&agid(PrintDetailsPublic)&actionid1

While the FDA discredited the NEJM publication in court proceedings as outlined at the ProPublica link I don’t see where the publication it has been discredited by the NEJM nor the U.S. National Institutes of Health, Clinical Trials Unit who approved the trail?

Given that the allegations of impropriety and kickbacks where towards Dr. Charles Denham, who was not an author of the NEJM publication and the trail was a randomized, double-blind, placebo-controlled trial and conflicts of interest were disclosed the results and conclusion below may still be valid.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.

Results

“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P 0.008) and deep incisional infections (1% vs. 3%, P 0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups”.

Conclusion

“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

In addition I think you will find in the US that there are only 2 concentrations of CHG and alcohol available for surgical (preoperative) skin preparation – 2% or 4 % – happy to be corrected.

In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that I think jenny is referring to states the following on their users product guide:

* Do not use to disinfect therapeutic devices.

* Do not use to disinfect surfaces likely to come in contact with broken skin.

Regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

Hi Glenys,

Interesting. I had not yet seen the IHI Project JOINTS website. Some of the contents seem to be behind a login-wall, though.

The “2%” CHX specified percentage brings up an interesting issue; there was a recent US healthcare scandal in which it is alleged that an ex committee member of the US National Quality Forum (NQF) inappropriately influenced the NQF towards a 2% CHG-containing solution, at a time when only one manufacturer provided that particular percentage (meaning a 2% endorsement would direct consumers towards that manufacturer’s product) and at a time when there was no clear evidence to prefer a particular CHX percentage over another (as John Ferguson states).

http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group

People should not get so focused on the CHX component; as I have often emphasised, it is known from many decades of microbiological testing both in vitro and on human skin that alcohols, when well formulated, are about 10 times more microbiologically effective than CHX.

Interesting, the second reference (2014 Update) lists routine preoperative CHX showering/bathing/wiping as an unresolved issue. While this practice is supported by a good microbiological rationale (and those who know me know that I like microbiological rationales), it is not yet quite established whether this translates into better clinical outcomes. Note, this is different from specific preoperative decolonisation of MSSA/MRSA cariers, which seems indeed to translate into better outcomes. Also, for classical skin antisepsis (‘skin prep’) as discussed above, it is also well established that this translates into outcomes.

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 Jenny,

Sorry to join the discussion in relation to surgical preoperative skin preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement (IHI) Project JOINTS.
http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.aspx

In addition to the interventions recommended by the Surgical Care Improvement Project (SCIP) (i.e. appropriate use of prophylactic antibiotics, appropriate hair removal…..and so on) Project JOINTS recommends the following interventions for elective hip and knee arthroplasty procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin preparation.

Hospitals participating in the IHI Project JOINTS are using one of the following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

* 10% Iodophor plus alcohol
You can find additional information in the IHI Project JOINTS, “How to Guide” including the following.

* IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty: “The combination of a long-acting agent (either an iodophor or CHG) is better than povidone iodine alone for preventing SSI. There is insufficient evidence to support recommending the use of one combination agent over another”.
2. Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery – most are using CHG wipes (personal communication).
3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update – Intervention number one is a Grade 1 (high) level of evidence recommendation and may be worth a read.

“Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (quality of evidence: I).
a. Alcohol is highly bactericidal and effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with chlorhexidine gluconate or an iodophor.115
i. Alcohol is contraindicated for certain procedures, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
b. The most effective disinfectant to combine with alcohol is unclear…….”.

The publication is freely available online at the following link: http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been applied, although any staining (tinted CHG or Idophor) may obscure signs of inflammation post-operatively.

regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

thankyou to everyone who responded to my question – its given me a great basis for discusssion with the ortho surgeon !!

________________________________
Hi John,

I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.

One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.

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

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards
John

Dr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________

Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Michael Wishart]

Hi Matthias

I believe the labelling of the solution in question is more about TGA licensing than the actual formulation of the solution. That has been discussed here previously on this list. The manufacturer of that product has never explicitly stated you cannot use this solution for skin antisepsis, only that it is not current licensed for this use. A vexing issue indeed.

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

5th May 2014
[5may2014_top]

Hi Glenys,

Thank you very much for these additional points.

I would like to add a few points for clarification.

It is indeed the case that the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be automatically inferred to surgical skin preparation. Apart from the IHI document that you cited (apparently specifying 2%; I have not yet seen the document), there does not seem to be a widely specified CHG percentage (supported by data) to be added to the alcohol that is available in guidelines.

The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for surgical skin preparation that the combination of 1% iodine and 70% alcohol (i.e. two antiseptics) performs better than a combination of 0.5% CHG and 70% alcohol (i.e. two antiseptics). Note that the type of iodine and the alcohol types have not been specified in that study. These results seem congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC versus CHG+ALC).

The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two antiseptics) performs better than 10% povidone-iodine alone (i.e. only one antiseptic). For anyone who has followed the microbiological literature on antiseptics (which spans many decades), the outcome of this trial was hardly surprising, because this is a massively unequal comparison: two antiseptics against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it indeed looks like the scientific part of the Darouiche trial is solid (as you state).

The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol is any inferior to 2% CHG with alcohol (or vice versa).

I have not suggested to use alcohol alone for surgical skin preparation; the combinations of either CHG+ALC or PVI+ALC have clear benefits of being combination antiseptics with enhanced activity. What I was suggesting is that people should get less hung up about the role of CHG in the CHG+ALC combination. The microbiological properties of skin antiseptics have been studied for over 100 years (e.g. Harrington and Walker. Boston Medical and Surgical Journal. 1903; 148: 548-52), and a wealth of information particularly came from studies done in the 1970s and 1980s. From this branch of the literature, the microbiological properties of the various skin antiseptics are well defined. Alcohols are known to be far superior in their immediate antimicrobial activity than either CHG or PVI. While evidence from clinical trials is clearly the best evidence, this evidence CANNOT be assessed in isolation, and it is necessary — while assessing evidence — to have a holistic picture with taking the necessary scientific background (in this case: microbiological background) and the principles of biological plausibility into account. That this was not commonly done in evidence assessments for skin antisepsis — and people focussed blindly on clinical trial outcomes — is presumably the reason for the massive, large-scale medical literature error that we described in our PLoS One (2012) article and subsequently commented upon further in our recent J Antimicrob Chemother (2014) article.

The advice “Do not use to disinfect surfaces likely to come in contact with broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you mention presumably simply means that alcohol-containing antiseptics are unsuitable to be used on wounds (also mucous membranes).

The range of CHG concentrations that I have seen in CHG+ALC combinations for surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one particular manufacturer. The 4% CHG concentration would be typical of aqueous CHG antiseptics (as John Ferguson states).

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 Matthias,

To access IHI information – you just need to register and then you can get access to information such as the How to Guides – it’s free.

We should clarify for those following this thread that the CDC reference to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol…………….” is referring to skin preparation for intravascular devices not surgical (preoperative) skin preparation – extract from guidelines below.

Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

* “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives [82, 83]. Category IA”

While there may be supportive evidence for >0.5% chlorhexidine and alcohol preparations for the prevention of catheter-related bloodstream infections we shouldn’t assume that this will necessarily be the case for reducing surgical site infections(SSIs). Hence until we see the studies that clearly demonstrate that alcohol alone is better that CHG and alcohol, Iodine and alcohol, CHG alone or Iodine alone for surgical (preoperative) skin preparation to prevent surgical site infections we should be cautious about what we suggest people focus on.

This recent publication from St Vincent’s Hospital, Melbourne may be of interest to those considering a 0.5% CHG and alcohol preparation for surgical (preoperative) skin preparation

The study showed that patients who received skin prep with 0.5% chlorhexidine and alcohol prior to orthopaedic surgical procedures were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.

Carroll K. et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection, Volume 20, Issue 2, pages 130-135, February 2014

* “The study was performed over an 18-month period (January 2011 to June 2012) and included 964 patients undergoing prosthetic hip or knee replacement surgery

* In the multivariable logistic regression analysis patients who received skin prep with 0.5% chlorhexidine and alcohol were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.

* The authors acknowledge findings may reflect surgeon preference and experience and that skin prep requires more evaluation/RCT”.

*
Thanks for forwarding the ProPublica scandal publication, very interesting reading.

I see the US company concerned settled with the US Dept of Justice avoiding criminal charges for allegations of fraud against the government and the product is now approved by the FDA as outlined in a US Department of Justice Press Release titled “CareFusion to Pay the Government $40.1 Million to Resolve Allegations That Include More Than $11 Million in Kickbacks to One Doctor” on Thursday, January 9, 2014:

* ” The settlement resolves allegations that, under agreements entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses and recommends standardized health care performance measures and practices. The government contends that the purpose of those payments was to induce Denham to recommend, promote and arrange for the purchase of ChloraPrep by health care providers. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.

* “This settlement also resolves allegations that, during the period between September 2009 and August 2011, CareFusion knowingly promoted the sale of ChloraPrep for uses that were not approved by the Food and Drug Administration, some of which were not medically accepted indications, and made unsubstantiated representations about the appropriate uses of ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
http://www.justice.gov/opa/pr/2014/January/14-civ-021.html
http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdf

In addition the product concerned has also been registered with the TGA in Australia and is on the ARTG list for use as “Sterile tinted antiseptic applied to patient’s skin prior to invasive medical procedures”.

https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbidebs/PublicHTML/pdfStore.nsf&docidD9C1698728A822FDCA257CA5003CC3EC&agid(PrintDetailsPublic)&actionid1

While the FDA discredited the NEJM publication in court proceedings as outlined at the ProPublica link I don’t see where the publication it has been discredited by the NEJM nor the U.S. National Institutes of Health, Clinical Trials Unit who approved the trail?

Given that the allegations of impropriety and kickbacks where towards Dr. Charles Denham, who was not an author of the NEJM publication and the trail was a randomized, double-blind, placebo-controlled trial and conflicts of interest were disclosed the results and conclusion below may still be valid.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.

Results

“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P 0.008) and deep incisional infections (1% vs. 3%, P 0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups”.

Conclusion

“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

In addition I think you will find in the US that there are only 2 concentrations of CHG and alcohol available for surgical (preoperative) skin preparation – 2% or 4 % – happy to be corrected.

In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that I think jenny is referring to states the following on their users product guide:

* Do not use to disinfect therapeutic devices.

* Do not use to disinfect surfaces likely to come in contact with broken skin.

Regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

Hi Glenys,

Interesting. I had not yet seen the IHI Project JOINTS website. Some of the contents seem to be behind a login-wall, though.

The “2%” CHX specified percentage brings up an interesting issue; there was a recent US healthcare scandal in which it is alleged that an ex committee member of the US National Quality Forum (NQF) inappropriately influenced the NQF towards a 2% CHG-containing solution, at a time when only one manufacturer provided that particular percentage (meaning a 2% endorsement would direct consumers towards that manufacturer’s product) and at a time when there was no clear evidence to prefer a particular CHX percentage over another (as John Ferguson states).

http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group

People should not get so focused on the CHX component; as I have often emphasised, it is known from many decades of microbiological testing both in vitro and on human skin that alcohols, when well formulated, are about 10 times more microbiologically effective than CHX.

Interesting, the second reference (2014 Update) lists routine preoperative CHX showering/bathing/wiping as an unresolved issue. While this practice is supported by a good microbiological rationale (and those who know me know that I like microbiological rationales), it is not yet quite established whether this translates into better clinical outcomes. Note, this is different from specific preoperative decolonisation of MSSA/MRSA cariers, which seems indeed to translate into better outcomes. Also, for classical skin antisepsis (‘skin prep’) as discussed above, it is also well established that this translates into outcomes.

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 Jenny,

Sorry to join the discussion in relation to surgical preoperative skin preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement (IHI) Project JOINTS.
http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.aspx

In addition to the interventions recommended by the Surgical Care Improvement Project (SCIP) (i.e. appropriate use of prophylactic antibiotics, appropriate hair removal…..and so on) Project JOINTS recommends the following interventions for elective hip and knee arthroplasty procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin preparation.

Hospitals participating in the IHI Project JOINTS are using one of the following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

* 10% Iodophor plus alcohol
You can find additional information in the IHI Project JOINTS, “How to Guide” including the following.

* IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty: “The combination of a long-acting agent (either an iodophor or CHG) is better than povidone iodine alone for preventing SSI. There is insufficient evidence to support recommending the use of one combination agent over another”.
2. Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery – most are using CHG wipes (personal communication).
3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update – Intervention number one is a Grade 1 (high) level of evidence recommendation and may be worth a read.

“Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (quality of evidence: I).
a. Alcohol is highly bactericidal and effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with chlorhexidine gluconate or an iodophor.115
i. Alcohol is contraindicated for certain procedures, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
b. The most effective disinfectant to combine with alcohol is unclear…….”.

The publication is freely available online at the following link: http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been applied, although any staining (tinted CHG or Idophor) may obscure signs of inflammation post-operatively.

regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

thankyou to everyone who responded to my question – its given me a great basis for discusssion with the ortho surgeon !!

________________________________
Hi John,

I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.

One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.

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

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards
John

Dr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________

Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Michael Wishart]

Thanks Sue for this generous offer.

Just a reminder that if you wish to discuss any material offered on this discussion list with the person who offers it, please contact them directly, not by replying to the list.

Thanks
Michael Wishart
ACICP Infexion Connexion Administrator

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

5th May 2014
[5may2014_top]

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Sue Atkins
Sent: Tuesday, 29 April 2014 12:31 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Aseptic Technique Auditing

Rebecca and Joe,
We have completed a training program for aseptic technique auditing and education for our region using the train the trainer model.
Happy to discuss how we went about it and lessons learnt off line. Please feel free to email questions or call to discuss using the below details.
Regards
Sue
[cid:_2_0A67CA7C0A67C83C000DE377CA257CC9]

[cid:_2_0A67C6380A67C0D0000DE377CA257CC9]

Sue Atkins
Regional Infection Control Consultant | CICP | Service & Workforce Development | Grampians Region
Department of Health | 35 Armstrong Street South, Ballarat, Victoria, 3350
p. 03 5333 6023 | f. 03 5333 6093 | m. 0438 227 989
e. sue.e.atkins@health.vic.gov.au | http://www.grhc.org.au

From:

Rebecca O’Donnell

To:

AICALIST@AICALIST.ORG.AU

Date:

29/04/2014 11:52 AM

Subject:

Re: Aseptic Technique Auditing

Sent by:

ACIPC Infexion Connexion <AICALIST@AICALIST.ORG.AU>

________________________________

Hi Joe,

I havent started the training as yet either, in planning stages as well. I would also be interested to hear feedback on this.

Kind regards,

Rebecca ODonnell | Infection Prevention and Control Co-ordinator
St Vincent’s Hospital Toowoomba | 22-36 Scott Street TOOWOOMBA 4350
T 07 4690 4042 | F 07 46904400
E rebecca.odonnell@svha.org.au | W http://www.stvincents.org.au

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This e-mail and any attachments to it (the “Communication”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. The Communication may contain copyright material of St Vincent’s Health & Aged Care (“SVHAC”), or any of its related entities or of third parties. If you are not the intended recipient of the Communication, please notify the sender immediately by return e-mail, delete the Communication, and do not read, copy, print, retransmit, store or act in reliance on the Communication. Any views expressed in the Communication are those of the individual sender only, unless expressly stated to be those of SVHAC. SVHAC does not guarantee the integrity of the Communication, or that it is free from errors, viruses or interference.

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Joe-Anne Bendall
Sent: Monday, 28 April 2014 11:23 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Aseptic Technique Auditing

Good morning everyone

I am currently writing a training program for aseptic technique auditors.

We will be using 2 types of auditing tools – electronic and paper.

Does anyone want to share any lessons learned from their auditor training programs? I want to make sure the training program meets the requirements for auditing!

Thanks

Joe

Joe-Anne Bendall
(Monday – Wednesday)
HAI Project Officer | Clinical Nurse Consultant Infection Prevention and Control
Clinical Governance Unit
Phone: 93827621
Mobile: 0434323222

(Thursday/Friday)
Joe-anne Bendall | Clinical Nurse Consultant Infection Prevention and Control
Sydney Hospital and Sydney Eye Hospital
8 Macquarie St
SYDNEY NSW 2000
| ph +61 2 9382 7199 |page 22070 via switch 9382 7111| 7 Fax 93827510 |
Mobile 0418984255 | Joe-anne.Bendall@SESIAHS.HEALTH.NSW.GOV.AU

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[Michael Wishart]

Hi Nicola

My biggest concern would be fluid spillage. Can you really be assured that no fluid of any kind has been spilled under the mattress?

No idea what our mattresses weigh, but housekeeping staff do clean underside (and turn over mattress regularly).

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

5th May 2014
[5may2014_top]

Hi All,

The new mattresses we have, weigh in at 18kg and are difficult to manoeuvre by one person Eg ( the housekeeping staff when cleaning rooms on patient discharge)

Could anyone share what their housekeeping staff do on discharge of a patient unknown to have a multi resistant colonisation/infection. Is the mattress turned over and wiped with detergent on both sides or just the side the patient was lying on?

My thoughts were that the patient or nurse does not directly touch the underside of the mattress and therefore unless visibly soiled no need for it to be turned and wiped. Or is it that it is in the patient zone and all though not frequently touched should still be wiped over. Does anyone else have any views they can share with me.

Thank you and Kind Regards

Nicola Swindells Clinical Nurse Consultant
Infection Control / Skin Integrity
Mater Hospitals Central Queensland
Rockhampton Gladstone Yeppoon

nswindells@mercycq.com
tel 07 49313420

Clean Hands are caring hands, remember the five moments of hand hygiene

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[Michael Wishart]

Hi Nicola

My biggest concern would be fluid spillage. Can you really be assured that no fluid of any kind has been spilled under the mattress?

No idea what our mattresses weigh, but housekeeping staff do clean underside (and turn over mattress regularly).

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email

5th May 2014
[5may2014_top]

Hi All,

The new mattresses we have, weigh in at 18kg and are difficult to manoeuvre by one person Eg ( the housekeeping staff when cleaning rooms on patient discharge)

Could anyone share what their housekeeping staff do on discharge of a patient unknown to have a multi resistant colonisation/infection. Is the mattress turned over and wiped with detergent on both sides or just the side the patient was lying on?

My thoughts were that the patient or nurse does not directly touch the underside of the mattress and therefore unless visibly soiled no need for it to be turned and wiped. Or is it that it is in the patient zone and all though not frequently touched should still be wiped over. Does anyone else have any views they can share with me.

Thank you and Kind Regards

Nicola Swindells Clinical Nurse Consultant
Infection Control / Skin Integrity
Mater Hospitals Central Queensland
Rockhampton Gladstone Yeppoon

nswindells@mercycq.com
tel 07 49313420

Clean Hands are caring hands, remember the five moments of hand hygiene

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