Upload File

Download - What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

Transcript
Page 1: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

What’stheenvironmentgottodowithit?

MichaelParry,MD,FACP,FIDSA,FSHEAThomasJayBradsell ChairofInfectiousDiseases,StamfordHospital

ProfessorofClinicalMedicine,ColumbiaUniversityCollegeofPhysiciansandSurgeons

Page 2: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

GoldenRulesofInfectionPrevention

hand hygiene

environmentalhygiene

engineered processes of care

Page 3: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

HandHygiene

Page 4: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

Bundleimplementation(SSIprevention)• Pharmacologic

– Mechanicalbowelprep– Oralantibioticsthedaypriortosurgery(Correctdrugs,doses)– Prophylacticintravenousantibiotics(Appropriateselection,timing,re-

dosing,postoplimitation)• NonPharmacologic

– Preoperativeshowers– Appropriatehairclipping– Appropriateskinprep– Maintainbodytemperature– Postoperativeoxygenation– Laparoscopicwhenpossible

• Technical– Reduceintraoperativecontamination-- minimizespillage– Maintain“clean”areasseparatefromcontaminated– Changegloves,gowns,suction,bovie tip– Protectsuperficialwound– Recognizehighrisksituations-- Delayedprimaryclosure

• Systematic– Time-out– Checklist– Debriefingform– Quarterlydatareview

Page 5: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 6: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

6

Contaminatedsurfaces

• 70%ofsurfacesincolonizedpatients’roomsarecontaminatedwithMRSAorVREorC.difficile.– Countertops– Bedrails– Equipment– Telephone,callbutton

• MorethanhalfthepatientswhobecamecolonizedwithMRSAafterenteringtheICUacquireastrainNOT presentonotherpatientsthereatthetime.

• Oncecaregiverstouchthesesurfaces,theirhandsorglovesarecontaminated.

Infection Control and Hospital Epidemiology (v. 9, 1997) 622-627.Infection Control and Hospital Epidemiology (v.20.2, 2006).

Page 7: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

7

SurvivalofMulti-drug-resistantOrganismsintheEnvironment

• DurationofsurvivalofMRSAindryconditions– Plasticcharts=11days– Laminatedtabletop=12days– Clothcurtains=9days

• EnvironmentalsurvivalofVRE– Upholstery,furnitureandwallcoverings=7days

• SurvivalofClostridiumdifficile– Months

Huang et al, Infect Control Hosp Epidemiol 2006;27:1267-1269Lankford et al, Am J Infect Control2006;34:258-263

Page 8: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

8

Contamination of Computer Keyboards

Beforecleaning

Aftercleaning

Keyboards,Telephones,Equipment–allharborStaph,Strep,andotherPathogens

Page 9: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

9

Manypersonneldon’trealizewhentheyhavemicroorganismsontheirhands

Nurses,doctorsandotherhealthcareworkerscangetthousandsofbacteriaontheirhandsbydoingsimpletasks,like

• pullingpatientsupinbed• takingabloodpressureorpulse• touchingapatient’shand• rollingpatientsoverinbed• touchingthepatient’sgownorbedsheets• touchingequipmentlikebedsiderails,over-bedtables,IVpumps

Cultureplateshowinggrowthofbacteria24hoursafterhandplacedontheagarplate

Page 10: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

10

RoleofasymptomaticcarriageofCdifficile inpatientsataLTCFRiggs,etal.ClevelandClinic,2007.

• 68asymptomaticpatientsinLTCF• 51%carriersofC.difficile

– 49%ofthesehadNAP-1strain

• Carriershadhighskin(61%)carriage– versus70%inCDIcases

• Carriershadhighenvironmental(59%)contamination– Versus70%inCDIcasesand20%innon-carriers

• PriorCDIandrecent(<3mo)antibioticusewasassociatedwithcarriage

• 20%ofcarriersdevelopedCDIover4mofollow-up

Page 11: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

11

Wherearethegerms?

Page 12: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

12

Wherearethegerms?

Page 13: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

13

Page 14: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

14

TheChallenge:tocreateaneffectiveenvironmentalhygieneprogram

• CleaningPolicies&Procedures– Everyone’sjob!– Dailycleaningandterminalcleaning– Hightouchsurfacesfocus– Equipmentcleaning– “Rollingstock”management– Unitcorecleaning

• Staffneededucationonanongoingbasis.• Checklistforroomcleaning• Roomturn-overtimeforanisolationpatienttakes

approximately45-60minutes.• Staffshouldberoutinelyevaluatedonperformance

– DirectandClandestineobservation

Page 15: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

15

ElementsoftheInterdisciplinaryCleaningandDisinfectionInitiative

• ProgramimplementedOctober,2005• Useofafluorescentmarkertodetect

surfacecleaning• Collaborativeevaluationofcleaningprocess• Nursingserviceperformedcleaning

assessments• Ongoingevaluationofeffectiveness

– Groupfeedbacktohousekeepingdepartmentatlarge

– Personalfeedbackonindividualperformancetomanager

• Incorporationintoperformancemanagementprocess

Page 16: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

16

EnvironmentalSitesTesting

• Toiletseat• Toilethandle• Toilethandhold• Sink• Sinkfaucethandle• BRdoorknob• BRlightswitch• Telephone• TVcontrol/callswitch• Siderails• Traytable• Bedsidetable• Chairhandrail• Roomdoorknobs

Page 17: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 18: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

18

EnvironmentalCleaningSHOverallProgress

Page 19: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

Percentofsurfacescleaned

19

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

perc

ent c

lean

ed

Percent of surfaces cleaned 10/12 to 6/15

Page 20: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

IncidenceofHospital-acquiredClostridiumdifficile Infection.

Leffler DA, Lamont JT. N Engl J Med 2015;372:1539-1548

Page 21: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

DifficultiesincontrollingthespreadofC.difficile

• Highcommunityprevalence– especiallyLTAC(30-50%);SNF(10-20%);community(3-6%)

• Difficultypreventinginfectioninhighrisksettings– “incidentdensity”pressure– carriers+ill

• Hospital“onset”versushospital“acquisition”• Antibioticuseandthemicrobiome

– necessaryandunnecessary– breadthandlengthandtypeofrx

• Prevalenceofacidsuppressiontherapy– VAPprevention;otherordersets

• Prolongedfecalandskincarriage– Clinicallysuccessfultreatmentdoesn’teradicatethespore

• Frequentrecurrence– Treatment,ageandimmunocompetence dependent

• Persistenceofsporesintheenvironment– Resistancetogermicides– Patientingestion

21

Page 22: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

22

PersistenceofC.difficileDuringandAfterTreatment

0

10

20

30

40

50

60

70

80

90

100

Prior to treatment Day 3 of treatment Resolution of diarrhea

End of treatment 1-6 weeks after treatment

Perc

ent P

ositi

ve

Percentage of positive cultures for C. difficile before, during, and after treatment

Stool Skin Environment

Wafa Al Nassir, et al. Cleveland VA. ICHE, 2010

Page 23: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 24: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 25: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 26: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

26

StamfordHospital-acquiredC.difficile

Page 27: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

27

Page 28: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

C.difficile bundle• Environmentalcleaningprogram• Bleach/peracetic acidprogram• Dailyandterminalcleaning• IsolationforCdiff

– GownandGlove– Soapandwater– Durationofhospitalization

• Rapiddetection– PCR– Isolatefordiarrhea– Readmissionflag

• Dedicatedequipment– Yellowstethoscopes;disposableBPcuffs,thermometers,etc– Norectaltemperatures

• Treatmentinitiatives– vancomycinandfidaxomycin• PPIreductioninitiative• Antibioticstewardshipprogram• Fecaltransplantationprogram• NewHospitalinitiatives

Page 29: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

TheNewStamfordHospital

Page 30: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 31: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 32: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 33: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

Whathelpisonthehorizon?

• Antimicrobialsurfaceengineering– Copper,silver– Nanotechnology– Fabrics(curtains,scrubs,linens)

• UVlightandotherlighttechnologies• Aerosols• Focusonthemicrobiome

– Fecaltransplantation– Syntheticstool– Alternativetreatmentmodalities

• Focusontheimmunesystem– Monoclonalantibodies– Immunization

Page 34: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

MicrobialLoadonEnvironmentalSurfaces:TheRelationshipBetweenReducedEnvironmentalContaminationandReductionofHealthcare-AssociatedInfections(TheBETRDisinfectionStudy)

IDWEEKAbstract262,2016

WILLIAMRUTALA,etalUniversityofNorthCarolinaHealthCare,ChapelHill,NC

Background:Disinfectionofnoncriticalenvironmentalsurfacesandequipmentisanessentialcomponentofinfectionpreventionassurfacesmaycontributetocross-transmissionofepidemiologicallyimportantpathogens(EIPs).

Results: Enhanceddisinfectioninterventions(i.e.,Quat/UV,Bleach,Bleach/UV)weresignificantlysuperiortoaQuat aloneinreducingEIPs.

Conclusion:Comparisonofthebeststrategywiththeworststrategy(i.e.,Quat vsQuat/UVorBleach/UV)revealedthatareductionof>90%inEIPsledtoa35%decreaseinsubsequentpatientcolonization/infection.Ourdatademonstratedthatadecreaseinroomcontaminationwasassociatedwithadecreaseinsubsequentpatientcolonization/infection.

Page 35: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

AntimicrobialActivityofaContinuousVisibleLightDisinfectionSystem

IDWEEKAbstract267,2016

WILLIAMRUTALAandDANIELSEXTON,etal.UniversityofNorthCarolina,ChapelHill,NCandDukeUniversityMedicalCenter,Durham,NC

Background:Anoverheadlightfixturetechnology,whichcontinuouslyandsafelydisinfectstheenvironmentwasassessedtodeterminetheeffectivenessforthereductionofEIP. Thistechnologycreatesanarrowbandwidthofhigh-intensityvisiblebluelightwithapeakoutputof405nmthatgeneratesreactiveoxygenspeciesandkillsmicroorganisms.

Results:Theseresultsdemonstratedthatthe405nmlightinactivatedthreevegetativebacteria(MRSA,VRE,MDRA)onsurfaceswithcontacttimesof1-96hr.Statisticaldifferences(p<0.05)wereobservedusingbluelightforVREat24hr,forMRSAat3-7hr,forMDRAat5-24hr,andforC.difficile sporesat5hrand72hr.Theinactivationwasmoresignificantwhenthesurfaceirradiancewasincreasedbyaddingthebluelight.

Conclusion: Highintensitylighttechnologycouldbeconsideredforseveralhealthcaredecontaminationapplications

Page 36: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and
Page 37: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

ReducedHealthcareAssociatedInfectionsinanAcuteCareCommunityHospitalusingaCombinationofSelf-DisinfectingCopper-ImpregnatedCompositeHardSurfacesandLinens

IDWEEKAbstract263,2016

COSTISIFRI,MD,KYLEENFIELD,MDandGENEBURKEMD.UniversityofVirginiaHealthSystemandSentaraHealthcare,Norfolk,VA

Background:Effortstodecreaseenvironmentalbioburden areassociatedwithreducedtransmissionofmicrobialpathogensanddevelopmentofHAIs.Copperoxidehaspotentbiocidal activity.Herewereporttheresultstrialofacopperoxide-impregnatedcompositeproductincorporatedintohospitalcountertops,moldedsurfaces,patientgownsandlinens.

Results:Thestudywasconductedovera25.5-monthtimeperiod.HAIratesobtainedfromthecopper-containingnewtower(72beds;14,479patient-days)andtheunmodifiedhospitalwing(84beds;19,177patient-days)werecomparedtothosefromthebaselineperiod(204beds;46,391patient-days).Thenewtowerhad78%(P=.023)fewerhealthcare-associatedinfectionsduetoMDROsorC.difficile ,83%(P=.048)fewercasesofC.difficile infection,and68%(P=.252)fewerinfectionsduetoMDROsrelativetothebaselineperiod.Nochangesinratesofhealthcare-associatedinfectionswereobservedintheunmodifiedhospitalwing.

Conclusion:Copperoxide-impregnatedcompositehardsurfacesandlinensmaybeusefultechnologiestopreventhealthcare-associatedinfectionsintheacutecarehospitalsetting.

Page 38: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

TheAntisepticScrubContaminationandTransmission(ASCOT)TrialtoDeterminetheImpactofAntiseptic-

ImpregnatedScrubsonHealthcareWorkerContaminationIDWEEKAbstract1351,2016

DEVERICKANDERSON,MDetal.DukeInfectionControlOutreachNetwork,DukeUniversityMedicalCenter,Durham,NC

Background:HCPclothingbecomescontaminatedduringpatientcareandcanserveasavectorforsubsequenttransmission. Antimicrobial-impregnatedclothingmayreducecontamination,butclinicaldataarelacking.

Methods:Scrubsimpregnatedwith(1)acomplexelementcompoundwithasilver-alloy,or(2)anorganosilane-basedquaternaryammoniumandahydrophobicfluoroacrylate copolymeremulsion,werecomparedtotostandardcotton-polyscrubsduringclinicalcare

Results:167uniquepatientsreceivedcarefrom40nursesubjectsover120individualshifts.2,185cultureswereobtainedfromHCPclothing,455frompatients,and2,919frompatients’environments. Themedianunadjustedincreasesincontaminationweresimilaramongscrubtypes.ScrubtypewasnotassociatedwithadecreaseinHCPclothingcontamination.

Conclusion:Antimicrobial-impregnatedscrubsdidnotleadtodecreasedcontaminationofnursesclothing.

Page 39: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

AreAntimicrobialCurtainsasCleanasYouThink?IDWEEKAbstract260,2016

SHELASRIAR,MD,etal.MedicalCollegeofWisconsin,Milwaukee,WI,

Background:Weaimedtodeterminethedegreeofbacterialcontaminationonantimicrobialcurtainswithinourmedicalintensivecareunit(ICU).

Results:Wefoundthatoutof20curtains,95%(n=19)showedbacterialgrowth.Outofthe10doorcurtains50%(n=5)showedGram-negativebacilliand100%(n=10)hadGram-positiveorganisms.Outofthe10commodecurtains,10%(n=1)showedGram-negativeorganismsand90%(n=9)hadGram-positiveorganisms

Conclusion:Antimicrobialcurtainsarecontaminatedwithpathogenicorganisms;therefore,theyshouldbethoroughlydisinfected,exchanged,ortotallyforegoneinbetweenpatients.

Page 40: What’s the environment got to do with it? · What’s the environment got to do with it? Michael Parry, MD ... Bundle implementation ... transmission of microbial pathogens and

Thankyou!

Questions?


Top Related

What’s P.T. Got to Do With It?...• Retrograde ejaculation • Incontinence – rare
What’s P.T. Got to Do With It?...• Retrograde ejaculation • Incontinence – rare
What’s BEPS got to do with it? Exploring the effectiveness
What’s BEPS got to do with it? Exploring the effectiveness
What’s the brain got to do with it
What’s the brain got to do with it
The Credit Crunch: What’s Crime Got to Do With It?
The Credit Crunch: What’s Crime Got to Do With It?
What’s FOOD Got To Do With It?
What’s FOOD Got To Do With It?
Sep WHAT’S NEXT? WHATEVER IT IS, WE GOT IT!
Sep WHAT’S NEXT? WHATEVER IT IS, WE GOT IT!
What’s Color Got To Do With It?
What’s Color Got To Do With It?
What’s Fundraising got to do with Trustees?
What’s Fundraising got to do with Trustees?