CONTENTS:

NEWS FEATURE

• Virus Transfer from Personal Protective Equipment to Healthcare Employees' Skin and Clothing

• I have been told that healthcare facilities should have splash guards built next to sinks in some situations. Can you clarify the rationale and provide references?

• Hand Hygiene and The Joint Commission (TJC)

• 2008 International Infection Prevention Week, October 19-25, 2008
• NCHA System for Hospital Infection Measurement (NC SHIM)
• New Rule for Dialysis Centers
• CMS issues final rule, tables some IC measures
• Joint Commission's 2009 IC standards posted
• Prevention and Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008

NEWS FEATURE

Virus Transfer from Personal Protective Equipment to Healthcare Employees' Skin and Clothing

Caring for patients with communicable diseases places healthcare workers (HCWs) at risk. Infected HCWs may suffer serious illness or death, and may spread infection to other HCWs, their families, or patients. Methods to prevent HCW infections include vaccination, hand hygiene, and isolation of patients with communicable diseases.

A key aspect of patient isolation is proper use of personal protective equipment (PPE) to protect HCWs from pathogen exposure during patient care. PPE includes use of barriers (gowns, gloves, eye shields) and respiratory protection (masks, respirators) to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The importance of PPE was underscored in the outbreak of Severe Acute Respiratory Syndrome (SARS). HCWs accounted for approximately 20% of cases and developed SARS while performing patient care. Studies demonstrated that failure to properly use PPE was a risk factor for HCW infection.

This outbreak raised concern that HCWs could contaminate their skin or clothes with pathogens during PPE removal, resulting in accidental self-inoculation as well as subsequent virus spread to patients, other HCWs, or fomites. The Centers for Disease Control and Prevention (CDC) addressed this by designing a protocol to minimize wearer contamination during the PPE removal process. However, the effectiveness of this protocol in preventing self-contamination has not been validated.

By examining the fate of viruses after removal of experimentally contaminated PPE under controlled conditions, it can be determined if removing PPE according to the CDC protocol prevents viral contamination of the wearer. A human challenge study was undertaken using a non-pathogenic virus to determine the fate of viruses on items of PPE when a wearer removes PPE in accordance with the CDC protocol.

PPE (gowns, gloves, respirators, and goggles) donned by volunteers was contaminated with bacteriophage MS2, a non-enveloped, non-pathogenic RNA virus suspended in 0.01M PBS. Sites of contamination were: front shoulder of the gown, back shoulder of the gown, right side of the N95 respirator, upper right front of the goggles, and palm of the dominant hand. Each site was contaminated with a total of 10⁴ plaque forming units (PFU) of MS2 in 5 drops of 5 μL each. Participants performed a health care task (measuring blood pressure on a mannequin) and then removed PPE according to the CDC protocol. Hands, items of PPE, and scrubs worn underneath were sampled for virus using the most probable number (MPN) enrichment infectivity assay.

Transfer of virus to both hands, the initially uncontaminated glove on the non-dominant hand, and the scrub shirt and pants worn underneath the PPE was observed in most volunteers (i.e., 80% to nondominant glove, 90% to skin of right hand, 70% to the skin of left hand, 100% scrub suit and 75% scrub pants). The amount of virus recovered ranged from 1-3 log₁₀ MPN for hands and 1-4 log₁₀ MPN for scrubs. The mean amount of virus recovered from the right hand (the dominant hand of 9/10 volunteers) was greater than that recovered from the left hand.

PPE is vital for protecting HCWs from occupationally acquired infection during patient care, particularly droplet- or airborne-transmitted diseases. However, removing PPE after patient care without contaminating skin or clothes is important. PPE is usually worn only for short periods, while viruses such as influenza and SARS-CoV can survive for hours on surfaces, and viral infection can be spread by surface-to-hand and hand-to-hand contact.

Developing and validating an algorithm for the removal of PPE that prevents contamination of the skin and clothes of HCWs is key to interrupting nosocomial transmission of potentially serious infectious agents, including SARS and avian influenza. These experiments showing viral transfer to the hands and clothing demonstrate that an altered protocol or other measures are needed to prevent healthcare worker contamination.

L Casanova, E Alfano-Sobsey, WA Rutala, DJ Weber, M Sobsey. Emerg Inf Dis 2008;14:1291

Q: I have been told that healthcare facilities should have splash guards built next to sinks in some situations. Can you clarify the rationale and provide references?

A: During an outbreak investigation in an ICU setting, the soiled utility sink was strongly implicated as the inanimate reservoir for HAI pathogens. Rodac samples from sterile items on the counter and environmental surfaces near the soiled utility sink demonstrated a variety of gram-negative bacilli similar to those recovered from the patients.(1) In another study, Holder demonstrated that contaminated splash from a sink reached a distance of 48 inches from the sink.(2) Therefore, it has been recommended that sinks should be situated to avoid splashing at a minimum of 36 inches from patients or clean supplies, or supplied with a splash guard made of nonporous materials to avoid splash contamination.(3)

References
1. Dandalides PC, WA Rutala and FA Sarubbi, Jr. Postoperative infections following cardiac surgery: Association with an environmental reservoir in a cardiothoracic intensive care unit. Infect Control Hosp Epidemiol, 1984;5:378-384.
2. Holder, IA: Epidemiology of Pseudomonas aeruginosa in a burns hospital. In: Young VM (ed): Pseudomonas aeruginosa: Ecological Aspects and Patient Colonization. New York, Raven Press, 1977:77-95.
3. Bartley J, APIC State-of-the-Art Report: The role of infection control during construction in health care facilities. AJIC, 2000;28:156-169.

Hand Hygiene and The Joint Commission (TJC)

A medical center in North Carolina received a "Requirement for Improvement" for the failure to perform hand hygiene prior to donning nonsterile gloves. This hospital appealed the survey finding regarding hand hygiene before nonsterile glove placement prior to patient contact issue. It stated in its appeal that neither the CDC guideline nor the WHO guideline on hand hygiene recommends hand hygiene before nonsterile glove use and patient contact. The CDC guideline does recommend "decontaminate hands before having direct contact with patients" and lists two references. The two references are dated 1861 (Semmelweis) and 1962 (Mortimer), both publications are before nonsterile glove use in patient care. The hospital staff spoke to Dr. Boyce, first author of the CDC Hand Hygiene guideline, about this requirement. He said that he has spoken to The Joint Commission and told them there are no data that demonstrate that hands must be washed before nonsterile glove placement prior to patient contact. He also mentioned a paper that investigated glove contamination when hands were washed versus not washed and the investigators found no difference in glove contamination rates. Since there are no data that this practice provides patient benefit he believed that this should not be a Joint Commission recommendation (and will slow clinical care and may increase the likelihood of dermatologic problems in healthcare workers due to increase hand hygiene) and that health care facilities should emphasize hand hygiene practices that have been shown to prevent infections. It was also mentioned in the appeal that decontaminating hands before donning sterile gloves when inserting central intravascular catheters is a CDC recommendation which is the practice at the cited medical center.

The appeal was denied and now the hospital is reeducating all health care workers regarding the indications for hand hygiene to include prior to direct contact with patients. Full compliance with TJC recommendation will require a compliance rate of 90% with the CDC guidelines.

SPICE Infection Control Courses in 2009, Friday Center, Chapel Hill, NC:
(Information on all SPICE courses can be found on the Course page of the SPICE website: www.unc.edu/depts/spice/courses.html)

• Infection Control in Long Term Care Facilities will be held March 16-18 and November 2-4, 2009.
• Infection Control Part I: Surveillance of Healthcare-Associated Infections will be held April 27-May 1, 2009. Registration for the spring 2009 course will begin in January 2009.
• Infection Control Part II: The ICP as an Environmentalist will be held September 21-25, 2009

58th Annual Tuberculosis/Respiratory Disease Institute Conference:

The TBRD Institute has moved to a new location this year, Carolina Beach, NC, from October 29 to 31st. PURPOSE OF COURSE: To provide continuing education in the form of current diagnostic, management and research concepts as presented by local and regional experts. You can register for the conference and make hotel reservations by following the link:
http://www.mrsnv.com/evt/home.jsp?id=2168

• 2008 International Infection Prevention Week, October 19-25, 2008 Visit the APIC website for resources, background, merchandise, and stories. APIC website: www.apic.org/Content/NavigationMenu/Education/InfectionPreventionWeek/2008InternationalInfectionPreventionWeek/IIPW_2008.htm

 

• NCHA System for Hospital Infection Measurement (NC SHIM) (Summary taken from NC Quality Highlights Newsletter, October 2008) The North Carolina Center for Hospital Quality and Patient Safety has developed a voluntary, confidential, peer-review protected database to collect various measures related to infection prevention in support of the goal to eliminate HAIs. The NCHA Board of Trustees has endorsed this initiative and goal.

  The NC SHIM will collect data on these measures:

  1. Ventilator Process Measures/Bundle Compliance
  2. Line Insertion Process Measures/Bundle Compliance
  3. Central Line-Associated Bloodstream Infection Rate per 1000 central line days.
  Future measures for NC SHIM may include surgical site infection rates and methicillin-resistant Staphylococcus aureus (MRSA) rates.

  Why participate? NC SHIM will be North Carolina's first standardized surveillance system that will yield state-level infection data. Participation will also allow hospitals to begin compliance with the Joint Commission National Patient Safety Goal 7 (NPSG.07.04.01). This system will provide reliable, useful information that is usually not found in public reporting of hospital-level infection rates, such as:

  • Estimates of compliance rates to evidence-based processes of care to prevent ventilator-associated pneumonia and central-line bloodstream infections
  • Use of national measurement specifications that allows for the comparison of NC infection rates to the nation and other states
  • Opportunities to provide information on best practices and to stimulate quality improvement
  • Prepare for potential public reporting of infection rates

  As a participating hospital, you will receive confidential feedback which will allow you to compare performance against de-identified NC hospitals, peer groups, and national benchmarks and will help guide your hospital's ongoing efforts to prevent HAIs. For more information, contact Nancy Schanz (nschanz@ncha.org, 919-677-4105) or Joanne Campione (jcampione@ncha.org, 919-677-4133).

 

• New Rule for Dialysis Centers

  MMWR, August 15, 2008, published Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials

  April 2008, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule on Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities. The rule establishes new conditions dialysis facilities must meet to be certified under the Medicare program and is intended to update CMS standards for delivery of quality care to dialysis patients. CDC's 2001 Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients have been incorporated by reference into the new CMS conditions for coverage. Thus, effective October 14, 2008, all ESRD facilities are expected to follow the CDC recommendations as a condition for receiving Medicare payment for outpatient dialysis services.

  Link to MMWR article: www.cdc.gov/mmwr/preview/mmwrhtml/mm5732a3.htm?s_cid=mm5732a3_e

  Both the Federal Register rule and MMWR can be downloaded from the SPICE web site: www.unc.edu/depts/spice/new.html

 

• CMS issues final rule, tables some IC measures (taken from Infection Control Monitor, August 08, 2008)

  The Centers for Medicare & Medicaid Services (CMS) released the final rule on its 2009 inpatient prospective payment system and dropped some of the more controversial proposed IC measures that will affect a hospital's reimbursement.

  CMS added surgical site infections following certain elective procedures - including certain orthopedic procedures and bariatric surgery for obesity - to the list of conditions for non-payment. Beginning October 1, 2008, CMS will no longer reimburse hospitals for additional costs related to these and three other previously-approved infections acquired during a hospital stay.

  CMS said that, following public comment, it scaled back its original proposal to add nine new conditions to the non-reimbursement list. Dropped - at least for now - are infections related to Legionnaires' disease, ventilator-associated pneumonia, Staphylococcus aureus septicemia, and C. difficile-associated disease. CMS published the final rule in the August 19 Federal Register and it will take effect on October 1, 2008.

  Link to the Federal Register Document (NOTE: this is a very large file, 651 pages): edocket.access.gpo.gov/2008/pdf/E8-17914.pdf

 

• Joint Commission's 2009 IC standards posted (taken from Infection Control Monitor, 7/4/08)

  The Joint Commission (formerly JCAHO) has now posted its 2009 infection control standards online.

  Changes include renumbered standards in the Infection Prevention and Control chapter of the Comprehensive Accreditation Manual for Hospitals. The changes are effective January 1, 2009. Click here to view the 2009 standards: www.jointcommission.org/Standards/SII/sii_hap.htm

  You can also find Frequently Asked Questions (FAQ) addressing the 2008 National Patient Safety Goals (NPSG). The FAQ also includes changes from the 2009 goals announced last month. Click here to view the FAQ: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/faqs_2008_npsg.htm

 

• Prevention and Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008 This report updates the 2007 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine and antiviral agents (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2007;56[No. RR-6]). The 2008 recommendations include new and updated information. Link to the report: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm

• APIC-NC has chosen Katherine Brooks of Duke Health Raleigh Hospital as the 2008 recipient of the Eva Clontz CBIC Review scholarship. The award is in the amount of $100.00 and was applied to the registration fee for the 2008 CBIC Review Course held 8/22/08 at the Friday Center in Chapel Hill, NC.
• Congratulations to Suzanne Murphy, RN, MSN, CIC, Infection Preventionist Director at the Rowan Regional Medical Center in Salisbury, NC. She passed the CBIC exam in September 2008!

Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A. Rutala, PhD, MPH; David J. Weber, MD, MPH; Eva P. Clontz, MEd, Debby Pyatt, BA

Report of the Month is also available on the home page of the Statewide Program for Infection Control and Epidemiology at http://www.unc.edu/depts/spice/. The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by the General Assembly of North Carolina to serve the State. The SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.