Detailed linens, uniforms cleaning protocol essential to infection control

laundryDuring our last consulting session at a hospital, we asked what measures were being taken in the laundry process to prevent the spread of healthcare-associated infections. The VP for facilities said the CDC didn’t see laundry items as vehicles that contribute to the spread of infection. They were concerned about the contamination of hard surfaces, and had procedures in place to deal with those surfaces. But soft and porous surfaces – linens, uniforms, bedding, curtains – were not being addressed in any detailed fashion. He said his hospital was following CDC guidelines. Laundry simply wasn’t on the list of potential concerns as it relates to the spread of infection. More than just a little evidence exists, however, that suggests that thought process might be flawed. Consider:

  • NOLA.com ran a piece that says five children died at Children’s Hospital in 2008 and 2009 after coming in contact with a deadly fungus transmitted to them through the linens they slept on, according to court records, interviews and a new report published by a pediatric medical journal. They included two newborns, a 13-year-old boy, a 10-year-old girl and an 11-year-old girl, according to the findings of a study led by a medical officer with the Centers for Disease Control and recently published by the Pediatric Infectious Disease Journal.

Why wouldn’t hospitals have all staff in antimicrobial uniforms? Plenty of companies make them.

Strict protocol with the handling of laundry can help immensely. Take a look at some of the procedures advocated by Healthcare Laundry Accreditation Council (HLAC), a non-profit organization formed for the purpose of inspecting and accrediting laundries processing healthcare textiles for hospitals, nursing homes, and other healthcare facilities (http://www.hlacnet.org/standards.php).  The detailed procedures HLAC outlines are complete and impressive. And doable.

Too much compelling data exists to dismiss airborne transmission of infection any longer

plos oneWe recently attended a CDC workshop in Washington DC on nosocomial infections. The head of a modern hospital system categorically stated that there is no evidence to support airborne transmission. We agreed with him that perhaps no study has been done that meets the academic rigor needed to prove it as absolute law, but there certainly is some compelling data and evidence to suggest his stance is wrong. We challenged him to return to his hospital and turn off the electricity because that remains simply a theory. Clearly, that wouldn’t work so well. Theories examine what happens and then tell us how and why something happens. And they are, and should be, constantly tested.

Anecdotal evidence and compelling number of studies tell us infections indeed can be transferred via the air. There certainly is more than enough to suggest that it’s not only possible but likely, and further study and examination is warranted. An article recently published in the Public Library of Science – Concentration, Size Distribution, and Infectivity of Airborne Particles Carrying Swine Virus – by members of the veterinarian community, which has led many of the studies relating to airborne infection, provides some evidence. Among their findings:
• Particles of small size can remain suspended in the air for long periods, potentially exposing a large number of susceptible individuals, including those close to the source and those at greater distances.
• The study indicated that virus-associated particles disperse simultaneously across a wide range of particle sizes. This is important because it shows that viruses in airborne particles emitted or generated by animals can be transmitted simultaneously across both short and long distances.
• Determining the particle size distribution for both respiratory and enteric viruses has important implications for the control of animal and human diseases and the use of droplet and airborne infection control measures.
• The information generated in this study is especially important to design effective airborne disease control programs for both enteric and respiratory viruses, including mitigation of occupational exposure of zoonotic pathogens. Changes in recommendations to protect from airborne viruses should be considered based on exposure to particles of different sizes.

Certainly some of what these researchers found at the least should motivate us to look more closely at how and why theories on airborne infection should be scrutinized more closely. We can’t categorically dismiss the possibilities as this hospital leader did. It’s time we take these issues much more seriously.

Working sick is an unhealthy practice at hospitals, can be harmful to patients

It is wsick doctorell-documented that hospitals are the best places acquire infection. Read that back. Hospitals are the best places to acquire infection. How can it be that the places the sick go to get better actually often do the opposite? There’s no single answer, but certainly policy th
at latently encourages doctors and other health care workers to show up sick to avoid shaming don’t help. Nor do sick policies so inappropriate that workers are virtually forced to show up for fear they won’t have a sick day left when a child gets sick and needs their attention at home.

A study in JAMA Pediatrics sheds light on what illnesses physicians and advanced practice clinicians will attempt to work through. It asked 536 hospital workers about how frequently they came to work sick. While nearly all believed working sick put patients at risk, more than 4 out of 5 said they had worked sick at least once in the past year. It’s reasonable to suggest that’s one too many time. It also asked with what ailments they might do so. Almost 80 percent of the 280 doctors said they would work with a cough or runny nose, and 60 percent said they would with congestion and a sore throat. More than 21 percent said they would come to work with a fever, and nearly 8 percent said they would work even if they were vomiting.  The responses are alarming. Too often it seems our hospital human resource policies drive our nurses and medical staff to work while sick. With limited time off, they work despite being ill to preserve precious vacation days. What can we do to improve?

Some potential answers can be found in Presenteeism: A Public Health Hazard from the Journal of General Internal Medicine, an article that examines presenteeism, which gets far less attention than the much more discussed absenteeism. The article notes that health care personnel who return to work despite having ongoing symptoms of an infectious disease extend the risks of presenteeism far beyond reduced productivity issues into the realms of patient safety and public health. The article delves into why health care workers go into work despite being ill and suggests some solutions to correct it, listing unrestricted sick pay leave for health care workers as a starting point. It also suggests that any policy that mandates strict back-to-work rules must also ensure adequate staffing and coverage of health care personnel to limit feelings of personal responsibility that encourage presenteeism.

The last thing patients should need to worry about is the very people who ostensibly are there to help might be the ones who leave them in a worse place than where they started.  Redundant manpower, less draconian sick policy, developing a solid temporary force and better screening of employees for illness are just a few approaches that might help. We encourage you to leave a comment telling us your stories, your obstacles, where you think the issues lie and how they can be fixed.  A healthy dialogue is a beginning to fixing this unhealthy problem. It’s time to put patient safety ahead of the misguided notion that more money can be made by using sick caregivers. There’s too much at stake.

Monitoring air, surfaces and water are essential to proactive infection control plan

journal of environmental protection coverIf you don’t actively monitor the sources of contamination in air, water and surfaces in your building, quite simply, you aren’t doing your job as it relates to proactive infection control.

We recently were asked to consult with a hospital about the air quality in the building. The request came as a result of a problem that arose. Only then did it register there were issues they needed to address. Unfortunately, this reactive approach can cost lives and money. This particular hospital didn’t view air as a potential source for infection. In fact, the leaders had no idea what filter standards were recommended by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE). That was their first problem, which led to others. The Joint Commission wants all hospitals for follow industry standards. It is time to get serious about infection control.

A study that appeared recently in the Journal of Environmental Protection titled “Indoor Air Quality Real-Time Monitoring Result of Pathology Department concluded that “we must take effective measures to control the concentration of harmful gases . . .” The air quality changes constantly and that requires constant monitoring, just as it does on surfaces and in water. Better to address the potential problems before they become larger and more difficult to correct. Do you monitor your air, water and surface hygiene?

Read more here: http://www.scirp.org/Journal/PaperInformation.aspx?PaperID=58962&utm_campaign=linkedin&utm_medium=zyf

Comprehensive infection control plan in schools must address both surfaces and air

Another school year has kicked into high gear across the country, and with it, comes the ever-present concern about student health. In a piece that appeared in the magazine School Business Affairs, Charles P. Gerba, Ph.D., writes an article about the ongoing battle against germs in schools.

Among the keys to potentially help reduce illness and absenteeism, Dr. Gerba cites proper hand hygiene and cleaning methods. He notes that improper cleaning methods can actually increase contamination. Mops and cleaning cloths can be chock-full of germs and nastiness. Districts should ensure that facilities are cleaned with hospital-grade disinfectants, color-coded microfiber cloths and flat mops that reduce cross-contamination.

A related article appeared in Pediatrics®: Official Journal of the American Academy of Pediatrics. The article notes that “We found that a multidisciplinary infection-control intervention, consisting of surface disinfection plus alcohol-based hand-sanitizer use, reduced the absenteeism rate for gastrointestinal illness in elementary school classrooms. The absenteeism rate for respiratory illness was not reduced by this intervention.” Among the conclusions one might draw from this is that any comprehensive, effective infection control approach must consider options to filter and clean the air in addition improved surface and hand hygiene as well as proper cleaning methods.

Even the smallest of added costs to help ensure good hygiene and proper cleaning can be a hard sell because results are not immediately tangible. But when that short-shortsightedness leads to spikes in absenteeism and health care costs, it’s reasonable to suggest that pinching pennies can be even more costly. No one is suggesting schools be wasteful but rather thoughtful because that ounce of prevention truly is worth that pound of cure.

HVAC systems must be part of any comprehensive infection control plan

We recently consulted with a hospital and learned the facility manager rejects what we thought was a commonly known fact – that HVAC systems are a critical piece of the infection control puzzle. We were dumbfounded – and more than just a little alarmed – that someone who had such a key role at the hospital maintained this stance.  And the likelihood that he probably wasn’t the only one in his position to hold this erroneous belief was even more concerning. The most recent rash of illness in New York City brought on by Legionella, which at the time of this post has caused 12 deaths and at least 121 illnesses, is yet another example that demonstrates HVAC systems are intrinsically tied to Legionella and infection control in general.

Water cooling towers were determined to be the culprits nearly four decades ago in the wake of the outbreak that gave Legionnaires’ disease its name. They were identified as prime breeding grounds for the deadly disease, and that has been confirmed by an abundance of compelling evidence since. But even as cases have increased across the nation lately, and experts have called for more safeguards, New York City has been slow to address the risks the towers pose as they power air-conditioning systems in many large buildings. That needs to change in NYC and elsewhere.

Consider this from a report by the Cooling Technology Institute (CTI): “Various studies have shown that some 40 to 60% of cooling towers tested contained Legionella. Therefore, it is best to assume that any given system can harbor the organism, and that routine, continuous microbiological control practices should be implemented to minimize the risk of Legionella amplification and associated disease.” See the entire CTI best practices guidelines here in the report: http://www.cti.org/downloads/WTP-148.pdf

Another enlightening collection of helpful guidelines and information was published recently by ASHRAE in Legionellosis: Risk Management for Building Water Systems. The report includes a description of environmental conditions that promote the growth of Legionella and provides informative annexes and informative bibliography that contain suggestions, recommendations and references to additional guidance. Follow this link for additional information: https://www.ashrae.org/resources–publications/bookstore/ansi-ashrae-standard-188-2015-legionellosis-risk-management-for-building-water-systems

We can help, too. If you are seeking persistent, low-maintenance solutions for keeping cooling towers clean, contact us and we will be happy to point you to some companies who offer a variety of effective methods to address the issue.

Hard and porous surfaces harbor pathogens; cleaning critical to HAI prevention

hospital curtainsHealth care–associated infections (HAIs) are a leading cause of illness and death in the United States and worldwide. In 2011, an estimated 721,800 HAIs occurred in the United States, leading to 75,000 deaths, according to some reports. A multifaceted approach to preventing infection is critical to reducing the risk for HAIs, including hand hygiene practices, antimicrobial stewardship, and environmental cleaning and disinfecting.

Several studies demonstrate that health care–associated pathogens frequently contaminate the patient environment, including both porous surfaces (such as curtains) and hard, nonporous surfaces (such as bed rails and medical equipment).

The cleaning of hard surfaces in hospital rooms is critical for reducing health care–associated infections. The review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included.

Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Read more here:  http://annals.org/article.aspx?articleID=2424875

Airline poop studied to track global spread of AMR in bacterial pathogens

plane poopGlobally, infectious diseases are the cause of about 22% of all human deaths, according to a 2010 report, a number that seems likely to rise based on increasing population density, increasing use of antimicrobial agents, disruption of wildlife habitats, and an increase in global travel and trade this number seems likely to increase. Global spread of antimicrobial resistance in bacterial pathogens is another major threat against human health, yet we don’t know much about how these genes travel and spread worldwide.

In an effort to learn more about this, researchers at Technical University of Denmark studied the poop siphoned from airplane toilets from flights arriving from around the world. From the study’s abstract: Human populations worldwide are increasingly confronted with infectious diseases and antimicrobial resistance spreading faster and appearing more frequently. Knowledge regarding their occurrence and worldwide transmission is important to control outbreaks and prevent epidemics. Here, we performed shotgun sequencing of toilet waste from 18 international airplanes arriving in Copenhagen, Denmark, from nine cities in three world regions. An average of 18.6 Gb (14.8 to 25.7 Gb) of raw Illumina paired end sequence data was generated, cleaned, trimmed and mapped against reference sequence databases for bacteria and antimicrobial resistance genes. An average of 106,839 (0.06%) reads were assigned to resistance genes with genes encoding resistance to tetracycline, macrolide and beta-lactam resistance genes as the most abundant in all samples. We found significantly higher abundance and diversity of genes encoding antimicrobial resistance, including critical important resistance (e.g. blaCTX-M) carried on airplanes from South Asia compared to North America. Presence of Salmonella enterica and norovirus were also detected in higher amounts from South Asia, whereas Clostridium difficile was most abundant in samples from North America. Our study provides a first step toward a potential novel strategy for global surveillance enabling simultaneous detection of multiple human health threatening genetic elements, infectious agents and resistance genes.

Read more about the findings here: http://www.nature.com/articles/srep11444

Evolutionary dynamics of influenza A viruses in US exhibition swine

The role ofcover exhibition swine in influenza A virus (IAVs) transmission was recently demonstrated by over 300 human infections of H3N2v viruses while attending agricultural fairs, according to an August report published in The Journal of Infectious Diseases.

The abstract of the study says: Through active IAV surveillance in US exhibition swine and whole-genome sequencing of 380 isolates, we demonstrate that exhibition swine are actively involved in the evolution of IAVs, including zoonotic strains. First, frequent introduction of IAVs from commercial swine populations provides new genetic diversity in exhibition pigs each year locally. Second, genomic reassortment between viruses co-circulating in exhibition swine increases viral diversity. Third, viral migration between exhibition swine in neighboring states demonstrates that movements of exhibition pigs contributes to the spread of genetic diversity. The unexpected frequency of viral exchange between commercial and exhibition swine raises questions about the understudied interface between these populations. Overall, the complexity of viral evolution in exhibition swine indicates novel viruses are likely to continually re-emerge, presenting threats to humans.

Read the entire article here. http://jid.oxfordjournals.org/lookup/doi/10.1093/infdis/jiv400

Whole genome sequencing has capability to transform hospital practices

BacteriaPLOS logol whole genome sequencing is becoming increasingly common to microbiological research, but despite its great potential, has not yet been meaningfully integrated into clinical care. In an article in published in PLOS Genetics, a peer-reviewed, open-access journal, whole genome sequencing data from nearly all of the bacterial isolates prospectively collected from a hospital’s intensive care units over an entire year is examined and discussed. The analysis identifies novel microbiota in hospitalized patients, a high incidence of patient infection with multiple unrelated lineages of a bacterial species, and the possibility of cryptic transmission of bacteria among patients. The study is unprecedented in providing a broad and unbiased view of bacterial infections that affect the hospital’s sickest patients, and demonstrates the extent of information that can be learned from comprehensive genomic surveillance of clinical bacterial isolates over an extended period of time.

Authors say the most unanticipated results of the study are from molecular epidemiological analysis of bacterial clonal lineages, where they find data consistent with direct (0–3 SNV differences among isolates) and less direct (up to 40 SNV differences among isolates) bacterial transmissions involving multiple patients in these ICUs. The dynamics underlying bacterial colonization and transmission are surprisingly complex [34,39,40], and circumscribing transmission events according to specific thresholds of strain relatedness is certainly an oversimplification.

The article concludes that routine, unbiased, and large-scale sequencing of bacterial clinical isolates has the power to reveal unknown and unsuspected properties about bacterial infectious disease, and is becoming increasingly feasible with sustained advancements in massively parallel sequencing technologies. Comprehensive sequence information, derived from all bacterial isolates, has the capability to transform hospital practices not only within clinical microbiology laboratories but also by directly informing patient care in the form of infection control and treatment practices.

Read the article here. :  http://www.plosgenetics.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pgen.1005413&representation=PDF