New Technologies for the Built Environment The role of evidence. Declarations 21/06/2018. infection prevention and control

Transcription

1 New Technologies for the Built Environment The role of evidence Matthew P. Muller, MD, PhD, FRCPC Medical Director, Infection Prevention and Control, St. Michael s Hospital Chair, Ontario Provincial Infectious Diseases Committee on Infection Control Declarations I chair the Ontario PIDAC committee on infection prevention and control The application of scientific knowledge for practical purposes Machinery and equipment developed from the application of scientific knowledge 1

2 What makes it new technology? Revolutionary Technology Technology that has never been used before and will replace current processes Large potential upsides but significant risks Ancillary Technology that has never been used before and will support or augment current processes Large potential upsides with less risk Old Technology Known to work and not new although not in place at all facilities Examples Single rooms, appropriate spacing in waiting areas Correct number of sinks Correct number of airborne isolation rooms HVAC meeting air exchange standards Don t need new evidence to adopt old (but effective) technology Some Examples of New Technology for the Built Environment Smart Glass (or wipeable screen) instead of privacy curtains Automatic temperature controls in OR to maintain normothermia Lights in OR that use narrow spectrum indigo light to disinfect surfaces and air Copper surfaces and copper drains Antimicrobial spray on surfaces 2

3 Evidence what is it? Data collected from scientific studies to answer the following question(s): Does it work or not? How well does it work? Does it work better than something else? Not all evidence is helpful bad (incorrect, biased) evidence is worse than no evidence Evidence Hierarchy Evidence Heterarchy Different types of study data that work together to create a body of evidence The body of evidence is strongest when There are many different lines of evidence Within each line there are multiple studies Results are consistent across study designs, lines of evidence, variations in setting, etc. 3

4 No hand hygiene RCT in healthcare but Proof of principle studies crct data from non healthcare settings (indirect evidence) Observational and quasi experimental studies Data is consistent within and across lines of evidence Level of Evidence Required Revolutionary technology Example spray antimicrobial coating onto surfaces and then housekeepers can clean but don t need to disinfect More likely to fail or have adverse consequences and costs Should have strong evidence of efficacy (and safety) before widespread adoption Ancillary technology Example Smart glass to replace cloth privacy curtain Still new but similar or supportive of old approach Less likely to be harmful Can get by with a pilot study 4

5 The Role of the Environment Surfaces in patient rooms are contaminated with bacteria including ARO ARO can survive for prolonged periods on surfaces Hands and gloves get contaminated when care is provided even when patient not touched Intervention studies (mostly low quality ) aimed at improving environmental cleaning reduce transmission Enhanced environmental cleaning is often used in successful outbreak control efforts Risk of ARO higher if prior room occupant had ARO The weight of the evidence Multiple lines of evidence linking environment and pathogen transmission Each line of evidence includes good studies that are low quality based on the evidence hierarchy This weight of evidence leads to Higher confidence that the environment is important Increased likelihood that effective interventions targeting the environment could reduce infection rates Increased focus on interventions targeting the environment But we still don t know exactly what will work! Evidence to Action EVIDENCE ACTION OTHER CONSIDERATIONS Importance of the Problem Urgency of the Problem Adverse Effects Unintended Consequences Cost Cost effectiveness Alternative Solutions 5

6 Copper Surfaces Environmental contamination infection transmission Copper has continuous antimicrobial effects Copper surfaces in healthcare settings harbor fewer bacteria than non copper comparators Is this enough evidence to act? It depends Copper Surfaces Do copper surfaces really prevent infection? (i.e. not just reduce bacterial burden) and if so which surfaces specifically? Are copper surfaces / items functional? Are copper surfaces cost effective? Is there any risk of harm or unintended consequences? PIDAC Recommendation 2012 Surfaces treated with antimicrobial substances are not recommended. [CIII] 6

7 Antimicrobial Surfaces to Prevent Healthcare Associated Infection: a systematic review. Muller MP et al. JHI 2016 Most studies evaluated copper Copper results in 0 to 1 log reduction in bacterial load Is this good enough? What are we comparing to? Is this the correct metric? Only two studies of copper surfaces used infection as an outcome but this is the evidence we need Copper Surfaces concerns Only two studies looked at clinical outcomes One looked at 6 copper items in ICU (Salgado et al.) One looked at copper linens in LTCF (Lazary et al.) One was very low quality (quasi experimental) and the other was low quality (controlled trial but not properly randomized) Role of industry / Risk of publication bias I would like to see an independently conducted cluster RCT confirm these findings 7

8 Antimicrobial surfaces have huge potential! The environment is important Continuous action not dependent on human error Lets use copper! As long as it is functional As long as the price is similar Maybe copper doesn t really work (direction of effect) Maybe it works but not that well (magnitude of effect) Is the problem lack of trained cleaning staff or supervisors? Unanswered questions Which surfaces? Is there something better? PIDAC Recommendation 2018 There is insufficient evidence to recommend for or against the installation of copper surfaces either to prevent health care associated infections or to reduce the transmission of antibiotic resistant organisms (low quality evidence; no recommendation Conclusions New technology should be supported by evidence Does it work? How well? Is it better than the old technology? The level of evidence required will vary Evidence alone is not enough but if we don t demand evidence we won t get it 8