SOURCES OF INFECTION IN LONG-TERM CARE FACILITY - ENVIRONMENTAL ISSUES

Transcription

1 SOURCES OF INFECTION IN LONG-TERM CARE FACILITY - ENVIRONMENTAL ISSUES Slides provided by: William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety at UNC Health Care; Research Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology at University of North Carolina School of Medicine at Chapel Hill, USA

2 OBJECTIVES Discuss Potential Sources of Infection Environmental Point of Care Testing (Blood Glucose Monitoring) Safe Injections

3 EPIDEMIOLOGY OF INFECTIONS IN EXTENDED CARE FACILITIES Relative contribution of the following unclear (limited studies) Endogenous flora Person-to-person transmission (direct and indirect) Other residents Staff-to-patients Visitors Role of the contaminated environment

4 ENVIRONMENTAL SAMPLING The only routine microbiologic sampling recommended as part of quality assurance program is: Biological monitoring of sterilization process by using bacterial spores (e.g., steam sterilizers should be monitored at least once per week with commercial preparation of Bs spores) Monthly cultures of water used in hemodialysis applications (e.g., water <200mo/ml, and dialysate at the end of dialysis <2,000mo/ml)

5 ENVIRONMENTAL SAMPLING Situations Quality assurance such as assuring that equipment or systems have performed to specifications Support of an investigation of an outbreak of disease or infections if environmental reservoir is implicated Research purposes using a well-designed and controlled experimental method Monitor a potentially hazardous environmental condition

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8 BLOOD PRESSURE CUFF NON-CRITICAL PATIENT CARE ITEM

9 SURFACE DISINFECTION NONCRITICAL PATIENT CARE RUTALA, WEBER. Disinfecting Noncritical Patient-Care Items Process noncritical patient-care equipment with a EPA-registered disinfectant at the proper use dilution and a contact time of at least 1 min. Category IB Ensure that the frequency for disinfecting noncritical patient-care surfaces be done minimally when visibly soiled and on a regular basis (such as after each patient use or once daily or once weekly). Category IB

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11 SURFACE DISINFECTION ENVIRONMENTAL SURFACES RUTALA, WEBER. Disinfecting Environmental Surfaces in HCF Disinfect (or clean) housekeeping surfaces (e.g., floors, tabletops) on a regular basis (e.g., daily, three times per week), when spills occur, and when these surfaces are visibly soiled. Category IB Use disinfectant for housekeeping purposes where: uncertainty exists as to the nature of the soil on the surfaces (blood vs dirt); or where uncertainty exists regarding the presence of multi-drug resistant organisms on such surfaces. Category II

12 12 ENVIRONMENTAL CLEANING AND DISINFECTION Environmental cleaning/disinfection: Routine cleaning and disinfection of high-touch surfaces in common areas, resident rooms, and at the time of discharge; and NOTE: Privacy curtains in the resident s room should be changed when visibly dirty by laundering or cleaning with an Environmental Protection Agency (EPA)-registered disinfectant per manufacturer s instructions. Cleaning/disinfection of resident care equipment including equipment shared among residents (e.g., blood pressure cuffs, rehabilitation therapy equipment, blood glucose meters, etc.).

13 LINEN Soiled linens can be a source of large amounts of microbial contamination, although the risk of disease transmission appears to be negligible. Personnel must handle, store, process and transport linens so as to prevent the spread of infection Handle as little as possible Bag at location used Wet linen transported in bags to prevent leakage

14 LINEN Clean linen should be covered during transport and storage All soiled linen should be transported in well covered and clearly identified carts used exclusively for linen. Linen should be washed with a detergent in water hotter than 160 o F for 25 minutes or if low-temperature laundry cycles are used, the wash formula must be controlled especially the amount of bleach (follow manufacturer s IFUs) All soiled linen will be treated as potentially infectious. There is no recommendation to treat linen from isolation rooms differently (special bags, special laundry procedures)

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17 NUTRITION AND FOOD SERVICES Why? Job of providing food for residents that is wholesome, appetizing, economical and safe to eat. What? General principles of protection, equipment, storage, preparation, service. How? Rounding

18 NUTRITION AND FOOD SERVICES STAFF Exclude employees with communicable diseases (skin, respiratory, gastrointestinal) from contact with food products or utensils in accordance with the occupational health policy Routine culturing of food service personnel for enteric pathogens has not been shown to be cost-effective Wash hands after: using toilet, handling raw food, contact with unclean equipment and work surfaces, soiled clothing; wash rags and touching the mouth, nose, ears, eyes and hair.

19 INJECTION SAFETY BEST PRACTICES

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21 UNSAFE INJECTION PRACTICES HAVE DEVASTATING CONSEQUENCES

22 UNSAFE INJECTION-RELATED OUTBREAKS SINCE recognized outbreaks Viral hepatitis (n=21) or bacterial infections (n=27) 90% (n=43) occurred in outpatient settings 10 in pain management clinics 9 in outpatient oncology clinics >150,000 patients potentially exposed *CDC Grand Rounds 11/14/12 & Guh et al, Medical Care 2012

23 HBV OUTBREAKS RELATED TO BLOOD GLUCOSE MONITORING, recognized outbreaks due to the assisted monitoring of blood glucose (AMBG) ~2,000 notifications >170 incident infections Accounted for 92% of all HBV outbreaks in LTC facilities *Thompson et al, Annals Int Med 2009;

24 OUTBREAK CAUSES 1. Syringe reuse (direct and indirect) 2. Misuse of single-dose/single-use vials 3. Failure to use aseptic technique 4. Unsafe diabetes care

25 1. SYRINGE REUSE Direct Reuse Insulin pens, IV tubing, vaccines Indirect Reuse or double dipping Common cause of large hepatitis outbreaks Syringe that had been used to inject medication into a patient and reused to enter a medication vial Contents of the vial are then used for subsequent patients

26 ENDOSCOPY CENTER, NEVADA (2008) 9 clinic-associated HCV cases 106 possible clinic-associated cases 63,000 potential exposures $16 21 million total cost

27 THE NEVADA OUTBREAK: MECHANISM Two breaches contributed to transmission: Re-entering propofol vials with used syringes Using contents from these single-dose vials on more than one patient MMWR (19);

28 DANGEROUS MISPERCEPTIONS 1. Changing the needle makes a syringe safe for reuse. 2. Syringes can be reused as long as an injection is administered through an intervening length of IV tubing. 3. If you don't see blood in the IV tubing or syringe, it means that those supplies are safe for reuse. Once they are used, both the needle and syringe are contaminated and must be discarded!

29 Best Practices Needles & Syringes Needles and syringes are single use devices A new sterile needle and syringe should be used for each injection Needles and syringes should never be used for more than one patient or reused to draw up additional medication (even for the same patient)

30 2. MISUSE OF SINGLE-DOSE/SINGLE-USE VIALS CDC is aware of at least 19 outbreaks involving SDV use 7 outbreaks involved BBPs 12 involved bacterial infections (majority of patients requiring hospitalization) All outbreaks occurred in outpatient settings Almost half in pain remediation clinics (n=8)

31 INVASIVE S. AUREUS INFECTIONS ASSOCIATED WITH PAIN INJECTIONS AND REUSE OF SDVS ARIZONA AND DELAWARE, 2012 Clinic Type Suspected Breaches Outcomes Pain Clinic (AZ) Prepared morning and afternoon contrast solution from SDVs at start of day for multiple patients Failed to wear facemasks during spinal injections 3 MRSA infections among patients receiving afternoon solution All patients hospitalized, ranging from 4-41 days 1 additional patient found deceased in home; invasive MRSA could not be ruled out Orthopedic Clinic (DE) SDV accessed over the course of several hours for multiple patients until all contents were withdrawn 7 methicillin-susceptible S. aureus infections All patients required debridement of infected sites and antimicrobial therapy Average length of hospitalization was 6 days Invasive Staphylococcus aureus Infections Associated with Pain Injections and Reuse of Single-Dose Vials, Arizona and Delaware, 2012; Morbidity & Mortality Weekly Report. 2012;61(27):

32 SINGLE DOSE VIALS: CDC POSITION STATEMENT, 2012 Vials labeled by the manufacturer as single dose or single use should only be used for a single patient. Ongoing outbreaks provide ample evidence that inappropriate use of single-dose/single-use vials causes patient harm. Leftover parenteral medications should never be pooled for later administration In times of critical need, contents from unopened SDVs can be repackaged for multiple patients in accordance with standards in United States Pharmacopeia General Chapter 797

33 BEST PRACTICE SDVS Single-dose/single-use vials should only be used for a single patient and a single procedure.

34 FAILURE TO USE ASEPTIC TECHNIQUE Handling and preparing supplies used for injections in a manner that prevents microbial contamination between the injection materials and the nonsterile environment American Journal of Infection Prevention, 2011

35 Manufacturing BEST PRACTICES ASEPTIC TECHNIQUE Out of your hands? Maybe. Maybe not. Storage Medications should be discarded upon expiration or any time there are concerns regarding sterility Preparation Medications should be drawn up in a designated clean medication preparation area Any item that could have come in contact with blood or body fluids should be kept separate

36 36 MEDICAL DEVICE SAFETY MEDICAL DEVICES MAY BE USED FOR ADMINISTRATION OF MEDICATIONS, POINT-OF-CARE TESTING, OR FOR OTHER MEDICAL USES. Point-of-Care Testing Point-of-care testing is diagnostic testing that is performed at or near the site of resident care. This may be accomplished through use of portable, handheld instruments such as blood glucose meters or prothrombin time meters. This testing may involve obtaining a blood specimen from the resident using a fingerstick device.

37 Sharing of blood glucose meters without cleaning and disinfection between uses 4. UNSAFE DIABETES CARE Use of fingerstick devices or insulin pens on multiple persons Patel et al. ICHE 2009; 30:209-14, Thompson et al. JAGS 2010, MMWR 2005; 54: Failure to perform hand hygiene or change gloves between procedures

38 38 FINGERSTICK DEVICES CDC recommends the use of single-use, auto-disabling fingerstick devices in settings where assisted blood glucose monitoring is performed. This practice prevents inadvertent reuse of fingerstick devices for more than one person. Additionally, the use of single-use, auto-disabling fingerstick devices protects healthcare staff from needlestick injuries. If reusable fingerstick devices are used for assisted monitoring of blood glucose, then they must never be used for more than one resident.

39 39 BLOOD GLUCOSE METERS Blood glucose meters, can become contaminated with blood and, if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer s instructions for multi-patient use. Additionally, staff must not carry blood glucose meters in pockets. The FDA has released guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

40 BLOOD GLUCOSE METERS Blood glucose meters dedicated for single-patient use should, ideally, be stored in the patient s room in a manner that will protect against inadvertent use for additional patients and cross-contamination via contact with other meters or equipment. If meters are dedicated for single-patient use and facilities have taken steps to assure that they are stored in a location to prevent inadvertent use for the wrong patient and/or cross-contamination, then meters should be cleaned and disinfected according to manufacturer s instructions and, at a minimum, anytime they are being reassigned to a different patient.

41 INSULIN PENS Insulin Pens containing multiple doses of insulin are meant for single-resident use only, and must never be used for more than one person, even when the needle is changed Insulin pens must be clearly labeled with the resident s name or other identifiers to verify that the correct pen is used on the correct resident Facilities should review their policies and procedures and educate their staff regarding safe use of insulin pens State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities

42 MOST OUTBREAKS ARE NEVER DETECTED Asymptomatic infection Under-reporting of cases Under-recognition of healthcare as risk Long incubation period; difficult to identify single healthcare exposure Barriers to investigation, resource constraints

43 GROWING RESERVOIR Aging population more frequent interactions with the healthcare system growing reservoir of infected individuals who can serve as a source of transmission to others if safe injection practices and other basic infection control precautions are not followed Perz et al, Hepatology Accepted Article, doi: /hep.25688

44 2010 SURVEY OF PROVIDER PRACTICES 5,500 healthcare professionals 1% sometimes or always reuse a syringe on a second patient (direct) 1% sometimes or always reuse a multidose vial after accessing it with a reused syringe (indirect) 6% use single-dose/single use vials for more than one patient Pugliese et al AJIC. Available at: or

45 BASIC PATIENT SAFETY Safe injection practices are basic but they are not optional Dr. Michael Bell, CDC Healthcare should not provide any avenue for transmission of bloodborne pathogens or microorganisms Entirely preventable through Standard Precautions / safe injection practices

46 BEYOND GOOD PRACTICE Designate someone to provide ongoing oversight Develop written infection control policies Provide training Conduct quality assurance assessments

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48 ONE & ONLY CAMPAIGN GOAL Ensure patients are protected each and every time they receive a medical injection Increase understanding and implementation of safe injection practices among healthcare providers Empowering patients

49 CAMPAIGN RESOURCES Print Materials Audio & Visual Social Media Toolkits

50 PRINT MATERIALS

51 THANK YOU!