Disclaimer Jim is employed by Diversey. His expenses to attend this - - PDF document

2019-11-19 1

Bending The Rules Without Breaking the Principles

Jim Gauthier, MLT, CIC Senior Clinical Advisor, Infection Prevention ∗ Jim is employed by Diversey. His expenses to attend this meeting (travel, accommodation, and salary) are paid by this company. Diversey has had no input into this presentation from a commercial interest.

Disclaimer

∗ Talk about what we do for a living ∗ Discuss Standards, Guidelines, Best Practices! ∗ Some ‘sort of real’ stories (the names have been changed…)

Objectives

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∗ Who are we? ∗ Nurses ∗ MLT ∗ Public Health

Infection Prevention and Control

* Epidemiologists * ID Physicians * Microbiologists ∗ < 2 years? ∗ 2 – 5 years? ∗ 5-10 years? ∗ OMG!?!

Who is Here Today?

∗ Ain’t the money, Honey ∗ Keen, inquiring minds? ∗ Save lives? ∗ Fixation on feces, or other filth? ∗ Love auditing performance? ∗ Always wanted to be the ‘hygiene police”?

Why Do We Do What We Do?

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Infection Control

Art Or Science

?

∗ Science becomes art when you exceed the boundaries of set rules or explicit instructions and run

• n instinct

∗ Anyone can follow a set of rules, it takes an artist to make that object or action artful and graceful

Art vs. Science

http://www.bordeglobal.com/foruminv/index.php?showtopic=18935

∗ Going for a walk ∗ Checking e mails before going home ∗ Not saying anything and letting them work it out

Gut Instinct

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Breaking the Rules

∗ A piece of the delegated legislation drafted by subject matter experts to enforce a statutory instrument (primary legislation)

∗ A rule that we must follow

∗ Rules that the government make under an Act ∗ Both Provincial, State and Federal Acts

Definition – Regulation

https://en.wikipedia.org/wiki/Regulation

∗ The codification of the general and permanent rules and regulations (administrative law) published in the Federal Register by the executive departments and agencies of the federal government of the United States ∗ Divided into 50 titles

Code of Federal Regulations (CFR)

https://en.wikipedia.org/wiki/Code_of_Federal_Regulations

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∗ Federal agencies are authorized by "enabling legislation" to promulgate regulations (rulemaking). ∗ In administrative law, rule-making is the process that executive and independent agencies use to create, or promulgate, regulations. ∗ It is the LAW!

Rule Making

∗ Document that provides requirements, specifications, guidelines or characteristics that can be used consistently to ensure that materials, products, processes and services are fit for their purpose

Definition - Standard

http://www.iso.org/iso/home/standards.htm

∗ A collection of actions gleaned from previous mistakes!

Definition - Standard

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∗ Typically refer to how to do a job ∗ Not written by government ∗ Have no authority on their own, but may be adopted into regulations making them legal requirements

∗ Canadian Standards Association

Standard

www.3m.com/intl/ca/english/centres/safety/personal_safety/standards.html

∗ Word of obligation ∗ Only word that imposes a legal obligation that something is mandatory

‘Must’

www.faa.gov/about/initiatives/plain_language/articles/mandatory/

∗ Is used to express a requirement, i.e. a provision that the user is obliged to satisfy in order to comply with the standard ∗ Most litigated word in English language ∗ Can mean ‘May’

https://www.faa.gov/about/initiatives/plain_language/articles/mandatory/

‘Shall’

Canadian Standards Association Standard Z314.15-10

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∗ Is used to express a recommendation or that which is advised but not required

‘Should’

∗ Is used to express an option or that which is permissible within the limits of the standard

‘May’

∗ Is used to express possibility or capability

‘Can’

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∗ Any document that aims to streamline particular processes according to a set routine ∗ By definition, following a guideline is never mandatory (protocol would be a better term for a mandatory procedure).

Guideline

http://guidelines.askdefine.com/

∗ Are generally-accepted, informally-standardized techniques, methods, or processes that have proven themselves over time to accomplish given tasks.

Best Practice

Http://en.wikipedia.org/wiki/best_practice

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∗ The best practices in this document reflect the best evidence and expert opinion available at the time of

• writing. As new information becomes available, this

document will be reviewed and updated.

PIDAC* Best Practice Disclaimer

*PIDAC: Provincial Infectious Disease Advisory Committee (Ontario Canada)

∗ PIDAC-IPC’s work is guided by the best available evidence and updated as required. Best Practice documents and tools produced by PIDAC-IPC reflect consensus positions on what the committee deems prudent practice and are made available as a resource to public health and health care providers.

PIDAC Best Practice 2012

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∗ Best Practice documents and tools produced by PIDAC-IPC reflect consensus positions on what the committee deems prudent practice and are made available as a resource to public health and health care providers. ∗ PHO assumes no responsibility for the results of the use of this document by anyone.

PIDAC Best Practice 2014

∗ The application and use of this document is the responsibility of the user. PHO assumes no liability resulting from any such application or use.

PIDAC Best Practice 2018 Legally…

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∗ Performance based

∗ “an employer shall take every reasonable precaution to protect…”

∗ Much of Infection Prevention is basis of reasonable precautions ∗ Common sense NOT a defense

∗ Needs to be elevated in healthcare

∗ PPE – needs to be available

Ministry of Labour – Ontario

∗ What is our cornerstone?

Guiding Principle – Infections

http://diseasedetectives.wikia.com/wiki/Chain_of_Transmission

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∗ Are all the links there?

• Need all six!

Questions

∗ Would it be easy to break one link, or more?

• Hand Hygiene
• PPE
• Cleaning and Disinfection

Questions?

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∗ Etiologic Agent ∗ Asymptomatic ∗ Symptomatic

Examples – Outbreaks

* Incubation Period * Prodromal Period ∗ To themselves ∗ To others on the wards ∗ To other wards (off the ward)

Risks

∗ Outbreak at Long Term Care facility

∗ Traditionally limit the movement of patients/residents and staff ∗ Exposed, asymptomatic ∗ 60th wedding anniversary ∗ Tommy Hunter in town!

Norovirus

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∗ To themselves

∗ Pick up community Norovirus ∗ Hand hygiene reminders!

∗ To others

∗ Become symptomatic in community with Norovirus

Risks

∗ Isolation and Mood Issues

∗ Norovirus-ish symptoms on open ward ∗ Possibly environmental odor sensitivities ∗ Patients very aware of their grouping for getting off ward ∗ Borderline Code White

Behavioral Health Considerations

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∗ Norovirus outbreak

∗ Second Incubation period ∗ St. Patrick’s Day!

Long Term Care

1 2 3 4 5 6 1 2 3 4 5 6 07-Mar-19 08-Mar-19 09-Mar-19 10-Mar-19 11-Mar-19 12-Mar-19 13-Mar-19 14-Mar-19 15-Mar-19 16-Mar-19 17-Mar-19 18-Mar-19 19-Mar-19 20-Mar-19 21-Mar-19 22-Mar-19 23-Mar-19

Right?

∗ Continent, Compliant ∗ Other patients/staff ∗ Future discharge issues ∗ Good papers on the necessity of Contact Precautions

Risks - MRSA

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Let’s Bend Some Rules!

A New Study with Improved Hydrogen peroxide (IHP)

John M. Boyce, MD

AJIC 2017;45:1006-10

* 12-month prospective trial with cross-over design conducted on two campuses of a university-affiliated hospital * The 4 study wards included

* An MICU and its step-down unit on one campus * Two general medical wards on the other campus

Study Design

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∗ On each campus, 2 wards were randomized to have EVS perform routine daily cleaning/disinfection of surfaces

* Quat disinfectant, applied using meltblown polypropylene and bleach for CDI rooms * IHP disinfectant wipes containing 0.5% IHP ONLY * NO BLEACH IN C. DIFFICILE ROOMS!!

∗ After the initial 6 months, ward assignments were changed

Study Design Results

23% fewer cases/1000 Pt-days on IHP wards

)

Healthcare Outcome IHP Wards (10,741 Pt. Days) Quat Wards (11,490 Pt. Days) Cases (Rate per 1000 pt. days) Cases (Rate per 1000 pt. days)

VRE Acquisitions + BSIs

59 (5.49) 75 (6.52)

MRSA acquisitions + BSIs

21 (1.95) 32 (2.78)

• C. difficile infection

6 (0.56) 12 (1.04)

Composite Outcome

86 (8.0) 119 (10.4)

∗ Hand hygiene compliance rates comparable on study wards ∗ Antibiotic usage: Non-C. difficile agent use was 10.8% higher on IHP wards which would be expected to lead to more VRE, MRSA and CDI outcomes, not fewer as

• bserved

Confounders

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∗ Our Rule ∗ Our Principle ∗ Our guiding light ∗ Do we need to remind people?

Routine Practices

This patient has:

∗ Skin! ∗ Feces! ∗ Mucous Membranes!

PERFORM HAND HYGIENE AFTER CONTACT WITH THIS PATIENT OR THEIR ENVIRONMENT!

WARNING!!

Hi Healthcare Person I have Skin, Feces and Mucous Membranes! Please sanitize your hands after contact with me or my surroundings

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∗ Principles

∗ Sound or not? ∗ Heightened awareness when we KNOW! ∗ Medical student comment: ∗ If I do Routine Practices the way you indicate, why do we need Contact Precautions?

Contact Precautions

∗ WE JUST FOUND OUT THAT THIS PATIENT HAS A BUG THAT COULD BE CARRIED TO THE NEXT PATIENT. ∗ NOW WE REALLY MEAN YOU HAVE TO PERFORM HAND HYGIENE AND TRY NOT TO SOIL YOUR UNIFORM! ∗ WE ARE NOT SURE ABOUT THE GUY NEXT DOOR, YET, SO DO WHATEVER YOU WANT!

CONTACT PRECAUTIONS

Horizontal vs Vertical Infection Control

Wenzel 2010

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∗ The degree of attention to precautions is directly proportional to the mystique or fear of the organism ∗ MRSA * SARS ∗ Pandemic H1N1 * CPE ∗ MERS-CoV * Ebola

Jim’s Theorem of Isolation

test

SARS Ebola

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∗ The mystique of the organism is inversely proportional to the amount of information staff retain about Routine Practices!

Jim’s Addendum

∗ If they are leaking, protect yourself and limit their movement ∗ It if is dirty or you used it, clean it! ∗ 20 Words!

In a Nut Shell

∗ Vomit ∗ Diarrhea ∗ Uncontrolled nasal secretions ∗ Wound drainage with frequent dressing changes required

Leaking

(Wet, icky, sticky, not yours!)

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∗ Isolation or Transmission Based Precautions ∗ Contact ∗ Droplet

Limit Their Movement

∗ In my opinion, really the only precaution we need ∗ N95 Respirator/PAPR

∗ Science here is also a bit sketchy!

∗ Airborne Infection Isolation Room (AIIR)

Airborne

∗ Gloves

* Blood * Body Fluids * Excretions * Secretions * Equipment that is soiled by above

Protect Yourself

Exposure or Potential Exposure

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∗ Face Protection ∗ Mask, Mask with attached eye shield, Visor

* Risk of splash or spray * Irrigation * Cough * Trach care

Protect Yourself

∗ Gowns

* Risk of splash or spray * Bathing patients * Anything to do with feces

Protect Yourself

∗ Hands ∗ Equipment

∗ Vital tower ∗ Bladder Scanner

If it is Dirty or You Used It

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∗ Point of Care Disinfection

* Readily available * To all staff * 0/0/0 HMIS rating

Clean It!

RULE: C. difficile and Sporicidal Agents

∗ ER/Urgent Care bathrooms ∗ Rooms of patients on Contact Precautions for CD ∗ Twice daily bathrooms of patients with CDI ∗ Twice daily ‘cleaning’ of patients room, disinfectant OR sporicide ∗ Commode chair for CDI patient – Consider!

PIDAC Environmental Cleaning- Sporicide

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∗ “Perform daily cleaning using a C. difficile sporicidal agent” ∗ https://www.cdc.gov/cdiff/clinicians/cdi-prevention- strategies.html#c ∗ References cited do not state this!

73

CDC May 2019 Update

∗ SHEA/IDSA 2014 ∗ “…beneficial effect has been reported when bleach has been used in outbreak or hyperendemic settings, typically in conjunction with other enhanced CDI control measures”

RULE: C. difficile and Sporicidal Agents

Dubberke 2014

∗ SHEA/IDSA Treatment Guidelines 2017:

∗ XX. 1. Terminal room cleaning with a sporicidal agent should be considered, in conjunction with other measures, to prevent CDI during endemic high rates or

• utbreaks, or if there is evidence of repeated cases of

CDI in the same room (weak recommendation, low quality of evidence).

• C. difficile and Sporicidal Agents

McDonald 2018

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∗ Weber 2013

∗ “Most studies that evaluated the level of microbial contamination

• f the environment reported that surfaces were contaminated

with <1- to 2-log10 C. difficile. However, some studies have reported somewhat higher levels of contamination. Two studies reported >2-log10 C difficile on surfaces; one reported “1> to >200” colonies, and a second study that sampled several sites with a sponge found up to 1,300 colonies.” ∗ 3.1 log!

Bend the Rule: What is There?

∗ Efficacy of different cleaning and disinfection methods against Clostridium difficile spores: importance of physical removal versus sporicidal inactivation ∗ Tested the removal of C. difficile spores from environmental surfaces using various cleaners, disinfectants and wipes. Wipes with a non-sporicidal agent showed 2.9 log10 reductions of C. difficile spores. Wiping with a sporicidal agent increased the removal efficacy by 1 log10 (3.9 log10).

Elbow grease does the job

Rutala 2012

∗ Results: Any method that included wiping the surface (physical removal) resulted in a 3 log10 reduction in C. difficile spores, even if the cleaner or disinfectant was not a sporicidal agent.

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∗ Alfa et al wanted to get rid of sodium hypochlorite ∗ Tested 0.5% IHP and found it to have a 2 – 3 log kill of

• C. difficile spores

∗ Not sporicidal! (5-6 log)

Is it Possible to Kill Some Spores?

∗ Feces clean up: standardize for all feces

∗ Wipe up visible feces a couple of times (paper towels) ∗ Wipe area with a disinfectant/sporicidal wipe ∗ Use 2 if first wipe appears soiled (clean) ∗ allow contact time

What About Colonized Patients?

∗ Once per day

∗ Why? ∗ CDC 2003, 2008 PIDAC 2018

∗ Hand hygiene (if you used them, clean them)

∗ 4 Moments

Rule: Daily Disinfection

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∗ How much care happens in a room?

∗ On average, ~83 people enter a room per day ∗ On average, in Med/Surg side rail touched >250 times per day (Cohen 2012, Huslage 2010, Jinadatha 2017)

∗ Should we clean/disinfect more than 1x/d?

Bend The Rule

Targeted Moments of Environmental Disinfection

1. Before placing food or drink on an over-bed table 2. After any procedure involving feces or respiratory secretions within the bed space 3. Before/after any aseptic practice (care to wounds, lines, etc.) 4. After patient/resident bathing (within bed space) 5. After any object used on/by a patient/resident touches the floor

∗ A full recording of Protecting Patients Beyond Once per Day, with the science behind the points, is available at:

∗ http://www.diverseydigital.com/natools/videoHub/276229450.php

∗ An updated re-mix:

∗ https://event.on24.com/eventRegistration/EventLobbyServlet?target=r eg20.jsp&referrer=&eventid=1957251&sessionid=1&key=B44F5E9B939 0F495A5269A2938E25948&regTag=&sourcepage=register

Shameless Self-Promotion

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∗ What do you think? Art or science? ∗ Our Guidelines and Best Practices set a standard ∗ Case by case is always necessary, in some cases! ∗ Keep the Chain of Transmission in your mind’s eye ∗ Get people to understand simple Routine Practices

Summary

∗ Think ‘Horizontal’ ∗ I think it is okay to bend…without breaking the previous thoughts!

Summary

∗ Alfa et al. Improved eradication of Clostridium difficile spores from toilets of hospitalized patients using an accelerated hydrogen peroxide as the cleaning agent. BMC Infectious Diseases 2010, 10:268 http://www.biomedcentral.com/1471-2334/10/268 ∗ Boyce JM, et al. Prospective cluster controlled crossover trial to compare the impact of an improved hydrogen peroxide disinfectant and a quaternary ammonium-based disinfectant

• n surface contamination and health care outcomes. Am J Infect Control 2017;45:1006-10

∗ Cohen B, et al. Frequency of patient contact with health care personnel and visitors: implications for infection prevention. Jt Comm J Qual Patient Safety 2012;38(12):560-5

References

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∗ Dubberke ER, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. ICHE 2014;35(6):628-45. DOI: 10.1086/676023 ∗ Hulsage K, et al. A quantitative approach to defining “high-touch” surfaces in hospitals. ICHE 2010;31(8):850-3 DOI:10.1086/655016 . ∗ Jinadatha C, et al. Interaction of healthcare worker hands and portable medical equipment: a sequence analysis to show potential transmission opportunities. BMC Infect Dis 2017;17:800 DOI 10.1186/s12879-017-2895-6

References

∗ McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66:e1-e48. DOI: 10.1093/cid/cix1085 ∗ Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best practices for environmental cleaning for prevention and control of infections in all health care

• settings. 3rd ed. Toronto, ON: Queen’s Printer for Ontario; 2018.

∗ Wenzel RP et al. Infection control: the case for horizontal rather than vertical interventional programs. Int J Infect Dis 2010;14S4:S3-S5

References Questions?

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∗ www.sdfhc.com/CE

∗ Introduction to Microbiology ∗ Breaking the Chain of Infection ∗ The Dirty Dozen – Key Pathogens ∗ What can go Wrong with Cleaning and Disinfection ∗ Are You Addressing the Risk? ∗ Using a Sporicidal Agent Everywhere is NOT the Solution to CDI ∗ Collaborate to Eradicate ∗ Targeted Moments of Environmental Disinfection

Additional Resources/CEU

∗ james.gauthier@diversey.com ∗ julie.larose@diversey.com ∗ http://www.diverseydigital.com/natools/videoHub/index.php

Additional Resources