Fomites: a Vector

for Infection
Transmission
March 20, 2012
SUSAN MANGICARO
 Acknowledgement

Employed by Welch Allyn

Board Member of Crouse Irving Memorial Hospital

Foundation, Syracuse, NY
Agenda

Introduction
HAI stats & NYS data
Review role surfaces play in nosocomial infections
Use of evidence based clinical policy to improve compliance
Solutions
Q&A
 HAIs
According to the Centers for Disease Control and
Prevention (CDC), there were an estimated 1.7
million healthcare-associated infections and 99,000
deaths from those infections in 2002

1.7 million infections in hospitals

Most (1.3 million) were outside of ICUs
9.3 infections per 1,000 patient-days
4.5 per 100 admissions

Klevens RM, Edwards JR, Richards CL, Horan TC., Gaynes RP, Pollack DA, Cardo DM. Estimating Health Care-Associated Infections and
Deaths in U.S Hospitals, 2002. Public Health Reports 2007: 122:160-166
Cost
A recent CDC report estimated the annual
medical costs of healthcare-associated
infections to U.S. hospitals to be between $28
and $45 billion, adjusted to 2007 dollars1

Increase ICU days by 8 days2

Increase average hospital stay 7.4 9.4 days3

1
Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009. (accessed
April 7, 2009) URL: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
2
Brachman PS, Dan BB, Haley RW, Hooten TM, Garner JS, Allen JR. Nosocomial surgical infections: incidence and cost. Surg Clin North Am
1980; 60: 15-25.
3
Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003 Oct;
290(14): 1868-1874.
 NYS
In July, 2005, the Legislature passed and the
Governor signed Public Health Law 2819 requiring
hospitals to report select hospital-acquired
infections (HAIs) to the New York State
Department of Health

Using the 2007 CPI for inpatient services,

reduction of HAIs since 2008 has resulted in an
estimated cost savings of between $7.9 million to
$23.1 million for SSIs and $7.3 million to $29.4
million for CLABSIs in NYS.

http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs/hospital_acquired_infection.pdf
 NYS DOH HAI Reporting Program Next Steps
The NYSDOH will work to improve HAI reporting and infection prevention
efforts including taking the following actions:

Continue to focus on hospitals with the highest and lowest infection rates to
identify risk factors for infection and opportunities for improvement.

Integrate the hospital-specific infection rates into the NYSDOHs

hospital profile web site, in a manner that is easy to understand.

Continue to monitor the accuracy and timeliness of data being submitted,

discuss findings, ensure corrective action is taken, and provide technical
assistance as needed.

Conduct onsite audits to evaluate surveillance methods, verify appropriate

use of surveillance definitions, and assess completeness and accuracy of
reporting.
http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs/hospital_acquired_infection.pdf
 NYS DOH HAI Reporting Program Next Steps
Continue to provide education, training, and ongoing support to hospital
infection reporting staff.

Continue to provide hospitals with information about risk factors, strategies and
interventions and to encourage adoption of policies and procedures to reduce
risk and enhance patient safety.

Evaluate and monitor the effect of prevention practices on infection rates

and seek opportunities to enhance patient safety.

Evaluate the relationship between infection prevention personnel

resources and surveillance activities, infection rates, and prevention
projects.

Collaborate with other NYSDOH staff to investigate outbreaks and evaluate

emerging trends.
http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs/hospital_acquired_infection.pdf
 NYS DOH HAI Reporting Program Next Steps
Consult with infection preventionists, hospital epidemiologists, surgeons,
neonatologists, and the Cardiac Advisory Committee to identify risk factors
and prevention strategies to reduce infections.

Monitor HAI prevention projects for compliance with program objectives, fiscal
responsibility and potential applicability to other hospitals or healthcare settings.

Continue to work with the TAW and seek guidance on the selection of reporting
indicators, evaluation of system modifications, evaluation of potential risk factors,
methods of risk adjustment and presentation of hospital-identified data.

Continue to, refine and report hospital-specific HAI indicators to allow

consumers to make informed choices.

Evaluate the impact of audit and validation on reported HAI infection rates and
state-based comparisons

http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs/hospital_acquired_infection.pdf
 AHRQ Data
Adults who developed health care-associated infections
(HAIs) due to medical or surgical care while in the hospital
in 2007 had to stay an average of 19 days longer than
adults who didn't develop an infection, (24 days versus 5
days), according to the latest News and Numbers from
the Agency for Healthcare Research and Quality (AHRQ).

Jennifer Lucado, M.P.H., Kathryn Paez, Ph.D., M.B.A., R.N., Roxanne Andrews, Ph.D., and Claudia Steiner, M.D., M.P.H. Adult Hospital Stays
with Infections Due to Medical Care, 2007 Healthcare Cost and Utilization Project , Agency for Healthcare Research and Quality (AHRQ)
 AHRQ Data

In 2007, about 45% of patients with HAIs were 65 or

older, 33% were 45 to 64 and 22% were ages 18 to 44.

The top three diagnoses in hospitalized adult patients

who developed HAIs were: septicemia (12%), adult
respiratory failure (6%), and complications from surgical
procedures or medical treatment (4%).

http://www.ahrq.gov/news/nn/nn082510.htm
 AHRQ Information

Stays with infections were more likely to be at

hospitals with any of the following characteristics:
size of 500 or more beds; located in a metropolitan
area; private, for profit; and teaching hospital.

http://www.ahrq.gov/news/nn/nn082510.htm
 AHRQ Information

For patients with an HAI, the rate of death in the

hospital, on average, was 6 times as high as the
rate for patients without an HAI (9% versus 1.5%)

On average, the cost of a hospital stay of an adult

patient who developed an HAI was approx.
$43,000 more expensive than the stay of a patient
without an HAI ($52,096 versus $9,377).

http://www.ahrq.gov/news/nn/nn082510.htm
 Cost Benefit of Infection Control/Prevention
In the Study on the Efficiency of Nosocomial Infection Control
(1974-1983), US hospitals with one full-time infection control
nurse (ICN) per 250 beds, an infection control doctor (ICD),
moderately intense surveillance, and system for reporting wound
infection rates to surgeons, reduced their HAI rates by 32%.

In the other hospitals, the HAI rate increased by 18%. The study
estimated that (in 1975 dollars), the annual cost of HAI in US
hospitals was $1b. The cost of infection control teams (0.2 ICD,
1 ICN, 1 clerk per 250 beds) was $72m per annum, only 7% of
the infection costs.

Therefore, if infection control programs were effective in

preventing only 7% of nosocomial infections (normally
distributed), the costs of the programs would be covered. A 20%
effectiveness would save $200m, and 50% would save $0.5b
(1975 US prices).
Infection Control Basic Concepts and Practices, International Federation of Infection Controll,The Costs of Hospital Infection,
http://www.ific.narod.ru/Manual/cost.htm
 Cost to Hospitals
In a report from 55
hospitals in 20 states,
the cost of care of the
4% of patients with HAI
wiped out profits from
all other patients1

(note the numbers

were prior to 2008
when CMS no longer
reimbursed for HAIs)

Figure 1 Information from 55 hospitals in 20 states shows that the cost of

infections to facilities wipes out operating profits

Hess W, Finck W. Real-time infection protection: using real-time surveillance data payers and providers are averting infection saving lives
and reapoing benefits: Healthcare Inform: 2007:24(8): 63-64.
Role Surfaces Play in Nosocomial Infections
Review
The role of medical devices, such as bronchoscopes, in the
transmission of healthcare- associated infections (HAIs) has long
been recognized, however, the evidence that environmental and
medical equipment surfaces play a role in the transmission of
HAIs has been weak

Studies have demonstrated that pathogens can be transmitted

from surfaces to personnel and patients, and that these
pathogens are not adequately removed by routine room cleaning

This has led to an increased focus on the importance of cleaning

and disinfecting hospital surfaces and medical equipment and
efforts to assess and improve the effectiveness of these
practices.
Kathleen Meehan Arias, MS, CIC.Contamiination and Cross Contamination on Hospital Surfaces and Medical Equipment, Initiatives in Safe
Patient Care,
 Numerous studies have shown that hospital
surfaces and frequently used medical equipment
become contaminated by a variety of pathogenic
and nonpathogenic organisms.

Hayden MK, Bonten MJM, Blom DW, Lyle EA, van de Vijver DAMC, Weinstein R. Reduction in acquisition of vancomycin-resistant
enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis. 2006;42:1552-1560.
Carling PC, Parry MF, Von Beheren SM, Group HEHS. Identifying opportunities to enhance environmental cleaning in 23 acute care
hospitals. Infect Control Hosp Epidemiol. 2008;29:1-7.
 Infection Control Today
Most gram-positive bacteria, including vancomycin-resistant
enterococcus (VRE), methicillin-resistant Staphylococcus aureus
(MRSA), and Streptococcus pyogenes can survive for months on dry
surfaces.

In general, there was no obvious difference in survival between

multiresistant and susceptible strains of Staphylococcus aureus and
Enterococcus spp.,

Only in one study was such a difference suggested, but the susceptible
strains revealed a very brief survival as such. Many gram-negative
species, such as Acinetobacter spp., Escherichia coli, Klebsiella spp.,
Pseudomonas aeruginosa, Serratia marcescens, or Shigella spp. can
survive on inanimate surfaces even for months.

These species are found among the most frequent isolates from
patients with nosocomial infections

http://www.infectioncontroltoday.com/articles/2006/11/fomites-and-infection-transmission.aspx
 An estimated 20% to 40% of HAI have been attributed to cross infection via the
hands of health care personnel, who have become contaminated from direct
contact with the patient or indirectly by touching contaminated environmental
surfaces.

Multiple studies strongly suggest that environmental contamination plays an

important role in the transmission of methicillin-resistant Staphylococcus aureus
and vancomycin-resistant Enterococcus spp. More recently, evidence suggests
that environmental contamination also plays a role in the nosocomial
transmission of norovirus, Clostridium difficile, and Acinetobacter spp.

All 3 pathogens survive for prolonged periods of time in the environment, and
infections have been associated with frequent surface contamination in hospital
rooms and health care worker hands

David J. Weber, MD, MPH,a,b William A. Rutala, PhD, MPH,a,b Melissa B. Miller, PhD,c,d Kirk Huslage, RN, BSN, MSPH,band Emily
Sickbert-Bennett, MSb, Role of hospital surfaces in the transmission of emerging health careassociated pathogens: Norovirus, Clostridium
difficile, and Acinetobacter species, American Journal of Infection Control, June 2010; S25-S33.
 Limitations of the Efficacy of Surface Disinfection in the
Healthcare Setting
Numerous studies have reported on the ability of pathogens such
as Staphylococcus aureus to contaminate and survive on surfaces in close
proximity to patients.
Infection control regimens that include effective cleaning and the use of
disinfectants have been encouraged, to minimize the spread of pathogens and
prevent their transmission to high risk patients and, ultimately, to reduce the
associated financial burden.
The measures implemented, however, have to be effective at preventing the
survival of potential pathogens in hospitals. Simple cleaning regimens alone might
be ineffective at eliminating microbial contamination.
The use of surface disinfectants as a preventive measure is therefore of prime
importance, and the efficacy of these agents needs to be ensured as part of the
overall strategy to control healthcare acquired infection.

Gareth J. Williams, PhD; Stephen P. Denyer, FRPharmS; Ian K. Hosein, MD; Dylan W. Hill, BSc; JeanYves Maillard, PhD From the Welsh
School of Pharmacy, Cardiff University (G.J.W., S.P.D., J.Y.M.), the Infection Prevention and Control Department, Cardiff and Vale National
Health Service Trust (D.W.H.), and National Public Health Service Microbiology (D.W.H.), Cardiff, Wales; and the Microbiology Department,
North Middlesex University Hospital National Health Service Trust, London, England (I.K.H.), UK. Infection Control and Hospital
Epidemiology
 Surfaces
Environmental contamination with C. difficile has been reported to occur in areas near
infected or colonized patients.

Commodes, bedpans, blood pressure cuffs, walls, floors, washbasins, and

furniture are commonly affected. The organism has also been found in low numbers
on shoes and on stethoscopes, and hospital floors have remained contaminated
with C. difficile for up to five months.

Contamination of fomites with VRE has been found on many occasions in the literature,
including gowns worn by patients and healthcare workers, medical equipment,
microsphere beds, and environmental surfaces. The degree of environmental
contamination with VRE has also been shown to correlate with the number of body site
that have been colonized with VRE.

Transmission from surfaces to patients might occur: contact with contaminated

surfaces alone is almost as likely to lead to contamination of the hands of
healthcare workers as is contact with a colonized patient, Hota writes. Other data
supporting environment- to-patient transmission demonstrate that noncolonized
patients who were admitted to contaminated rooms had highly increased odds of
acquisition of VRE.

http://www.infectioncontroltoday.com/articles/2006/11/fomites-and-infection-transmission.aspx
Cleaning and Disinfecting
 Spauldings Classification System
More than 30 years ago, Earle H. Spaulding devised a rational approach to
disinfection and sterilization of patient-care items and equipment.

This classification scheme is still used today

The classification system categorizes instruments and items for patient

care into the following groups: critical, semicritical, and noncritical
according to the degree of risk for infection involved in use of the items

The CDC Guideline for Handwashing and Hospital Environmental Control

21, Guidelines for the Prevention of Transmission of Human
Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) to Health-Care
and Public-Safety Workers22, and Guideline for Environmental Infection
Control in Health-Care Facilities employ this terminology.

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and
the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
 Critical Items
Critical items carry a high risk for infection if they are
contaminated with a microorganism(s)

Objects that enter or penetrate sterile tissue or the

vascular system must be sterile because any
microbial contamination could transmit disease.

Items in this category must be purchased sterile or

sterilized
surgical instruments, cardiac and urinary catheters, implants,
and ultrasound probes used in sterile body cavities

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and
the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
 Semicritical Items
Semicritical items contact mucous membranes or nonintact skin.

This category includes respiratory therapy and anesthesia equipment,

some endoscopes, laryngoscope blades, esophageal manometry
probes, cystoscopes, anorectal manometry catheters, and diaphragm
fitting rings.

These medical devices should be free from all microorganisms;

however, small numbers of bacterial spores are permissible. Intact
mucous membranes, such as those of the lungs and the
gastrointestinal tract, generally are resistant to infection by common
bacterial spores but susceptible to other organisms, such as bacteria,
mycobacteria, and viruses.

Semicritical items minimally require high-level disinfection using

chemical disinfectants High-level disinfection traditionally is defined as
complete elimination of all microorganisms in or on an instrument,
except for small numbers of bacterial spores

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and
the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
 Noncritical Items
Noncritical items are those that come in contact with
intact skin but not mucous membranes.

Intact skin acts as an effective barrier to most

microorganisms; therefore, the sterility of items
coming in contact with intact skin is "not critical."

Noncritical items are divided into noncritical patient

care items and noncritical environmental surfaces.

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and
the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
 Noncritical environmental surfaces
Noncritical environmental surfaces
Housekeeping surfaces (such as bed rails, bedside
tables, walls and floors) and the surfaces of medical
and electronic equipment (such as ventilators, IV
poles, and computer equipment)

Noncritical items and environmental surfaces

can be cleaned and disinfected with low- or
intermediate level disinfectants.

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and
the Healthcare Infection Control Practices Advisory Committee (HICPAC)3 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
 Decontamination
In contrast to critical and some semicritical items,
most noncritical reusable items may be
decontaminated where they are used and do not
need to be transported to a central processing area.

Virtually no risk has been documented for

transmission of infectious agents to patients
through noncritical items when they are used as
noncritical items and do not contact non-intact
skin and/or mucous membranes

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
 Issues
Noncritcal environmental surfaces include bed rails, some food
utensils, bedside tables, patient furniture and floors. Noncritical
environmental surfaces frequently touched by hand (e.g.,
bedside tables, bed rails) potentially could contribute to
secondary transmission by contaminating hands of health-care
workers or by contacting medical equipment that subsequently
contacts patients

Mops and reusable cleaning cloths are regularly used to achieve

low-level disinfection on environmental surfaces. However, they
often are not adequately cleaned and disinfected, and if the
water-disinfectant mixture is not changed regularly (e.g., after
every three to four rooms, at no longer than 60-minute intervals),
the mopping procedure actually can spread heavy microbial
contamination throughout the health-care facility

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
 Medical Equipment Surfaces
Medical equipment surfaces (e.g., blood pressure cuffs,
stethoscopes, hemodialysis machines, and X-ray
machines) can become contaminated with infectious
agents and contribute to the spread of health-care
associated infections.

For this reason, noncritical medical equipment surfaces

should be disinfected with an EPA-registered low- or
intermediate-level disinfectant.

Use of a disinfectant will provide antimicrobial activity

that is likely to be achieved with minimal additional
cost or work.

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
 Link Surfaces Nosocomial Infections

It is difficult to directly link noncritical hospital surfaces and medical

equipment to infection transmission

The role of fomites and the inanimate hospital environment in the

transmission of infection has been debated for many years, however,
there is increasing evidence that contaminated inanimate surfaces,
especially those frequently touched by hand, can contribute to the
spread of healthcare-associated pathogens.

Kramer A, Scwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious
Diseases 2006;6:130
Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized
patients. Infect Control Hosp Epidemiology 2004;25:164-7
http://www.initiatives-patientsafety.org/Initiatives4.pdf
 Link Surfaces Nosocomial Infections
Transmission can occur either indirectly when a
healthcare workers hands or gloves become
contaminated by touching contaminated surfaces
after which they touch patients, or when a patient
comes in direct contact with a contaminated
surface

http://www.initiatives-patientsafety.org/Initiatives4.pdf
Kramer et al. BMC Infectious Diseases 2006 6:130 doi:10.1186/1471-2334-6-130
 Pathogens that have been linked to
transmission via contaminated environmental
surfaces and medical equipment include
MRSA, VRE, Clostridium difficile,
Acinetobacter spp and norovirus.

Except for norovirus, these organisms pose

clinically important antimicrobial resistance
problems and are among the most common
causes of HAIs in intensive care units

http://www.initiatives-patientsafety.org/Initiatives4.pdf
 MRSA & VRE
The primary reservoirs for MRSA in the hospital are
colonized or infected patients who readily
contaminate medical and electronic equipment and
the environment in their vicinity. MRSA can survive
on dry environmental surfaces for several months

Several studies have demonstrated that medical

equipment (e.g. electronic rectal thermometers and
fluidized beds) and contaminated hospital surfaces
can play a role in the transmission of VRE

http://www.initiatives-patientsafety.org/Initiatives4.pdf
FACTORS AFFECTING THE EFFICACY OF
DISINFECTION AND STERILIZATION

Number and Location of Microorganisms

Innate Resistance of Microorganisms
Concentration and Potency of
Disinfectants
Physical and Chemical Factors
Organic and Inorganic Matter
Duration of Exposure
Biofilms
http://www.initiatives-patientsafety.org/Initiatives4.pdf
Reuse of Single-Use Medical Devices
The reuse of single-use medical devices began in the late 1970s.
Reuse of single-use devices increased as a cost-saving measure.
Approximately 20 to 30% of U.S. hospitals reported that they
reuse at least one type of single-use device.
Reuse of single-use devices involves regulatory, ethical, medical,
legal and economic issues and has been extremely controversial
for more than two decades
The U.S. public has expressed increasing concern regarding the
risk of infection and injury when reusing medical devices intended
and labeled for single use.
Although some investigators have demonstrated it is safe to reuse
disposable medical devices such as cardiac electrode catheters,
additional studies are needed to define the risks and document the
benefits.

www.fda.gov
 In August 2000, FDA released a guidance document on single-use
devices reprocessed by third parties or hospitals.

In this guidance document, FDA states that hospitals or third-party

reprocessors will be considered manufacturers and regulated in the
same manner.

A reused single-use device will have to comply with the same regulatory
requirements of the device when it was originally manufactured.

The options for hospitals are to stop reprocessing single-use devices,

comply with the rule, or outsource to a third-party reprocessor.

The reuse of single use medical devices continues to be an evolving

area of regulations. For this reason, healthcare workers should refer to
FDA for the latest guidance

www.fda.gov
 CDC Guideline
CDC Isolation Guideline recommends that noncritical equipment
contaminated with blood, body fluids, secretions, or excretions be
cleaned and disinfected after use.

The same guideline recommends that, in addition to cleaning,

disinfection of the bedside equipment and environmental surfaces
(e.g., bedrails, bedside tables, carts, commodes, door-knobs, and
faucet handles) is indicated for certain pathogens, e.g., enterococci,
which can survive in the inanimate environment for prolonged periods.

OSHA requires that surfaces contaminated with blood and other

potentially infectious materials (e.g., amniotic, pleural fluid) be
disinfected.

Using a single product throughout the facility can simplify both

training and appropriate practice.
http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
Justification for Use of Disinfectants for
Noncritical Environmental Surfaces
Surfaces may contribute to transmission of epidemiologically important microbes
(e.g., vancomycin-resistant Enterococci, methicillin-resistant S. aureus, viruses)
Disinfectants are needed for surfaces contaminated by blood and other potentially
infective material
Disinfectants are more effective than detergents in reducing microbial load on
floors
Detergents become contaminated and result in seeding the patients environment
with bacteria
Disinfection of noncritical equipment and surfaces is recommended for patients on
isolation precautions by the Centers for Disease Control and Prevention
Advantage of using a single product for decontamination of noncritical surfaces,
both floors and equipment
Some newer disinfectants have persistent antimicrobial activity
Justification for Using a Detergent on
Noncritical Environmental Surfaces
Noncritical surfaces contribute minimally to endemic healthcare-
associated infections
No difference in healthcare-associated infection rates when
floors are cleaned with detergent versus disinfectant
No environmental impact (aquatic or terrestrial) issues with
disposal
No occupational health exposure issues
Lower costs
Use of antiseptics/disinfectants selects for antibiotic-resistant
bacteria (?)
More aesthetically pleasing floor
Evidence Based Clinical Policy to Improve
Compliance
Evidence Based Practice

The care of patients using the best of the growing

volume of available research evidence to guide
clinical decision making.

Used to describe a type of research where the

researcher is aware of certain evidence before
exploring the subject.

Goal is to apply the best available evidence ranging

from randomized control double blinded studies to
clinical decision making examine the risks and
benefits involved in patient care to determine the best
practice and whether it will do more harm than good.
Evidence Pyramid
PICO Question and Components

PICO is an acronym that describes the elements of a

well-formed clinical question.

P for the patient or problem

I for the intervention of interest
C for comparison, and
O for outcome.
 PICO Question

Example:
For persons entering a health care facility, is hand
rubbing with a waterless, alcohol based solution, as
effective as standard hand washing with antiseptic
soap for reducing hand contamination?

Example from: DiCenso A, Guyatt G, Ciliska D. (2005). Evidence-Based Nursing: A Guide to Clinical Practice. St. Louis, MO: Mosby.
 Evidence-based practice, research, and quality
improvement drive practice and process
improvement facilitating patient- and family-
centered best practice outcomes; thus providing
quality healthcare from the collaborative efforts of
a multidisciplinary team.

(Kowal, 2009)
Key Points
Evidence-based nursing practice is an approach to nursing care that
is essential to the improvement of patient outcomes.

Situational issues present within clinical practice settings have made

a more evidence-based approach difficult to attain for many
registered nurses.

Clinical nurse educators have the opportunity to become potential

change agents in the facilitation of evidence-based nursing within the
clinical practice setting.
Evidence-Based NursingPenz, K. l., Bassendowski, S. l. (2006). Evidence-Based Nursing in Clinical Practice: Implications for Nurse
Educators. The Journal of Continuing Education in Nursing, 37(6), 250-254.
Solutions
 Disposable vs. Reusable ECG wires
Reusable electrocardiography (ECG) wires, specifically the
wire lead sets that connect the electrodes placed on a
patients chest to the trunk cable of a hardwired monitor or
telemetry box, are a ubiquitous pathway for communication
for of HAIs caused by resistant organisms

The finding that reusable wires carry and transport resistant

bacteria after the wires are cleaned per hospital protocol
has been reported in 2003, 2008 and 2009
Barnett TE The not-so-hidden cost of surgical site infections. AORN J.2007;86(2): 249258.
Albert NM . Multicenter study on reused ECG wires: are monitored patients at risk for nosocomial infections [research poster]
Maki DG, Brookmeyer PR. A survey of EKG telemetry harnesses as a reservoir of resistant nosocomial pathogens. In: Abstracts of the Interscience Conference
on Antimicrobial Agents and Chemotherapy.Washington, DC: American Society for Microbiology; 2003. Abstract K-746.
Ghandi H, Sharma S, Gilski D, Beveridge R, Patel P. Investigating electrocardiography lead wires as a reservoir for antibiotic-resistant pathogens [abstract
186]. Circulation. 2008;117(21):e454
Albert NM, Hancock K, Krajewski S, et al. Multicenter study on reused ECG wires: are monitored patients at risk for nosocomial infections
http://www.aacn.org/WD/NTISpeakerMats/PosterPresentations/00040270/00040270.swf.
Figure 1 Photograph of woman after bilateral lung transplant surgery shows at least 3
reusable electrocardiograph wires directly contacting her exposed incision.
 Solution
Strict adherence and surveillance of hospital
protocol for cleaning and disinfection of ECG leads
however . . . .

Because of the nature of bacteria and the methods

of development and transfer of antibiotic resistance,
cleaning methods with bactericidal agents may be
compounding the problem

Disposable ECG leads may eliminate the problem

and the pathway created by reusable ECG wires.
Moellering RC Jr., Graybill JR, McGowan JE Jr., Corey L American Society for Microbiology. Antimicrobial resistance prevention initiativean
update: proceedings of an expert panel on resistance. Am J Infect Control.2007;35(9):S1S23.
 Blood Pressure Cuffs
In a study by Base-Smith, sphygmomanometer cuffs from various inpatient
settings were found to have bacterial colonization rates of 81-100%.9 Also,
45.7% of the clean cuffs were contaminated with organic and/or inorganic
substances. The patient contact sides of cuffs were contaminated twice as
often as the nonpatient sides.

Stemicht et al found similar colonization rates of re-used disposable blood

pressure cuffs.

Myers et al identified a single blood pressure cuff as the common source of

a nosocomial infection outbreak in a neonatal intensive care unit. 11

Stemicht AL. Significant bacterial colonization of the surface of non-disposable sphygmomanometer cuffs and reused disposable cuffs.
Comet Med. Ctr., New York, NY 10021.
Myers MG. Longitudinal evaluation of neonatal nosocomial infections: association of infection with a blood pressure cuff. Pediatrics 1978;
61:42-45.
 Blood Pressure Cuffs
One study assessed the level of bacterial contamination
on blood pressure cuffs in use on hospital wards. Viable
organisms were recovered from all the 24 cuffs sampled
at a density of between 1,000 and more than 25,000
colony-forming units per100 cm2.

Another study investigated the role of blood pressure cuffs

in the spread of bacterial infections in 18 hospital units.10
Potentially pathogenic microorganisms were isolated from
27 (13 percent) of the 203 blood pressure cuffs evaluated.
The highest rates of contamination were observed on
cuffs used in intensive care units and those kept on
nurses carts. For four patients with a personal
sphygmomanometer, the authors found a genetic link
between the strains isolated from the blood pressure cuffs
and the strains isolated from the patients.

http://www.infectioncontroltoday.com/articles/2006/11/fomites-and-infection-transmission.aspx
 Blood Pressure Cuffs

The capacity of blood pressure cuffs to act as

vehicles of hospital infection has been recognised.
We describe the microbial flora of in-use DINAMAP
blood pressure cuffs used in the operating theatres
and one recovery room in a teaching hospital.
Results show significant microbial contamination of in
use blood pressure cuffs.

Cormican MG, Lowe DJ, Keane P, Flynn J, O'Toole D. Department of Medical Microbiology, University College Hospital, Galway The
microbial flora of in-use blood pressure cuffs, .Ir J Med Sci. 1991 Apr;160(4):112-3.
Solution
Strict adherence and surveillance of hospital protocol
for cleaning and disinfection
however . . . .

Due to the nature of cuff use, frequency, multiple

patients, the difficulty cleaning with cleaning the
velcro/material recommendation is to . . .

Provide each patient with a new disposable blood

pressure cuff that remains with the patient during
his/her hospital stay and is disposed of when the
patient is discharged from the hospital.
 Reusable Pulse Oximetry Sensors
An early study demonstrated that standard cleaning
techniques did not adequately disinfect reusable pulse
oximetry sensors that had been intentionally contaminated
with high titers of pathogenic microorganism

Forty-four sensors were evaluated, 16 in the bacterial-growth

stage and 28 in the identification stage. Bacteria were
cultured from 29 of the 44 sensors (66%), including 20 that
had been cleaned with alcohol or an antibacterial/antiviral
agent. Among the isolated organisms were Staphylococcus
aureus, Staphylococcus haemolyticus, Enterococcus
faecalis, and Klebsiella oxytoca. Bacterial contamination was
found on sensors from 12 of the 15 participating hospitals.

Residual bacterial contamination on reusable pulseoximetry sensors. Wilkins MC. St Vincent Hospital and Medical Center,
Portland, OR 97225. Respir Care. 1993 Nov;38(11):1155-60.
Solution Wilkins MC - Residual bacterial
contamination on reusable pulse oximetry sensors.

Define effective cleaning methods for reusable

sensors

The data also suggest that disposable patient-

dedicated sensors may be the most appropriate
choice when infection control is of particular concern.

Residual bacterial contamination on reusable pulseoximetry sensors. Wilkins MC. St Vincent Hospital and Medical Center,
Portland, OR 97225. Respir Care. 1993 Nov;38(11):1155-60.
 Stethoscopes

Marinella et al found that 100% of stethoscopes were

contaminated with coagulase negative staphylococcus and
38% were contaminated with Staphylococcus aureus.

Most stethoscopes harbour potential pathogens. The

isolation of Gram-negative organisms pose a real risk of
spreading potentially serious infections, especially in the
setting of intensive care departments. . . current
recommendations of regular disinfection of stethoscopes
are not carried out by health personnel that participated in
the study.
Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential source of nosocomial infection? Arch Intern Med 1997; 157:786-790.
The stethoscope as a vector of infectious diseases in the paediatric division. Youngster I, Berkovitch M, Heyman E, Lazarovitch Z, Goldman M.
Division of Paediatrics, Assaf Harofeh Medical Center, Zerifin, Israel. Acta Paediatr. 2008 Sep;97(9):1253-5. Epub 2008 Jun 12
Stethoscopes

Seventeen of the thirty stethoscopes (57%) that were

applied to the patients' chest grew Staphylococcus
aureus.

This proves the occurrence of organism transfer from

the patient's skin to the stethoscope and makes
stethoscopes as possible sources of nosocomial
infection.

All disinfected stethoscopes, regardless of the agent

used, failed to grow any organism after incubation
Solution
Stethoscopes can be a potential source of
nosocomial infection due to the transfer of
organisms from the patient's skin flora

After cleaning with isopropyl alcohol, sodium hypochlorite

or benzalkonium chloride, bacterial colony counts were
shown to be significantly reduced

Create evidence based solution on routine cleaning of staff

stethoscopes for institution
 Conclusion
HAIs are associated with high mortality and morbidity rates and markedly affect
hospital economies

Healthcare interventions that are based on research provide a sound scientific

foundation for practice

Clients who receive research- based care make significant gains in outcomes
compared with those receiving routine care

Therefore hospital staff should be educated about the potential health risks
associated with fomites as a vector for infection transmission

In particular the link between contaminated surfaces noted: ECG leads, BP cuffs,
Pulse Oximetry Sensors and Stethescopes with a focus on developing and
implementing validated standard operating procedures for the use and
maintenance of these items in particular, cleaning and disinfection protocols or use
of disposable and one per patient devices when possible.
Heater, Becker, and Olsen, 1988 as cited in Melnyk Fineout-Overholt, 2011

C. de Gialluly, MD; V. Morange, MD; E. de Gialluly, MD; J. Loulergue, MD; N. van der Mee, PhD; R. Quentin, MD, PhD,
Blood Pressure Cuff as a Potential Vector of Pathogenic Microorganisms: A Prospective Study in a Teaching Hospital
(Infection Control and Hospital Epidemiology, September 2006, vol. 27, no. 9
Questions?

Thank you!