Future Forcast

Future Forcast
Peering Into the Crystal Ball for 2005s Biggest IC Issues

By Kelly M. Pyrek

The new year seems to be picking up where 2004 left off, withthe anticipated release of updated guidelines, plus continued work on issuesthat persist, such as tackling ventilator-associated pneumonia, fightingsurgical site infections (SSIs) and much more. Here is a look at the mostimportant issues and concerns that 2005 will bring to the members of theinfection control community.

Mandatory Infection Rate Reporting

One current issue that will heat up in 2005 is the mandatorypublic reporting of infection rates (see November 2004 cover story in ICT). Inearly February 2005, the Association for Professionals in Infection Control andEpidemiology (APIC) will convene a consensus conference, Healthcare-Associated Infections: Realizing the Benefi ts of Mandatory Public Reporting,to discuss the mandatory public reporting of infection data legislation that isalready underway in a handful of states. A number of stakeholders, includinglegislative and regulatory offi cials, infection control professionals, hospitaladministrators, risk managers, and consumer and public safety advocates, havebeen invited to participate in the conference to work toward the development ofa standardized infection surveillance and reporting system that can address theneeds of consumers and healthcare institutions. The conference is sponsored byAPIC in partnership with the American Hospital Association, the Centers forDisease Control and Prevention (CDC), Consumers Union, National Quality Forum,and Society for Healthcare Epidemiology of America (SHEA).

There are two primary reasons for convening this consensusconference, says Kathy Warye, executive director of APIC. First andforemost, to bring key stakeholders together to share views and approaches withone another this is critically important given the complexity and importanceof reporting; second, to determine a path forward that will ultimately improveoutcomes. Since infection control professionals will be central to thisactivity, we feel it is important for APIC to provide a forum for the dialog anddecisions that will be made across the nation.

Mandatory reporting is a point of panic right now amonginfection control practitioners (ICPs), says Wava Truscott, PhD, director ofscientific affairs and clinical education at Kimberly-Clark Health Care. Oneof the most important things ICPs can do is to put forth a business case forinfection reduction, including looking at what an SSI costs and how data can betrended to show there is a reduction. The amount of data they are going to needto collect is significant, but its their love in life acquiring data andputting it into a framework that can easily represent whats happening withinfection rates.

While some in the infection control community are calling forgreater political activism from ICPs in 2005, Truscott believes ICPs primaryresponsibilities are their hospital and their community. They are at homewith that role, but of course, there will always be people who are comfortablein larger roles. Whatever their degree of participation, ICPs must have thatconduit of communication so they know whats going on in their statelegislatures, are empowered to communicate that with their hospitaladministration, and can comment if they disagree. Collecting the data, whetherits a hand-wrote system or computer based, is of paramount importance. One ofthe things the Joint Commission on the Accreditation of Healthcare Organizations(JCAHO) is really pushing is root cause analysis (RCA) and corrective actions showing the action, when its due, whos responsible for it but theyare also saying, Make sure that you also track that it was effective once itwas in place. You cant do that unless you have an effective datacollector.

Interim influenza Vaccination Recommendations for 200405 influenzaSeason

The CDC continues to remind healthcare professionals toobserve the interim flu vaccination recommendations in light of continued vaccination-shortage issues caused by the Chiron manufacturing plantcontamination late last year. These interim recommendations were formallyrecommended on Oct. 5, 2004, and take precedence over earlier recommendations.

Additional information is available at http://www.cdc.gov/fluor through the CDC public response hotline at (888) 246-2675.

CDC Issues 2004-05 Interim Guidance for the Use of Masks to Control influenza Transmission

On Nov. 18, 2004, the CDC issued interim guidance that wasdeveloped in response to questions about the role of masks for controlling humaninfluenza when suboptimal immunization of the public could increase thefrequency of influenza infection.

The document recommends a combination of infection controlstrategies to decrease transmission of influenza in healthcare settings,including:

• Placing influenza patients in private rooms when possible

• Having healthcare personnel wear masks for close patient contact (i.e.,within three feet) and gowns and gloves if contact with respiratory secretionsis likely

Use of surgical or procedure masks by infectious patients may helpcontain their respiratory secretions and limit exposure to others. Likewise,when a patient is not wearing a mask, as when in an isolation room, havinghealthcare personnel mask for close contact with the patient may prevent noseand mouth contact with respiratory droplets. However, no studies have definitively shown that mask use by either infectious patients or healthcarepersonnel prevents influenza transmission. In the United States, disposablesurgical and procedure masks have been used widely in healthcare settings toprevent exposure to respiratory infections, but they have not been used commonly in community settings (e.g.,schools, businesses, public gatherings).

During periods of increased respiratory infection activity inthe community, masks should be offered as part of a respiratory hygiene/coughetiquette strategy to patients who are coughing or have other symptoms of arespiratory infection when they present for healthcare services (see the CDCsRespiratory Hygiene/Cough Etiquette in Healthcare Settings).

Masks should be worn by these patients until it is determinedthat the cause of symptoms is not an infectious agent that requires isolationprecautions to prevent respiratory droplet transmission or the patient has beenappropriately isolated, either by placement in a private room or by placement ina room with other patients with the same infection (cohorting). Once isolated,the patient does not need to wear a mask unless transport outside the room isnecessary.

A surgical or procedure mask should be worn by healthcarepersonnel who are in close contact (i.e., within three feet) with a patient whohas symptoms of a respiratory infection, particularly if fever is present, asrecommended for standard and droplet precautions. These precautions should bemaintained until the patient has been determined to be noninfectious or for theduration recommended for the specific infectious agent.

Adults can shed influenza virus one day before symptomsappear and up to seven days after onset of illness; thus, the selective use ofmasks (e.g., in proximity to a known symptomatic person) may not effectivelylimit transmission in the community. Instead, emphasis should be placed on coughetiquette for persons with respiratory symptoms whenever they are in thepresence of another person, including at home and at school, work, and otherpublic settings. Important components of this strategy include encouragingsymptomatic persons to:

• Cover their nose and mouth when coughing or sneezing

• Use tissues to contain respiratory secretions and, after use, to dispose of themin the nearest waste receptacle

• Perform hand hygiene (e.g., handwashing withnon-antimicrobial soap and water, alcohol-based hand rub, or antiseptichandwash) after having contact with respiratory secretions and contaminatedobjects/materials

The guidance document can be found at:http://www.cdc.gov/flu/professionals/infectioncontrol/pdf/flumaskguidance.pdf. 

CMS to Allow Alcohol Handrub Dispensers in Hospital Corridors

In November 2004, APIC announced that the Centers for Medicareand Medicaid Services (CMS) would soon be lifting a regulation prohibiting theplacement of alcohol-based hand sanitizers in exit corridors in hospitals.

You have requested that CMS take action to ensure thatalcohol-based handrubs can be conveniently accessed in healthcare facilities,stated CMS in a letter to APIC. We agree that alcohol-based handrubs are auseful and effective infection control tool, and that convenient access toalcohol-based handrubs is an important factor in encouraging their use.

The interim final rule was published in the Dec. 23, 2004Federal Register, and the effective date of the rule is anticipated to be Feb.23, 2005.

In a Sept. 22, 2004, letter to CMS, APIC had urged the agencyto revoke its policy, in light of recent studies proving that alcohol-based handproducts (formerly considered to be a fi re hazard) could indeed safely beinstalled in exit corridors. As an organization of professionals dedicated topreventing and controlling healthcare-associated infections, we consider thesewall-mounted dispensers absolutely critical for assuring improved access andcompliance with recommended hand hygiene practices, the APIC letter stated.

In October 2002, the CDC issued recommendations stating thatalcohol-based handrubs may be a better option than traditional handwashing withplain soap and water. However, the outdated CMS policy made ensuring optimalaccess to these products a particular challenge.

This is an important step in the right direction and at theright time when every opportunity to make hand hygiene easier matters, saysAPIC member Judene Bartley, MS, MPH, CIC, who played a key role in the overalleffort to demonstrate the safety of these products and to change federal policyto ensure their ready access. We are thrilled that CMS understands thecritical nature of this issue and that the agency is moving forward to changethis policy based on solid data. She notes that the efforts of many broughtthis about, beginning with the AHA- and CDCsponsored stakeholders meeting inJuly 2003 that brought clinicians and fi re safety professionals together todetermine how they could effect this important change.

In the meantime, infection control professionals shouldcontinue to contact their local jurisdiction if their facility is cited forhaving dispensers in corridors. States vary in their approach, but CMS has beenrecommending that if facilities are cited for this defi ciency, they shouldrequest a temporary waiver from enforcement action in their plan ofcorrection.

There might be some state fi re marshals who still have aproblem with fi re-safety issues, but the easy accessibility of alcohol handrubsis an important thing to be doing, Truscott says. The most important thingfor healthcare workers to remember is to let the handrub dry before they takeoff gowns that could snap and spark a static discharge that can ignite a fi re.The handrub also must dry completely in order for it to kill the bugs.

But then again, there are certain bugs, like Candidaalbicans, for example, or Clostridium and anthrax spores, that areresistant to alcohol and always will be by nature of the organism. Alcoholhandrubs are going to make a positive impact on the reduction of infections, butits going to take continued education on these aspects.

Anticipated Release of HICPAC Isolation Guidelines

According to Michele Pearson, MD, of the CDC, ICPs likely willnow have to wait until mid-2005 for the issuance of the final Guidelines forIsolation Precautions: Preventing Transmission of Infectious Agents inHealthcare Settings from the CDC. Last summer, the CDCs HealthcareInfection Control Practices Advisory Committee (HICPAC) issued a draft guidelinethat updates and expands the 1996 Guideline for Isolation Precautions inHospitals. The period for public comment closed in mid-August 2004.

• The five-part draft guideline addresses several importantdevelopments since 1996:

• The transition from acute-care to other healthcaresettings such as ambulatory care

• The emergence of new pathogens such assevere acute respiratory syndrome (SARS) and the increased threat ofbioterrorism

• Evidence that environmental controls decrease the risk of lifethreatening fungal infections in the most severely immuno-compromisedindividuals

• Evidence that factors such as nurse staf. ng levels and levelsof adherence by healthcare workers (HCWs) to infection control practices, hasled to new emphasis on administrations support of infection control programs

• Continued increase in the incidence of healthcare-acquired infections (HAIs)caused by multi-drug-resistant organisms (MDROs)

Earlier, the Society forHealthcare Epidemiology of America issued its SHEA Guideline for Preventing Nosocomial Transmission of Multi-drug Resistant Strains of Staphylococcusaureus and Enterococcus, which potentially could contradictportions of the anticipated HICPAC document.

The SHEA recommendations are:

• Active surveillance cultures to identify thereservoir for spread

• Use of proper hand hygiene

• Use of barrierprecautions for patients known for suspected to be colonized or infected with MRSA or VRE

• Use of good antibiotic stewardship

• Decolonization orsuppression of colonized patients

• Use of educational programs to raiseawareness

For the SHEA guidelines in depth, go to www.shea-online.org/pdfs/SHEA_MRSA_VRE.pdf.  For the draft HICPAC guidelines, go tohttp://www.gpoaccess.gov/fr/index.html.

Reprocessing of Single-use Devices

In November 2004, the Food and Drug Administration (FDA)completed a review of supplemental validation data submitted by firms thatreprocess medical devices originally intended for single use only (SUDs). TheFDA has allowed certain types of previously cleared reprocessed SUDs to bemarketed, however supplemental data for cleaning, sterility and functionalityhad to be submitted to the FDA for review to determine if certain reprocessedSUDs were safe for use. The FDAs review determined that although manyreprocessed SUDs can continue to be legally marketed, there are a number thatcan no longer be commercially distributed for use.

The lists of both legally and not legally marketed devices canbe found at http://www.fda.gov/cdrh/reuse/svs/svslist-legal.html and athttp://www.fda.gov/cdrh/reuse/svs/svslist-nolegal.html.

AIA Revised Healthcare Guidelines Open for Comment Until Jan. 31, 2005

The American Institute of Architects (AIA) and the FacilityGuidelines Institute still are accepting comments from the public on theproposed 2006 edition of the AIA-published Guidelines for Design andConstruction of Hospital and Health Care Facilities. The Health GuidelinesRevision Committee has spent the last two years considering proposals to changethe guidelines and to clarify and add information to the document.

According to committee chairman Joseph G. Sprague, FAIA, oneof the most significant proposed changes would make single-bed private rooms aminimum standard for new hospital construction. Healthcare professionals areencouraged to review the draft document and submit their comments by Jan. 31,2005. The draft document, which is marked to indicate text that has been added,deleted or changed from the 2001 edition of the guidelines, is available throughthe AIA Web site at http://www.aia.org/aah.

Senate Resolution Supports Goals of National Time Out Day

Louisiana Sen. Mary Landrieu, with Illinois Sen. RichardDurbin and Pennsylvania Sen. Richard Santorum, has introduced Senate Resolution469, which supports the goals and ideas of National Time Out Day to promote the adoption of the Joint Commission onAccreditation of Healthcare Organizations (JCAHO)s universal protocol forpreventing errors in the operating room. The resolution currently has beenreferred to the Committee on Health, Education, Labor, and Pensions.

For the first time, nurses, surgeons, and hospitalsthroughout the country are being required by JCAHO to adopt a common set ofoperating room procedures in order to help curb the alarming number of deathsand injuries due to medical errors. The universal protocol, endorsed by morethan 50 national healthcare organizations, calls for surgical teams to call atime out before surgeries begin in order to verify the patientsidentity, the procedure to be performed, and the site of the procedure. JCAHOs 4,579 accredited hospitals, 1,261 ambulatory carefacilities, and 131 accredited offi ce-based surgery centers were required toadopt the universal protocol beginning July 1, 2004.

For the language of SR 469, go to http://www.aorn.org/policy/sr469.htm. 

Issues of Continuing Importance in 2005

Truscott is joined by thousands of ICPs who express concernover issues that will continue to plague them in 2005.

Ventilator-associated pneumonia (VAP) is a huge issue; itwill take continued education and teaching the things we already know that canmake a big difference. We also need to remain vigilant on bioterrorism-relatedissues, continuing our drills and preparation. We should remember that treatingplague is not a lot different than treating another droplet-borne disease; if weare treating normal diseases the way we should and just connecting the two, wewouldnt panic we would already know what to do. Related to biologicalprotection, one of the areas in which we are seeing tremendous weakness is eyeprotection I think it is being neglected. Healthcare workers must realizethat if they are wearing a mask to stop droplets, those same droplets can getinto the eye and the mucousal inlet. This year, the CDC and APIC are trying toemphasize proper removal of used personal protective garments. Experts arefairly certain that SARS was transferred via touching the exterior of masks andother personal protective equipment (PPE) and then touching the nose or the eyes its an action we dont think about enough.

Truscott says that another hot topic for 2005 could be theincreased emphasis on supplemental oxygen for reducing infections. Recentlythere was a large colorectal surgery study wherein half the group was given 30percent supplemental oxygen and the other group was given 80 percentsupplemental oxygen; the difference in infection rate was 50 percent. This couldbe a significant finding for the infection control community.

Truscott adds that the implementation of the fi t testing ofrespirators, as mandated by the Occupational Safety and Health Administration(OSHA) last year, will be an important issue. Many respirator manufacturersare working on methods that might be much more user-friendly, faster and easierto do, she says.

For 2005 Id like to see continued work to decrease theamount of fl ash sterilization, Truscott continues. I have been in someORs lately that are getting farther and farther away from the old red line; Iknow all about killing the sacred cows, but even so, we are getting lax in theOR. I have seen long earrings; a stylish use of headwear aboutthree inches back behind the hairline; doors propped open while ORs were beingprepped; I have seen eggcrate foam rubber on surgery tables with merely a sheetover it, and it is only changed out when it looks dirty these things scareme. Truscott says she has witnessed these infractions in large teachingfacilities, and quips, They are also teaching people to do things the wrongway!

Truscott also believes 2005 will see even more of a shift fromlatex gloves to synthetic gloves. This will be driven by not only the expenseof latex, but so that people dont have to worry about latex allergies, she says. There is a constant argument about what type ofsynthetics to use, as far as barrier properties go; I am anti-vinyl for thewrong places; vinyl always has a place in maybe 30 percent of the hospital,but just not in the other 70 percent. And then there is the argument aboutpowder. All of the emphasis on the reduction of powder has beenfocused around decreasing latex allergy, and the inhalation route; well, itabsorbs protein, but it also absorbs endotoxins, chemicals, and organisms. Thereare several studies that show if you use powder gloves, whether they are exam orsurgical, there are more bugs in the air that can get into your patient. I thinkthat issue will be a push, especially in the OR; were doing so much better onexam gloves, but in the OR, its about 55 percent powder. If you bring onepowder glove into the OR, you might as well discount the rest of the powder-freegloves because you are contaminating the area.

The injurious effects of micro foreign bodies and debris acombination of powder, lint, not cleaning up after suture trims, and hair thatis falling into the wound, are documented. There also are particles that are notcleaned properly in CS or SPD that are sterile but nonetheless they areforeign-body particles that are introduced into the wound, thus affectinggranulomas, adhesions, wound healing, and infection rates.