Future Forcast

By Kelly M. Pyrek

One current issue that will heat up in 2005 is the mandatory public reporting of infection rates (see November 2004 cover story in ICT). In early February 2005, the Association for Professionals in Infection Control and Epidemiology (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 is already underway in a handful of states. A number of stakeholders, including legislative and regulatory offi cials, infection control professionals, hospital administrators, risk managers, and consumer and public safety advocates, have been invited to participate in the conference to work toward the development of a standardized infection surveillance and reporting system that can address the needs of consumers and healthcare institutions. The conference is sponsored by APIC in partnership with the American Hospital Association, the Centers for Disease 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 consensus conference,” says Kathy Warye, executive director of APIC. “First and foremost, to bring key stakeholders together to share views and approaches with one another – this is critically important given the complexity and importance of reporting; second, to determine a path forward that will ultimately improve outcomes. Since infection control professionals will be central to this activity, we feel it is important for APIC to provide a forum for the dialog and decisions that will be made across the nation.”

“Mandatory reporting is a point of panic right now among infection control practitioners (ICPs), says Wava Truscott, PhD, director of scientific affairs and clinical education at Kimberly-Clark Health Care. “One of the most important things ICPs can do is to put forth a business case for infection reduction, including looking at what an SSI costs and how data can be trended to show there is a reduction. The amount of data they are going to need to collect is significant, but it’s their love in life – acquiring data and putting it into a framework that can easily represent what’s happening with infection rates.”

While some in the infection control community are calling for greater political activism from ICPs in 2005, Truscott believes ICPs’ primary responsibilities are their hospital and their community. “They are at home with that role, but of course, there will always be people who are comfortable in larger roles. Whatever their degree of participation, ICPs must have that conduit of communication so they know what’s going on in their state legislatures, are empowered to communicate that with their hospital administration, and can comment if they disagree. Collecting the data, whether it’s a hand-wrote system or computer based, is of paramount importance. One of the 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 it’s due, who’s responsible for it – but they are also saying, ‘Make sure that you also track that it was effective once it was in place.’ You can’t do that unless you have an effective data collector.”

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

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

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

The document recommends a combination of infection control strategies 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 secretions is likely

Use of surgical or procedure masks by infectious patients may help contain their respiratory secretions and limit exposure to others. Likewise, when a patient is not wearing a mask, as when in an isolation room, having healthcare personnel mask for close contact with the patient may prevent nose and mouth contact with respiratory droplets. However, no studies have definitively shown that mask use by either infectious patients or healthcare personnel prevents influenza transmission. In the United States, disposable surgical and procedure masks have been used widely in healthcare settings to prevent 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 in the community, masks should be offered as part of a respiratory hygiene/cough etiquette strategy to patients who are coughing or have other symptoms of a respiratory infection when they present for healthcare services (see the CDC’s Respiratory Hygiene/Cough Etiquette in Healthcare Settings).

Masks should be worn by these patients until it is determined that the cause of symptoms is not an infectious agent that requires isolation precautions to prevent respiratory droplet transmission or the patient has been appropriately isolated, either by placement in a private room or by placement in a 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 is necessary.

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

Adults can shed influenza virus one day before symptoms appear and up to seven days after onset of illness; thus, the selective use of masks (e.g., in proximity to a known symptomatic person) may not effectively limit transmission in the community. Instead, emphasis should be placed on cough etiquette for persons with respiratory symptoms whenever they are in the presence of another person, including at home and at school, work, and other public settings. Important components of this strategy include encouraging symptomatic persons to:

• Cover their nose and mouth when coughing or sneezing
• Use tissues to contain respiratory secretions and, after use, to dispose of them in the nearest waste receptacle
• Perform hand hygiene (e.g., handwashing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after having contact with respiratory secretions and contaminated objects/materials

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

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

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

The interim final rule was published in the Dec. 23, 2004 Federal 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 agency to revoke its policy, in light of recent studies proving that alcohol-based hand products (formerly considered to be a fi re hazard) could indeed safely be installed in exit corridors. “As an organization of professionals dedicated to preventing and controlling healthcare-associated infections, we consider these wall-mounted dispensers absolutely critical for assuring improved access and compliance with recommended hand hygiene practices,” the APIC letter stated.

In October 2002, the CDC issued recommendations stating that alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water. However, the outdated CMS policy made ensuring optimal access to these products a particular challenge.

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

In the meantime, infection control professionals should continue to contact their local jurisdiction if their facility is cited for having dispensers in corridors. States vary in their approach, but CMS has been recommending that if facilities are cited for this defi ciency, they should request a “temporary waiver” from enforcement action in their plan of correction.

“There might be some state fi re marshals who still have a problem with fi re-safety issues, but the easy accessibility of alcohol handrubs is an important thing to be doing,” Truscott says. “The most important thing for healthcare workers to remember is to let the handrub dry before they take off 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 Candida albicans, for example, or Clostridium and anthrax spores, that are resistant to alcohol and always will be by nature of the organism. Alcohol handrubs are going to make a positive impact on the reduction of infections, but it’s going to take continued education on these aspects.”

According to Michele Pearson, MD, of the CDC, ICPs likely will now have to wait until mid-2005 for the issuance of the final “Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings” from the CDC. Last summer, the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) issued a draft guideline that updates and expands the “1996 Guideline for Isolation Precautions in Hospitals.” The period for public comment closed in mid-August 2004.

• The five-part draft guideline addresses several important developments since 1996:
• The transition from acute-care to other healthcare settings such as ambulatory care
• The emergence of new pathogens such as severe acute respiratory syndrome (SARS) and the increased threat of bioterrorism
• Evidence that environmental controls decrease the risk of lifethreatening fungal infections in the most severely immuno-compromised individuals
• Evidence that factors such as nurse staf. ng levels and levels of adherence by healthcare workers (HCWs) to infection control practices, has led to new emphasis on administration’s 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 for Healthcare Epidemiology of America issued its “SHEA Guideline for Preventing Nosocomial Transmission of Multi-drug Resistant Strains of Staphylococcus aureus and Enterococcus,” which potentially could contradict portions of the anticipated HICPAC document.

The SHEA recommendations are:

• Active surveillance cultures to identify the reservoir for spread
• Use of proper hand hygiene
• Use of barrier precautions for patients known for suspected to be colonized or infected with MRSA or VRE
• Use of good antibiotic stewardship
• Decolonization or suppression of colonized patients
• Use of educational programs to raise awareness

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

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

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

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

According to committee chairman Joseph G. Sprague, FAIA, one of the most significant proposed changes would make single-bed private rooms a minimum standard for new hospital construction. Healthcare professionals are encouraged 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 through the AIA Web site at http://www.aia.org/aah.

Louisiana Sen. Mary Landrieu, with Illinois Sen. Richard Durbin and Pennsylvania Sen. Richard Santorum, has introduced Senate Resolution 469, which supports the goals and ideas of “National Time Out Day” to promote the adoption of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)’s universal protocol for preventing errors in the operating room. The resolution currently has been referred to the Committee on Health, Education, Labor, and Pensions.

For the first time, nurses, surgeons, and hospitals throughout the country are being required by JCAHO to adopt a common set of operating room procedures in order to help curb the alarming number of deaths and injuries due to medical errors. The universal protocol, endorsed by more than 50 national healthcare organizations, calls for surgical teams to call a “time out” before surgeries begin in order to verify the patient’s identity, the procedure to be performed, and the site of the procedure. JCAHO’s 4,579 accredited hospitals, 1,261 ambulatory care facilities, and 131 accredited offi ce-based surgery centers were required to adopt the universal protocol beginning July 1, 2004.

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

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

“Ventilator-associated pneumonia (VAP) is a huge issue; it will take continued education and teaching the things we already know that can make a big difference. We also need to remain vigilant on bioterrorism-related issues, continuing our drills and preparation. We should remember that treating plague is not a lot different than treating another droplet-borne disease; if we are treating normal diseases the way we should and just connecting the two, we wouldn’t panic – we would already know what to do. Related to biological protection, one of the areas in which we are seeing tremendous weakness is eye protection – I think it is being neglected. Healthcare workers must realize that if they are wearing a mask to stop droplets, those same droplets can get into the eye and the mucousal inlet. This year, the CDC and APIC are trying to emphasize proper removal of used personal protective garments. Experts are fairly certain that SARS was transferred via touching the exterior of masks and other personal protective equipment (PPE) and then touching the nose or the eyes – it’s an action we don’t think about enough.”

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

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

“For 2005 I’d like to see continued work to decrease the amount of fl ash sterilization,” Truscott continues. “I have been in some ORs lately that are getting farther and farther away from the old red line; I know all about killing the sacred cows, but even so, we are getting lax in the OR. I have seen long earrings; a stylish use of headwear about three inches back behind the hairline; doors propped open while ORs were being prepped; I have seen eggcrate foam rubber on surgery tables with merely a sheet over it, and it is only changed out when it looks dirty … these things scare me.” Truscott says she has witnessed these infractions in large teaching facilities, and quips, “They are also teaching people to do things the wrong way!”

Truscott also believes 2005 will see even more of a shift from latex gloves to synthetic gloves. “This will be driven by not only the expense of latex, but so that people don’t have to worry about latex allergies,” she says. “There is a constant argument about what type of synthetics to use, as far as barrier properties go; I am anti-vinyl for the wrong 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 about powder. All of the emphasis on the reduction of powder has been focused around decreasing latex allergy, and the inhalation route; well, it absorbs protein, but it also absorbs endotoxins, chemicals, and organisms. There are several studies that show if you use powder gloves, whether they are exam or surgical, there are more bugs in the air that can get into your patient. I think that issue will be a push, especially in the OR; we’re doing so much better on exam gloves, but in the OR, it’s about 55 percent powder. If you bring one powder glove into the OR, you might as well discount the rest of the powder-free gloves because you are contaminating the area.

The injurious effects of micro foreign bodies and debris – a combination of powder, lint, not cleaning up after suture trims, and hair that is falling into the wound, are documented. There also are particles that are not cleaned properly in CS or SPD that are sterile but nonetheless they are foreign-body particles that are introduced into the wound, thus affecting granulomas, adhesions, wound healing, and infection rates.”