Infection Control 2001 Year In Review
Top Ten Infection Control-Related Issues
By Kelly M. Pyrek
As today's healthcare professionals cope with budget cuts, staff shortages, Joint Commission inspections, and nosocomial infections, they must contend with the threat of bioterrorism as well. The past 12 months have been fraught with both challenges and opportunities, and in this issue of Infection Control Today,® we take a look at some of the year's most significant infection control trends and infectious disease outbreaks.
And as we look to the new year, all of us at Infection Control Today® wish you a healthy and prosperous 2002!
1 The Threat of Bioterrorism
As infection control practitioners grapple with the threat of anthrax in the wake of the Sept. 11 terrorist attack, the Centers for Disease Control and Prevention (CDC) is warning healthcare professionals to look for possible cases of food poisoning, smallpox, and viruses such as Ebola. Physicians and nurses are being encouraged to watch for unusual age distribution in diseases, such as a chickenpox-like illness in adults. The CDC also is asking state health officials to formulate a plan for instructing healthcare providers about how to recognize unusual diseases that might be cases of bioterrorism.
"There is no evidence of any threat other than anthrax," says Julie Gerberding, MD, an acting deputy director and head of infection control at the CDC. "We are not experiencing a national outbreak." At presstime, there had been dozens of exposures to anthrax. Scientists and investigators believe that the anthrax found in New York, Washington, and Florida came from the same source, occurred naturally, and were not biologically engineered. As of late October, the FBI had investigated 3,300 chemical or biological threats; 2,500 of which were anthrax threats.
Gerberding adds that current concerns about anthrax can heighten awareness of other diseases that could be used by terrorists. The CDC has listed plague, anthrax, and tularemia on its list of most worrisome biological agents. For more information on bioterrorism, see related article on page 24.
2 CJD Hits Too Close to Home
This summer the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Alert (Issue 20, June 2001) on the dangers of exposure to variant Creutzfeldt-Jakob Disease. vCJD is a degenerative neurological disease caused by prions, which are malformed proteins. A new variant of the previously recognized genetic disease, vCJD has been linked to "mad cow" disease, and is more rapid in the onset of clinical symptoms. This alert mandates that hospitals review their policies and procedures for the processing of instrumentation used in surgical procedures on patients who could have vCJD. The World Health Organization (WHO) issued controversial new infection control guidelines for transmisssable spongiform encephalopathies that require the steam sterilization of instruments in sodium hydroxide solution which can endanger healthcare workers (HCWs) and possibly damage the sterilizer.
Medical literature has indicated that prions are resistant to most current forms of sterilization, and there have been documented cases of iatrogenic transmission of vCJD during surgical procedures involving the brain, eyes, and spinal cord. CJD is genetic and cannot be spread through instruments; vCJD is prion-based. Many healthcare professionals swear by the saying, if it cannot be cleaned, it cannot be sterilized, and recommendations have ranged from throwing away all potentially contaminated instruments, to soaking them in and then steam sterilizing them for a long duration at high temperatures. While much has been made of vCJD in the media, many infection control experts emphasize that there is no known or suspected risk of vCJD transmission to HCWs who handle vCJD-contaminated instruments and devices, if they have intact skin, if they are wearing the appropriate personal protective equipment, and take reasonable precautions.
3 Joint Commission Makes Its Presence Known (Again)
While the Joint Commission essentially paved the way for the establishment of infection control departments in 1976, many infection control practitioners quake at the mere mention of JCAHO. This healthcare watchdog agency has been particularly observant in recent years, and has been further spurred on by an Institute of Medicine report that quipped, "Healthcare harms too frequently and routinely fails to deliver its potential benefits." The new patient-safety standards that went into effect July 1 require hospitals to initiate specific efforts to prevent medical errors and to tell patients when they have been harmed during their treatment. A 1999 Institute of Medicine report estimates that medical errors kill between 44,000 and 98,000 hospital patients annually.
"Healthcare executives, physicians, and nursing leaders must radically change their thinking about medical mistakes," says Dennis O'Leary, MD, president of JCAHO. "We need to create a culture of safety in hospitals and other healthcare organizations, in which errors are openly discussed and studied so that solutions can be found and put in place. These new standards are intended to do just that."
The new standards underscore the importance of strong organization leadership in building a culture of safety that encourages the internal reporting of medical errors and actively engages clinicians and other staff in the design of remedial steps to prevent future occurrences of these errors. A second major focus of the new standards is on the prevention of medical errors through the prospective analysis and re-design of vulnerable patient care systems (e.g., the ordering, preparation, and dispensing of medications). Potentially vulnerable systems can readily be identified through relevant national databases such as JCAHO's Sentinel Event Database or through the hospital's own risk management program. Finally, the standards make clear the hospital's responsibility to tell a patient if he or she has been harmed by the care provided.
4 Nursing Shortage Imperils Good Infection Control Practices
In July, members of the Association for Professionals in Infection Control and Epidemiology (APIC) met with experts at the CDC to discuss how the ongoing nursing shortage, especial in infection control departments, could imperil patient and healthcare worker safety and wellbeing.
"Staffing is a huge issue that we can partner with our sister nursing organizations in working toward," says APIC president Judith English, RN, MSN, CIC. "It is more likely that healthcare-acquired infections will happen in an understaffed, overworked (institution)." While the direct link between understaffing and adverse outcomes can be difficult to establish, few dispute that a short-staffed unit undermines handwashing compliance and aseptic technique. William Jarvis, MD, associate director for program development at the CDC's division of healthcare quality promotion, calls it "a tremendous problem" and points to studies showing an increase in infection rates associated with decreasing nurse-to-patient ratios. He adds that even as infection-control departments and being downsized as non-revenue generating, there is an upswing in cases presenting antibiotic-resistant pathogens such as VRE and MRSA.
5& 6 Nosocomial Infections Flourish, Antibiotic Resistance on the Rampage
Even though Ignaz Semmelweis demonstrated in the 1840s the importance of hand hygiene for the control of transmittable infections, it wasn't until 1976 that JCAHO was the impetus behind the administrative and financial support for hospital infection control programs. In 1985, the CDC's Study on the Efficacy of Nosocomial Infection Control reported that facilities with a hospital epidemiologist, one infection control practitioner for every 250 beds, active surveillance mechanisms, and ongoing infection control efforts, reduced nosocomial rates by one-third.
Even with this progress, in 1995, the latest figures available, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths. Since Semmelweis' time, there has been a constant parade of culprits: For most of the early to mid 20th century, Staphylococcus aureus reigned supreme in hospitals; in the 1970s, Pseudomonas aeruginos arrived on the scene. In the 1980s, methicillin-resistant staph (MRSA) and vancomycin-resistant enteroccoci (VRE) debuted, while in the 1990s and today, 32% of nosocomial infections were caused by Escherichia coli, P. aeruginosa, Enterobacter spp, and Klebsiella pneumoniae.
Ongoing preventative measures include:
- Improving surveillance
- Employing risk stratification
- Improving the design of invasive devices
- Adopting aggressive antibiotic control programs
- Requiring strict handwashing compliance on the part of HCWs
With more than 133 million courses of antibiotics prescribed by physcians each year to non-hospitalized patients, and 190 doses of antibiotics administered in hospitals each day, there is ample room for antibiotic-resistant bacteria to wreak havoc. As superbugs flourish in today's hospitals and manufacturers scramble to create new and more powerful drugs to combat them, the winner of the battle between man and microbe remains to be seen.
7 The Single-use and Reprocessing Debate
While it's been 16 months since the US Food and Drug Administration (FDA)'s Center for Devices and Radiological Health (CDRH) re-examined its policy on the issue of reuse of medical devices labeled for single-use, hospitals are still grappling with the issue of in-house processing vs. using third-party reprocessors. The CDRH's primary goal is to protect the health of the public by assuring that the practice of reprocessing and reusing single-use devices is safe and based on solid science. Prior to publishing current re-use guidelines on Aug. 14, 2000, the CDRH conducted extensive research, inspections, and compliance investigations as well as held public meetings about the proposed strategies.
The guidelines equitably apply existing regulations to original equipment manufacturers (OEMs), third parties, and hospitals to minimize risks associated with reprocessed single-use devices (SUDs). Despite a lack of clear data that directly link injuries to reuse, FDA has concluded that the practice of reprocessing SUDs merits increased regulatory oversight. The FDA recognizes that current medical device problem reporting systems cannot adequately capture information about potential clinical problems related to reuse, so it plans to phase-in additional oversight based on assessment of current practice and potential risk.
The draft guidance, "Reprocessing and Reuse of Single-Use Devices: Review Prioritization Scheme," establishes factors that the FDA considers in categorizing the risk associated with SUDs that are reprocessed. The draft sets the FDA's priorities for enforcing premarket submission requirements for premarket notifications 510(k) or for premarket applications (PMA). For more details, visit www.fda.gov/cdrh/reuse.
8 Needlesticks Revisited
While infection control practitioners (ICPs) wait to see how the Needlestick Safety and Prevention Act (signed into law November, 2000) affects incident rates, ICPs continue to work toward better awareness of and compliance with the law. The CDC reports that up to 86% of needlestick injuries can be prevented by using safety-engineered needles and other devices. The EPINet research database indicated that the average hospital reported an overall rate of sharps injuries at 30 per 100 occupied beds, while a recent CDC/NIOSH Alert on Needlestick Injuries estimated that as many as half of all sharps-related injuries go unreported. Most incidences occurred during injections, blood-drawing procedures, and suturing, and nurses were injured at three times the rate of other occupations. For more information, see the Joint Commission's Sentinel Event Alert Issue 22, August 2001.
9 Hand Hygiene: Therein Lies the Rub
Instilling good hand-hygiene habits among HCWs has always been the cornerstone of an infection control practitioner's role, and it's a topic that persists year after year, for good reason, since research has shown it plays an important role in reducing nosocomial infection rates. As ICPs await a new draft guideline on hand hygiene from the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC, they follow the goal of "identifying skin hygiene practices that provide adequate protection from the transmission of infecting agents while minimizing the risk of changing the ecology and health of the skin and increasing resistance in the skin flora," as documented by noted researcher Elaine Larsen.
HCWs who wash their hands more than 35 times a day--the moment handwashing starts contributing to chronic skin irritation which can lead to dermatitis--are in a bind, says Rita McCormick, RN, CIC, a research coordinator in the Department of Infectious Diseases at the University of Wisconsin. While facilities demand high compliance rates for handwashing, HCWs who suffer from significant skin irritation open themselves up to greater infection and transmission of pathogens that seek refuge in the exposed cracks and crevices of damaged skin. Finding balance between handwashing compliance and HCW skin care has led many facilities toward alcohol gels that promise solid bacteria kill rates and longer-lasting residual action, McCormick says. She adds that supplying the right gloves, providing good-quality soaps and lotions, and educating HCWs about good hand hygiene can help ameliorate the problem.
10 Putting Sacred Cows Out to Pasture
Home-laundered scrubs. Artificial fingernails. Alcohol gels. What these items have in common is their status as highly debatable topics among OR personnel and infection control practitioners. They also are brought up when dialogue about sacred cows begins. According to healthcare consultant Jan Schultz, sacred cows are defined as "practices blessed by time but not necessarily by science."
In a 2000 survey conducted by OR Manager, certain sacred cows apparently are being put out to pasture. The survey revealed that requirements for shoe covers and cover gowns are waning, as is expiration dating for sterile packages, which is being replaced by an event-related approach. Other sacred cows are lingering. Despite literature showing that preoperative hair removal is unnecessary and even potentially harmful, many surgeons still use razors, not clippers. The survey also showed that more than 90% of OR managers surveyed said their facilities balk at home-laundered scrubs. Adoption of the shortened hand scrub continues, with almost half of OR managers reporting their personnel do a 5-minute initial scrub, with 1- to 3-minute scrubs in between cases. The survey also reported that corner-to-corner floor cleaning is falling out of favor, as is automatically discarding dropped packages. Flash sterilization is holding steady, while many Ors are relaxing policies on the wearing of artificial nails, nail polish, and jewelry.
Top Web Health Stories for 2001:
January 18: The American Red Cross announces new blood donor restrictions will be enforced in September to prevent vCJD from entering the American blood supply.
January 26: Health officials in San Francisco sound the alarm that AIDS rates are sky rocketing for the first time in many years. HCWs from other areas of the world report a similar increase, leading researchers to believe people are becoming more risky in their sexual behavior. Some theorize the efficacy of AIDS cocktail drugs are encouraging risky behavior.
February 1: Researchers report the first significant evidence of resistance to current AIDS cocktail medications.
February 12: Indian pharmaceutical company Cipla, Inc., announces it will begin producing generic AIDS medication for African nations. Officials estimate the drugs will cost each person $1 per day, in comparison to inflated and unreachable American and European company rates. Cipla faces patent infringement, but the UN encourages their actions.
March 9: An American and an Italian research team announce it will begin experiments to clone the first human being.
March 14: Foot and Mouth disease surprises the UK and much of Europe; leaving transportation nightmares and canceling many international activities across the continent.
March 15: Nurse Kristen Gilbert is convicted of killing four patients via injection in an alleged attempt to get the attention of her security guard boyfriend.
April 12: The Dutch legalize euthanasia.
May 25: 100th case of vCJD confirmed in UK.
June 5: 20th anniversary of first AIDS alert.
June 28: Californian officials struggle to keep foreign mosquitoes from invading LA after lucky bamboo shipments import dangerous bugs.
July 2: AMA fires CEO E. Ratcliffe Anderson, Jr.
July 12: WHO to provide developing nations with medical journals.
Staph found to swap genes-improves resistance.
July 18: Israeli researcher discovers Mad Cow markers in urine.
August 9: Chinese officials admit for the first time AIDS is rampant.
August 16: Pharmacist arrested for allegedly diluting chemotherapy drugs.
August 20: Chinese officials admit Hep B infects more than 60% of population.
August 21: US government announces it will begin regulating blood supply.
September 4: US government admits to funding, researching germ warfare.
September 10: Harvard researcher keeps AIDS-infected monkeys alive for 600 days via vaccine.
September 12: CDC, EPA, Red Cross officials evaluate health risks from attack. Americans asked to donate blood.
October 2: Researchers announce advances in understanding anthrax.
October 5: Robert Stevens becomes the first victim of inhalational anthrax since the September 11th attacks. Stevens, a Florida tabloid employee, is believed to have been exposed via mail sent to his office.
October 31: Kathy T. Nguyen, a New York healthcare worker, becomes the fourth victim of inhalational anthrax exposure. Researchers continue to investigate how the woman was exposed. 17 Americans now exposed.
November 2: British epidemiologists estimate thousands will die from vCJD.