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By Kelly M. Pyrek
As today's healthcare professionals cope with budget cuts, staffshortages, Joint Commission inspections, and nosocomial infections, they mustcontend with the threat of bioterrorism as well. The past 12 months have beenfraught with both challenges and opportunities, and in this issue of InfectionControl Today,Â® we take a look at some of the year's mostsignificant infection control trends and infectious disease outbreaks.
And as we look to the new year, all of us at Infection ControlTodayÂ® wish you a healthy and prosperous 2002!
1 The Threat of Bioterrorism
As infection control practitioners grapple with the threat of anthrax in thewake of the Sept. 11 terrorist attack, the Centers for Disease Control andPrevention (CDC) is warning healthcare professionals to look for possible casesof food poisoning, smallpox, and viruses such as Ebola. Physicians and nursesare being encouraged to watch for unusual age distribution in diseases, such asa chickenpox-like illness in adults. The CDC also is asking state healthofficials to formulate a plan for instructing healthcare providers about how torecognize unusual diseases that might be cases of bioterrorism.
"There is no evidence of any threat other than anthrax," says JulieGerberding, MD, an acting deputy director and head of infection control at theCDC. "We are not experiencing a national outbreak." At presstime,there had been dozens of exposures to anthrax. Scientists and investigatorsbelieve that the anthrax found in New York, Washington, and Florida came fromthe same source, occurred naturally, and were not biologically engineered. As oflate 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 ofother diseases that could be used by terrorists. The CDC has listed plague,anthrax, and tularemia on its list of most worrisome biological agents. For moreinformation 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 exposureto variant Creutzfeldt-Jakob Disease. vCJD is a degenerative neurologicaldisease caused by prions, which are malformed proteins. A new variant of thepreviously recognized genetic disease, vCJD has been linked to "madcow" disease, and is more rapid in the onset of clinical symptoms. Thisalert mandates that hospitals review their policies and procedures for theprocessing of instrumentation used in surgical procedures on patients who couldhave vCJD. The World Health Organization (WHO) issued controversial newinfection control guidelines for transmisssable spongiform encephalopathies thatrequire the steam sterilization of instruments in sodium hydroxide solutionwhich can endanger healthcare workers (HCWs) and possibly damage the sterilizer.
Medical literature has indicated that prions are resistant to most currentforms of sterilization, and there have been documented cases of iatrogenictransmission of vCJD during surgical procedures involving the brain, eyes, andspinal cord. CJD is genetic and cannot be spread through instruments; vCJD isprion-based. Many healthcare professionals swear by the saying, if it cannot becleaned, it cannot be sterilized, and recommendations have ranged from throwingaway all potentially contaminated instruments, to soaking them in and then steamsterilizing them for a long duration at high temperatures. While much has beenmade of vCJD in the media, many infection control experts emphasize that thereis no known or suspected risk of vCJD transmission to HCWs who handle vCJD-contaminatedinstruments and devices, if they have intact skin, if they are wearing theappropriate 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 ofinfection control departments in 1976, many infection control practitionersquake at the mere mention of JCAHO. This healthcare watchdog agency has beenparticularly observant in recent years, and has been further spurred on by anInstitute of Medicine report that quipped, "Healthcare harms too frequentlyand routinely fails to deliver its potential benefits." The newpatient-safety standards that went into effect July 1 require hospitals toinitiate specific efforts to prevent medical errors and to tell patients whenthey have been harmed during their treatment. A 1999 Institute of Medicinereport estimates that medical errors kill between 44,000 and 98,000 hospitalpatients annually.
"Healthcare executives, physicians, and nursing leaders must radicallychange their thinking about medical mistakes," says Dennis O'Leary, MD,president of JCAHO. "We need to create a culture of safety in hospitals andother healthcare organizations, in which errors are openly discussed and studiedso that solutions can be found and put in place. These new standards areintended to do just that."
The new standards underscore the importance of strong organization leadershipin building a culture of safety that encourages the internal reporting ofmedical errors and actively engages clinicians and other staff in the design ofremedial steps to prevent future occurrences of these errors. A second majorfocus of the new standards is on the prevention of medical errors through theprospective analysis and re-design of vulnerable patient care systems (e.g.,the ordering, preparation, and dispensing of medications). Potentiallyvulnerable systems can readily be identified through relevant national databasessuch as JCAHO's Sentinel Event Database or through the hospital's own riskmanagement program. Finally, the standards make clear the hospital'sresponsibility to tell a patient if he or she has been harmed by the careprovided.
4 Nursing Shortage Imperils Good Infection Control Practices
In July, members of the Association for Professionals in Infection Controland Epidemiology (APIC) met with experts at the CDC to discuss how the ongoingnursing shortage, especial in infection control departments, could imperilpatient and healthcare worker safety and wellbeing.
"Staffing is a huge issue that we can partner with our sister nursingorganizations in working toward," says APIC president Judith English, RN,MSN, CIC. "It is more likely that healthcare-acquired infections willhappen in an understaffed, overworked (institution)." While the direct linkbetween understaffing and adverse outcomes can be difficult to establish, fewdispute that a short-staffed unit undermines handwashing compliance and aseptictechnique. William Jarvis, MD, associate director for program development at theCDC's division of healthcare quality promotion, calls it "a tremendousproblem" and points to studies showing an increase in infection ratesassociated with decreasing nurse-to-patient ratios. He adds that even asinfection-control departments and being downsized as non-revenue generating,there is an upswing in cases presenting antibiotic-resistant pathogens such asVRE and MRSA.
5& 6 Nosocomial Infections Flourish, Antibiotic Resistance on theRampage
Even though Ignaz Semmelweis demonstrated in the 1840s the importance of handhygiene for the control of transmittable infections, it wasn't until 1976 thatJCAHO was the impetus behind the administrative and financial support forhospital infection control programs. In 1985, the CDC's Study on the Efficacy ofNosocomial Infection Control reported that facilities with a hospitalepidemiologist, one infection control practitioner for every 250 beds, activesurveillance mechanisms, and ongoing infection control efforts, reducednosocomial rates by one-third.
Even with this progress, in 1995, the latest figures available, nosocomialinfections cost $4.5 billion and contributed to more than 88,000 deaths. SinceSemmelweis' time, there has been a constant parade of culprits: For most of theearly to mid 20th century, Staphylococcus aureus reigned supreme inhospitals; in the 1970s, Pseudomonas aeruginos arrived on the scene. Inthe 1980s, methicillin-resistant staph (MRSA) and vancomycin-resistantenteroccoci (VRE) debuted, while in the 1990s and today, 32% of nosocomialinfections were caused by Escherichia coli, P. aeruginosa,Enterobacter spp, and Klebsiella pneumoniae.
Ongoing preventative measures include:
With more than 133 million courses of antibiotics prescribed by physcianseach year to non-hospitalized patients, and 190 doses of antibioticsadministered in hospitals each day, there is ample room for antibiotic-resistantbacteria to wreak havoc. As superbugs flourish in today's hospitals andmanufacturers scramble to create new and more powerful drugs to combat them, thewinner 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)'sCenter for Devices and Radiological Health (CDRH) re-examined its policy on theissue of reuse of medical devices labeled for single-use, hospitals are stillgrappling with the issue of in-house processing vs. using third-partyreprocessors. The CDRH's primary goal is to protect the health of the public byassuring that the practice of reprocessing and reusing single-use devices issafe and based on solid science. Prior to publishing current re-use guidelineson Aug. 14, 2000, the CDRH conducted extensive research, inspections, andcompliance investigations as well as held public meetings about the proposedstrategies.
The guidelines equitably apply existing regulations to original equipmentmanufacturers (OEMs), third parties, and hospitals to minimize risks associatedwith reprocessed single-use devices (SUDs). Despite a lack of clear data thatdirectly link injuries to reuse, FDA has concluded that the practice ofreprocessing SUDs merits increased regulatory oversight. The FDA recognizes thatcurrent medical device problem reporting systems cannot adequately captureinformation about potential clinical problems related to reuse, so it plans tophase-in additional oversight based on assessment of current practice andpotential risk.
The draft guidance, "Reprocessing and Reuse of Single-Use Devices:Review Prioritization Scheme," establishes factors that the FDA considersin categorizing the risk associated with SUDs that are reprocessed. The draftsets the FDA's priorities for enforcing premarket submission requirements forpremarket notifications 510(k) or for premarket applications (PMA). For moredetails, visit www.fda.gov/cdrh/reuse.
8 Needlesticks Revisited
While infection control practitioners (ICPs) wait to see how the NeedlestickSafety and Prevention Act (signed into law November, 2000) affects incidentrates, ICPs continue to work toward better awareness of and compliance with thelaw. The CDC reports that up to 86% of needlestick injuries can be prevented byusing safety-engineered needles and other devices. The EPINet research databaseindicated that the average hospital reported an overall rate of sharps injuriesat 30 per 100 occupied beds, while a recent CDC/NIOSH Alert on NeedlestickInjuries estimated that as many as half of all sharps-related injuries gounreported. Most incidences occurred during injections, blood-drawingprocedures, and suturing, and nurses were injured at three times the rate ofother occupations. For more information, see the Joint Commission's SentinelEvent Alert Issue 22, August 2001.
9 Hand Hygiene: Therein Lies the Rub
Instilling good hand-hygiene habits among HCWs has always been thecornerstone of an infection control practitioner's role, and it's a topic thatpersists year after year, for good reason, since research has shown it plays animportant role in reducing nosocomial infection rates. As ICPs await a new draftguideline on hand hygiene from the Healthcare Infection Control PracticesAdvisory Committee (HICPAC) of the CDC, they follow the goal of"identifying skin hygiene practices that provide adequate protection fromthe transmission of infecting agents while minimizing the risk of changing theecology and health of the skin and increasing resistance in the skinflora," as documented by noted researcher Elaine Larsen.
HCWs who wash their hands more than 35 times a day--the moment handwashingstarts contributing to chronic skin irritation which can lead to dermatitis--arein a bind, says Rita McCormick, RN, CIC, a research coordinator in theDepartment of Infectious Diseases at the University of Wisconsin. Whilefacilities demand high compliance rates for handwashing, HCWs who suffer fromsignificant skin irritation open themselves up to greater infection andtransmission of pathogens that seek refuge in the exposed cracks and crevices ofdamaged skin. Finding balance between handwashing compliance and HCW skin carehas led many facilities toward alcohol gels that promise solid bacteria killrates and longer-lasting residual action, McCormick says. She adds thatsupplying the right gloves, providing good-quality soaps and lotions, andeducating 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 itemshave in common is their status as highly debatable topics among OR personnel andinfection control practitioners. They also are brought up when dialogue aboutsacred cows begins. According to healthcare consultant Jan Schultz, sacred cowsare defined as "practices blessed by time but not necessarily byscience."
In a 2000 survey conducted by OR Manager, certain sacred cowsapparently are being put out to pasture. The survey revealed that requirementsfor shoe covers and cover gowns are waning, as is expiration dating for sterilepackages, which is being replaced by an event-related approach. Other sacredcows are lingering. Despite literature showing that preoperative hair removal isunnecessary and even potentially harmful, many surgeons still use razors, notclippers. The survey also showed that more than 90% of OR managers surveyed saidtheir facilities balk at home-laundered scrubs. Adoption of the shortened handscrub continues, with almost half of OR managers reporting their personnel do a5-minute initial scrub, with 1- to 3-minute scrubs in between cases. The surveyalso reported that corner-to-corner floor cleaning is falling out of favor, asis automatically discarding dropped packages. Flash sterilization is holdingsteady, while many Ors are relaxing policies on the wearing of artificial nails,nail polish, and jewelry.
January 18: The American Red Cross announces new blood donorrestrictions will be enforced in September to prevent vCJD from entering theAmerican blood supply.
January 26: Health officials in San Francisco sound the alarm thatAIDS rates are sky rocketing for the first time in many years. HCWs from otherareas of the world report a similar increase, leading researchers to believepeople are becoming more risky in their sexual behavior. Some theorize theefficacy of AIDS cocktail drugs are encouraging risky behavior.
February 1: Researchers report the first significant evidence ofresistance to current AIDS cocktail medications.
February 12: Indian pharmaceutical company Cipla, Inc., announces itwill begin producing generic AIDS medication for African nations. Officialsestimate the drugs will cost each person $1 per day, in comparison to inflatedand unreachable American and European company rates. Cipla faces patentinfringement, but the UN encourages their actions.
March 9: An American and an Italian research team announce it willbegin 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 activitiesacross the continent.
March 15: Nurse Kristen Gilbert is convicted of killing four patientsvia injection in an alleged attempt to get the attention of her security guardboyfriend.
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 mosquitoesfrom 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 chemotherapydrugs.
August 20: Chinese officials admit Hep B infects more than 60% ofpopulation.
August 21: US government announces it will begin regulating bloodsupply.
September 4: US government admits to funding, researching germwarfare.
September 10: Harvard researcher keeps AIDS-infected monkeys alive for600 days via vaccine.
September 12: CDC, EPA, Red Cross officials evaluate health risks fromattack. Americans asked to donate blood.
October 2: Researchers announce advances in understanding anthrax.
October 5: Robert Stevens becomes the first victim of inhalationalanthrax 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 thefourth victim of inhalational anthrax exposure. Researchers continue toinvestigate how the woman was exposed. 17 Americans now exposed.
November 2: British epidemiologists estimate thousands will die fromvCJD.