Transcript Cleaning in the ICU

Cleaning in the ICU:
strong evidence, strong
convictions and a dose
of reality ?
APR Wilson, G Moore, D Smyth, R Jackson, J
Singleton, E James, V Gant, S Shaw, M Singer
G Bellingan
University College London Hospitals
Royal Free Hospital
What do we know about
MRSA transmission?
How it is MRSA transmitted –
Hands?
Airbourne?
Why don’t some patients get MRSA?
Where are patients colonised?
How effective is isolation of MRSA patients?
Evidence MRSA can be controlled
Souweine (France 2000)
• Retrospective: contact, surveillance, isolation, mupiricin
• One year pre and one year post introduction
• MRSA rates fell from 4/1000 pt days to 2.2/1000
Jernigan (Charlottesville 1996)
Prospective, Neonatal ICU
4.8% colonised/infected – single strain
Contact, cohort, surveillance staff + patients
Transmission rates Isolation
0.009/day
Not isolated 0.14/day
p<0.0001
Yap, Gomersall et al. (Hong Kong) Clin Infect Dis 2004; 39: 511
Observational report of MRSA incidence on ICU
100% compliance with contact precautions during SARS
8 fold INCREASE in MRSA during this period
Returned to baseline after return to normal precautions
Isolation
No
Isolation
Air
Communal
Surfaces
Carrier of
pathogen
known or
unknown
Patient
Hands of staff
and visitors
Near patient
surfaces
Hospital acquired
pathogens
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Transmitted by unwashed hands, air
or environment or other?
In ICU hand hygiene more important
than physical segregation??
Towards Cleaner Hospitals, Matrons
Charter, linked to 50% MRSA
reduction target
Cleaning
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ICU patient susceptible to repeated
contamination
Microfibre removes 99% of surface
bacteria
Near patient equipment cleaned by
unsupervised nurses not domestics
Aims
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Compare standard cleaning and
intensively monitored enhanced
cleaning
Effect on local contamination rates
Effect on colonisation of patients
Effect on hospital acquired infection
Two month phases
Apr 07-Mar 08
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Randomised standard or enhanced
cleaning with one week washout
Standard – existing practices plus
nurses clean equipment
Enhanced – microfibre monitored by
ATP bioluminescence.
MRSA screening on admission and
weekly
Methods
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Normal domestic staff routine cleaning
beds, floors and walls
Nursing staff bedside equipment
Enhanced – team of technicians used
colour coded microfibre cloths, 15 min
per bed area
Methods
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Sampling daily - 20% of beds i.e. 12
bed days each ICU each week, total
1152 bed days, 20736 samples
1:4 MRSA bed
Air and environmental samples,
patient and general areas
Hourly sampling 1 day each phase
Methods
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Sites: drawer, bed rail, syringe driver,
nurse hands, monitor and
keyboard/chart
Three times each sampling day
Communal sites: apron dispenser,
doctors hands, telephone, air
Methods
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Both ICU screened for MRSA on
admission and 1-2 times/week
90% chance of detecting 50%
reduction in contaminated bed areas
67% chance of detecting 50%
reduction in rate of acquisition of
MRSA
Expected Outcome
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Show if enhanced cleaning beneficial
for environmental contamination and
acquisition of hospital pathogens
Acquisition of pathogens is/is not
related to level of contamination in
environment
Monitoring
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Steering Group meeting every 3-4
weeks
Daily supervision of staff by
investigators
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Relative light units
Typical Clean Trace Audit
ATP audit Phase 5
2000
1500
1000
500
0
ATP pre clean
ATP post clean
Hand hygiene audits
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Used Pittet criteria
Compliance in enhanced phases:
UCH 50% RFH 58%
Compliance in standard phases:
UCH 53% RFH 50%
Patients
A Enh A Std B Enh B Std
Patients
799
863
453
468
>48h
346
379
222
242
Median APACHE 17
16
17
17
Median age
61.3
58.1
59.0
61.2
Patients
A Enh
A Std B Enh B Std
Female %
41.9
46.4
42.4
41.2
ICU stay (IQR)
1-6
1-6
1-11
1-11
% pts MRSA
positive o/a
8.5
6.5
10.8
8.3
Number of bed areas contaminated with MRSA
Enhanced Cleaning reduced
MRSA in the environment
90
80
70
60
50
40
30
20
10
0
standard cleaning
enhanced cleaning
MRSA in environment
Bedspaces Samples
with MRSA tested
Standard
Enhanced
165
1.6%
70
0.7%
Odd ratio
10141
10068
0.45
0.34, 0.61
Repeated sampling 12h
Median Total Viable Count
20
enhanced A
15
enhanced B
10
standard A
standard B
5
20
:0
0
18
:0
0
16
:0
0
14
:0
0
12
:0
0
10
:0
0
0
08
:0
0
Median
CFU/contact slide
25
MRSA sites
7
6
5
%
4
3
2
1
0
Drawer handle
Chart
Keyboard
Bed rail
Syringe driver
Nurse's hand
Monitor
Apron dispenser
Air
Doctor hand
Telephone
Number of sites contaminated with
MRSA
Enhanced cleaning reduced MRSA
at all sites in patient environment
70
60
50
40
30
20
10
0
chart or
keyboard
bed rail
syringe
driver
standard cleaning
draw er
handle
monitor
enhanced cleaning
nurse's
hand
Hands
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MRSA reduced on doctors’ hands (OR
0.26 [0.07, 0.95]) during enhanced
cleaning
Nurse hands trend (OR 0.6 [0.29,
1.08])
Enhanced Cleaning had no
measurable effect on MRSA
acquisition or infections
% pts MRSA
positive o/a
MRSA
acquisitions
MRSA new
infection
A Enh A Std
B Enh B Std
8.5
6.5
10.8
8.3
12
1.5%
8
10
1.2%
4
18
4.0%
1
24
5.1%
3
Patient acquisition of
MRSA
Enhanced
vs.
standard
OR
95% CI
0.98
(0.58, 1.65)
Acquisition of other
pathogens – too low
Enh
Std
Enh
Std
Patients
799
863
453
468
Acinetobacter
2
0
2
9
ESBL
4
5
7
3
VRE
1
1
0
0
C difficile
2
6
8
2
Conclusions
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Enhanced cleaning reduced MRSA load
in environment 40%
Enhanced cleaning reduced bacterial
load on nurse/doctor hands
No significant reduction in acquisition
or infection
Bed rails highly touched and
contaminated – texture effect
Origin MRSA
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7 of 64 cases MRSA in environment
preceded isolation from patient of a
strain indistinguishable by PFGE
Further typing to establish chains of
transmission
Airborne Spread
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Why is MRSA commonly detected in the
nose?
Can detect distant MRSA in the air
after:
– physiotherapy or NIV for non-intubated
patients with MRSA pneumonia,
– bed linen changes from colonised patients
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Would expect the isolation study to
have shown a difference
The gut as a source of
colonisation?
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Silvestri et al.
– oropharyngeal carriage in up to 80% of cases during an
outbreak
– 33% in the absence of an outbreak.
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Oral vancomycin
– significantly reduced colonisation,
– reduce MRSA nosocomial pneumonia and
– contained an MRSA outbreak.
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No vancomycin resistant enterococci (VRE) or
intermediate sensitivity S. aureus (VISA) found
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Did not screen for topical MRSA - incidence of skin with
gut carriage unknown
Local variations in MRSA incidence
in ICU’s in the UK
London Teaching Hospitals
with >1000 admissions/year
Hospital a) no bacteraemias
in 6 months
Hospital b) 1 bacteraemia in
14 months
Hospital c) 12 bacteraemias
in 12 months
Local variations in MRSA incidence
in ICU’s in the UK
Hospital a) chlorhexidine wash daily for all, CVC
bundles, no 3 way taps, rapid screening,
isolation, linezolid for specific cases, standard
plus precautions for all.
Hospital b) chlorhexidine wash daily for all, CVC
bundle, full gowns, rapid screening,
no isolation.
Hospital c) rapid screening and chlorhexidine for positive
cases, CVC bundles, no 3 way taps,
isolation, standard plus precautions for all.
The evidence
We could not identify a major source for environmental
transmission of MRSA.
Enhanced cleaning may not reduce colonisation or
infection
Isolation may not reduce colonisation or infection
Clearly a broad “attack” on the environment, the
patient and ICU processes can reduce MRSA rates
Does it matter that we don’t know which of these are
effective…???
It would be great if infection control techniques could
be based on evidence rather than conjecture.