Hospital Water: Is it a Source for Nosocomial Infections?

Copyright 2002,

Robert Garcia, BS, MMT(ASCP), CIC

Susceptible host Causative Agent Reservoir Portal of entry Mode of Transmission Portal of exit

The Chain of Infection. Components of the Infectious Disease Process.

Water as a Reservoir of Nosocomial Pathogens

• Organisms such as

calcoaceticus Pseudomonas aeruginosa, Serratia marcescens, and Acinetobacter

can replicate in relatively pure water • May be present in drinking water that has acceptable limits of safety (<1 coliform bacterium/100 mL)

P. aeruginosa

Infections due to Hospital Water Sources

• >12 reports indicating transmission and development of infection from contaminated hospital water – Trautmann M, Michalsky T, et al. Tap water colonization with

Pseudomonas aeruginosa

in a surgical intensive care unit and relation to

Pseudomonas

infections of ICU patients.

Infect Control Hosp Epidemiol

2001;22:49-62.

Burn Infections

• Tap water has been cited as the source for serious wound and sepsis – Kolmos HJ, Thuesen B, et al. Outbreak of infection in a burn unit due to

Pseudomonas aeruginosa

originating from contaminated tubing used for irrigation of patients.

Infections from Hospital Sinks

• Many reports have identified the presence of gram-negative bacteria in hospital sinks • Organisms may survive for >250 days on sink surfaces – Simor AE, Ramage L, et al. Molecular and epidemiologic study of multiresistant Serratia marcescens infections in a spinal cord injury rehabilitation unit.

Infect Control Hosp Epidemiol

1988;9:20-27.

Tip of the Iceberg

• More than 40 citations of water as a source of nosocomial infections • Anaissie et al estimate that >1,400 deaths occur each year due to waterborne nosocomial pneumonia due to

P.aeruginosa

alone – Anaissie EJ, Penzak SR, Dignani C. The hospital water supply as a source of nosocomial infections. A plan for action.

Arch Intern Med

2002;162:1483-92.

“…In such settings, hospital water may have contaminated environmental surfaces (eg, sinks, drains, and whirlpool baths), medical equipment (eg, by rinsing tube feed bags, endoscopes, respiratory equipment, etc., with tap water), or health care providers, leading ultimately to patient exposure.”

- Anaissie EJ, et al. The hospital water supply as a source of nosocomial infections. A plan for action.

Arch Intern Med

2002;162:1483-92.

How are Patients Exposed to Hospital Water?

• Handwashing (cross-contamination) • Bedpans • Enteral feedings • Respiratory equipment • Drinking • Showering • Bed bathing

Basin Bath Drawbacks

• High consumption of resources • Negative impact on nursing and patients • Damaging effects on the skin • Contamination risks with basins & water • Real economics of basins

Why Should Hospitals Care?

• Most of your patients skin is at risk • Cost of skin breakdown in U.S.: $13 Billion • Nosocomial contamination may lead to nosocomial infection • Cost of nosocomial infection: $5.9 Billion • JCAHO Patient Safety Quality Indicators • Patient ‘barometer’ for their quality of care

Source: Stone P. et al, Outcomes of ICU Working Conditions, Nov 2001

Nursing Shortage vs. Patient Outcomes

JCAHO Expert Panel Report

“Insufficient staffing not only adversely impacts health care quality and patient safety, it also compromises the safety of nurses themselves” Source: Joint Commission on Accreditation of Healthcare Organizations, August 2002

Damage to the Skin

•

Soaps can strip the acid mantle, raise the pH and compromise the epidermis

•

Washcloths introduce friction because they are harsh and rough

•

Drying soap and rough washcloths are fragile skin’s worst enemy

Sources: Friers, S.A. Ostomy, Wound Management June 2001 Bryant R. A. Ostomy, Wound Management June 2001 Wysocki A. Acute and Chronic Wounds 2 nd Edition 2000

•

Whose Skin Are We Talking About?

Your Patient

– Majority are elderly – Most have pruritic skin condition – Epidermis and dermis are thinner – Skin has reduced barrier function – Reduced skin elasticity – Poor epidermal turnover – Lowered sebum production – Loss of subcutaneous fat and muscle Source: Thomas MD, D., Clinical Journal of Medicine, Cleveland

Pressure Ulcers

• 1.6 million cases per year in acute care • Varied settings: – medical wards – surgery and operating rooms – intensive care units – rehabilitation centers – long term and home care

Prevalence of Pressure Ulcers

• Reported rates to be between 3% and 11% • Two large studies: – 9.2% (148 hospitals) 1 – 7% (116 hospitals) 2 1. Meehan M. Multisite pressure ulcer prevalence survey. Decubitus 1990;3:4-14.

2. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.

Cost Impact: Hospitals

• Unadjusted mean costs: – With Pressure ulcers - $37,288 – Without pressure ulcers - $13,924 • Adjusted for admission predictors and nosocomial infections: – With pressure ulcers - $29,048 – Without pressure ulcers - $13,819 Allman RM, Goode PS, Burst N, et al. Pressure ulcers, hospital complications, and disease severity: Impact on hospital costs and length of stay. Adv Wd Care 1999;12:23-30.

Basinborne Contamination Study

• • •

Hospital personnel do not perceive basin bath water as significantly contaminated 100% of the samples in the study were positive for bacterial growth, 60.8% were gram negative The bacterial count in basin water was so high it was similar to the bacterial count in the urine from patients with UTI’s

• •

Employees, wearing contaminated gloves used during the procedure, were observed to touch many environmental surfaces.

Basin water may serve as a reservoir of antibiotic resistant organisms

Source: Shannon R et al., Patient Bath Water as a Source of Nosocomial Microbiological Contamination: An intervention Study using Chlorhexidine. J Healthcare Safety Infect Control, 1999;3:180-84.

Basinless Bathing

• Removes the risk of basin contamination • Removes the risk of waterborne contamination • 8 washcloths to reduce transfer of organisms • Mild cleanser helps maintain skin’s natural barrier • Single-use helps reduce environmental/cross contamination • No water spills reduce slips & fall potential

Better Science and Patient Safety

What’s the Real Cost of Basin Bathing?

Energy, Water Nursing $5.11

& Sewer $.10

Laundry Processing $.98

$6.84 per bath Materials $.65

Source: Total Delivered Cost Analysis Database from U.S. hospitals 1997 - 2002, Sage marketing data on file.

Solid Economics

$6.84

total

$5.11

Nursing Time

$3.68

total

$1.83

Nursing Time $1.73

$.98

Laundry &Linens $.10 Water,Sewer,Energy

$.65

Materials

Basinless Bath $1.10 to $1.90

Basin Bath Cost Basinless Cost

Source: Total Delivered Cost data analysis of U.S.hospitals 1997-2002 $1.90

$1.10

p r i c e H o s p i t a l $5.00

$5.50

Time is on Your Side

Original Price

 New Concept  High Distribution Margins

$4.00

 One or Two Product Choices

$3.75

$3.00

 Manufacturing Efficiencies  GPO Contracts

$2.00

$2.25

$1.00

$2.05

 Multiple Product Choices

$1.90

$1.10

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