Transcript Slide 1

“Let there be Light”:
New light-based
technologies to prevent
infections
Elizabeth Bryce
Regional Medical Director, Infection
Prevention and Control
The Goals of Infection
Prevention and Control
• Protect Patients
• Protect Staff & Visitors
• Do this in a cost effective manner
The Role of Infection Control
Research
Consultation
Surveillance
Education
Policy and Procedure
Standards and Guidelines
Topics for Today
• Immediate Pre-operative decolonization to
prevent surgical site infections
• Use of Ultraviolet C to disinfect patient
rooms
Immediate Preoperative
Decolonization
Therapy Reduces
Surgical Site
Infections:
A multidisciplinary quality
improvement project
Dr. Elizabeth Bryce
On behalf of the Vancouver General Hospital
Decolonization Team
Vancouver, British Columbia, Canada
5
Pre-operative Decolonization:
Background
• Most surgical site infections (SSIs) arise from the
patient’s own bacteria
• Decreasing the bacterial load on the skin and nose prior
to surgery can decrease the risk of surgical site
infections (SSIs) = DECOLONIZATION
• Traditional decolonization consist of antiseptic soap
(chlorhexidine) +/- intranasal antibiotics (mupirocin)
• Compliance with chlorhexidine + mupirocin poor
• Resistance to mupirocin is an issue
Our Innovative Approach
Nasal Photodisinfection
Chlorhexidine Wipes
• Methylene blue applied
to nares
• Two – 2 minute pulses
of red light
• applied to limbs
and torso the night
prior to or day of
surgery
Chlorhexidine Washcloths
• Alcohol-free washcloth impregnated
with CHG
• FDA and Health Canada approved
• Used below the neck day of or night
prior to surgery
• Left on the skin (not rinsed off)
• Equivalent to 4% CHG on skin
http://www.sageproducts.com/lit/20778C.pdf
MRSAid™ Treatment Protocol
1st Illumination Cycle
2nd Illumination Cycle
1. Connect nasal illuminator tips to laser cable port via fiber-optic connector
2. Illuminate for 2 minutes with tips placed as shown above (directed into
inner tip of nose for 1st cycle and posterior for 2nd cycle)
How Photodisinfection works
Treatment Site
Irrigation
Tissue
Apply
Colonized with Photosensitizer
Pathogenic
that binds to
Bacteria
bacterial
surfaces
Illumination
Eradication
Illuminate
the
Treatment
Site Using
Non-Thermal
Light Energy
“Activated”
Photosensitizer
creates reactive
oxygen species,
killing bacteria
Advantages of this Approach
11
VGH SSI reduction decolonization
QI project
Objectives:
1. To determine if immediate preoperative
decolonization using nasal photodisinfection
therapy + CHG wipes reduces SSI rates in
elective non-general surgeries.
2. To assess the feasibility of integration of a
decolonization program in the pre-operative
area
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Decolonization Protocol
Surgeries included:
•cardiac, thoracic, ortho-recon,
ortho-trauma, vascular,
neuro/spine, and breast cases.
Surgeries excluded:
•open fractures, dirty/contaminated
cases, duplicate cases, cases in 6
week introductory period
CHG within 24h
Nasal Culture
Photodisinfection
Therapy
(MRSAid)
SSI
Surveillance
Perform
Surgery
Document
Compliance, AE
1. Microbiological Efficacy,
Safety,
and Compliance
• Microbiological Efficacy
Growth
MSSA
reduction
n = 1286 (%)
MRSA
reduction
n=51 (%)
Heavy
105/109 (96.3%)
8 /10(80%)
Moderate
348/383 (90.9%)
13/16 (81.3%)
Scant
598/794 (75.3%)
18/25 (72%)
Total
1051/1286
(81.7%)
39/51 (76.4%)
*unpaired data was excluded
** reduction defined as complete or partial bioburden reduction
1. Microbiological Efficacy,
Safety,
and Compliance
• Safety:
– All adverse events were tracked and reported
– 7 cases of transient, mild burning sensation in
throat after application of methylene blue
– Total adverse event rate of 7/5691 = 0.123%
SSI Data - Extraction
Cases during study period and study hours
N=5176
SSI surveillance routinely done
N= 3274
Cases treated pre-op
N = 3068
94% compliance
SSI surveillance not routinely done
N = 1912
Cases not treated
N = 206
Comparing SSI rates: Treated and
Historical
Specialty
Treated Patients
SSIs
Cardiovascular 19/628
4-year Historical Group
Rate % SSIs (Average)
P value
OR
Rate %
3.0
83/3334 (21)
2.5
0.4373
0.82
31/2152(7.75)
50/2844 (12.5)
1.4
1.8
0.0764
0.0251
3.65
2.64
136/1606 (34)
8.5
14/1357 (3.5)
1.0
25/1094(6.25)
2.3
339/12,387 (
2.7
85) program in place previously
(1) CHG/mupirocin program in place previously (2) CHG bathing
0.0009
0.1478
0.9152
0.0004
2.35
4.48
1.07
1.73
1
Neuro2
Orthopedics1
(all)
2/502
6/892
0.4
0.7
Spine
Thoracic
Vascular
Total
18/475
1/431
3/140
49/3068
3.8
0.2
2.1
1.6
42%
reduction
Impact: Financial
Service
Cases Avoided
Case Cost*
Cost Avoidance
Neurosurgery
6
$25,000
$150,000
Cardiovascular
3
$30,000
$90,000
Orthopedics
8
$33,000
$ 264,000
Spine
15
$30,000
$450,000
Vascular
2
$20,000
$ 40,000
Thoracic
1
$10,000
$ 10,000
Total
35**
$1,040,000
*Case Cost provided by A. Karpa Financial Planning and Business Support
**Cases were rounded down by “1”
Impact: Readmissions
Parameter
Project Period
Average previous
two years
Average number of
readmissions/Fiscal
period
Average days stay
1.25/pd
4.04/pd
16.5
16.5 days
Readmissions/fiscal
year
Days Stay x Cost/dy
15
48.5
15 x 16.5 x $500/day
=$123,750
48.5 x 16.5 x $500/day
=
$400,125
Cost Avoidance
$276,375
Patient Days saved
552
Impact: Cost Avoidance
1. LPNs able to treat 5176 patients/yr
2. 3608 were cases routinely followed for SSI outcomes
3. If remaining 1912 cases had a similar SSI rate reduction
(0.016) , 31 additional infections prevented.
4. $20,000/SSI x 31 = $ 611,840 avoided costs
Total Cost Avoidance: $1,040,000 +
$276,375 + $611,840 = $1,928,215
Comparing Treated and
Untreated Patients in
Intervention Period
• 206/3274 (6.3%) of patients routinely
followed for SSI surveillance were not
treated during the intervention period
• 49/3268 (1.6%) treated patients had a SSI
• 17/206 (8.3%) of untreated patients had a
SSI
• Propensity score analysis with 1:4
matching performed
Propensity Score Analysis: 1:4 Matching
Untreated
188
Total
892
P-Value
Stand d
Number of Patients
Age
Treated
704
59.6 (± 1.2 )
59.3 (± 2.5 )
59.6 (± 1.1 )
0.832
0.15
Gender (Male)
329 (46.7%)
92 (48.9%)
421 (47.2%)
0.622
0.04
ASA (3-5)
433 (61.5%)
118 (62.8%)
551 (61.8%)
0.917
0.02
Scheduled Case
623 (88.5%)
160 (85.1%)
783 (87.8%)
0.211
0.1
Cancer
Suspected/Proven
Surgery Time
113 (16.1%)
32 (17%)
145 (16.3%)
0.379
0.14
149.2 (± 17.8 ) 151.5 (± 7.6 )
111
118
0.771
0.21
Median Time
Cases Greater than
2h
T time: cases higher
than 75 percentile
Type of Service
Cardiovascular
Neurological
Orthopedic
Spine
Thoracic
Vascular
Infected
152.1 (± 8.3 )
120
351 (49.9%)
87 (46.3%)
438 (49.1%)
0.412
0.07
141 (20%)
40 (21.3%)
181 (20.3%)
0.685
0.03
136 (19.3%)
39 (20.7%)
175 (19.6%)
0.68
0.04
117 (16.6%)
198 (28.1%)
29 (15.4%)
52 (27.7%)
146 (16.4%)
250 (28%)
0.74
0.927
0.03
0.01
104 (14.8%)
25 (13.3%)
129 (14.5%)
0.726
0.04
123 (17.5%)
26 (3.7%)
36 (19.1%)
7 (3.7%)
159 (17.8%)
33 (3.7%)
13
14
27
0.593
1
Not
applicable1
0.04
0
Not
applicable1
**Conditional logistic regression analysis of the matched data with treatment as
the only covariate: coefficient = -1.44, z = -3.65 p=0.0026
Conclusions
Reduction in surgical site infections by 42%
Takes 10 minutes: easily integrated into workflow
Safe and has excellent patient compliance (94%)
Cost-effective ($1.3 million in cost avoidance)
The Team
Surgery:
Bas Masri
Gary Redekop
Perioperative Services:
Debbie Jeske
Kelly Barr
Anna-Marie MacDonald
Lorraine Haas
Lucia Allocca
Steve Kabanuk
Claire Johnston
Shelly Errico
Tammy Thandi
Pauline Goundar
Dawn Breedveld
Infection Control:
Elizabeth Bryce
Leslie Forrester
Tracey Woznow
Medical Microbiology:
Diane Roscoe
Titus Wong
Patient Safety:
Linda Dempster
Ondine Biomedical:
Shelagh Weatherill et al
Chandi Panditha
Diane Louke
Thank you
Special Thanks: microbiology technologists, and perioperative staff
Ultraviolet Room Disinfection
Elizabeth Bryce
On behalf of the Innovation Award Team
January 9, 2013
Background
• Contaminated environments increase risk
of transmission of HAIs
• Prior room occupancy by a pt with an
antibiotic resistant organism (ARO)
increases risk to subsequent pts
• Novel disinfecting systems could minimize
this risk particularly of Clostridium difficile
infection
Clostridium difficile
• Clostridium difficile infection (CDI): most
common cause of nosocomial diarrhea,
with an incidence of 3-8 cases per 1000
hospital admissions.
• Symptoms:from mild or moderate diarrhea
to severe complications such as
pseudomembranous colitis, toxic
megacolon, septic shock, renal failure, and
mortality.
Ultraviolet surface
disinfection
• Used in laboratories for years
• New literature demonstrates its value as
an adjunct to cleaning
• Demonstrated to reduce CD spores,
MRSA, VRE within hospital rooms
• Ability to integrate the technology into
workflow needs to be evaluated
The technology
SmartUVC aka TruD
• UVC light automatically delivers
lethal UV doses required for each
room using a 3600 sensor
• Two settings: Bacterial and
sporicidal
• Evaluated already in USA for
effectiveness
• 9 hospital cross over study re
outcomes in USA underway
Similar technology but:
Allows repositioning of the
machine
Only one setting for all
organisms
The R-D RAPID DISINFECTOR:
Advanced Technology for Reducing Pathogens
in Patient Environments
August 20, 2013
Steriliz, LLC.
Is it Safe?
Yes, there are sensors that shut machine off
if door opened.
Additional barriers are across door.
UV light doesn’t penetrate through glass
http://www.vickers-warnick.com/news/uv-disinfecting-lights-brought-to-new-york-state-hospital-to-control-c-diff-outbreaks/
Project Proposal
• Use equipment on isolation rooms with
priority on floors with most Clostridium
difficile cases
• Use it on the ORs, endoscopy suite and
equipment depot at night
• Use it as required during outbreaks
• Assess its effectiveness microbiologically
• Assess it’s impact on bed turn around time
• Assess user satisfaction
Results
• Both machines effective: one machine
has slightly better microbial kill in the
presence of protein under lab conditions
• Both machines effectively remove
organisms in patient rooms
• Machine B is preferred by users
• Machine B has a faster disinfecting time
RD MRSA Bed
Kill at >7.2 x 103 CFU
Tru-D MRSA Bed
Kill at <7.2 x 100 CFU
UVC + Decluttering and Equipment
Cleaning Campaign: Impact
Total CDI Acquired at VGH (Pre & Post Implementation)
400
350
375
↓ 30%
Total Number of Cases
300
250
263
200
150
100
50
Jun 2011 - Aug 2012
Sep 2012 - Dec 2013
0
Pre
Post
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What’s next?
• Business case to purchase the machines
• Incorporation into regular work flow
• Monitor outcomes not only with C.difficile
but with other organisms
• If efforts can be sustained, roll out to other
regional facilities