“let there be light”: new light-based technologies to prevent infections
DESCRIPTION
“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. - PowerPoint PPT PresentationTRANSCRIPT
“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
Standards and G
uidelines
Policy and P
rocedure
Education
Surveillance
Consultation
Research
Topics for Today
• Immediate Pre-operative decolonization to prevent surgical site infections
• Use of Ultraviolet C to disinfect patient rooms
Immediate Pre-Immediate Pre-operative operative
Decolonization Decolonization Therapy Reduces Therapy Reduces
Surgical Site Surgical Site Infections: Infections:
A multidisciplinary quality A multidisciplinary quality improvement projectimprovement project
Dr. Elizabeth Bryce On behalf of the Vancouver General Hospital Decolonization TeamVancouver, 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 ApproachChlorhexidine Wipes
• applied to limbs and torso the night prior to or day of surgery
Nasal Photodisinfection
• Methylene blue applied to nares• Two – 2 minute pulses of red light
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
1. Connect nasal illuminator tips to laser cable port via fiber-optic connector2. Illuminate for 2 minutes with tips placed as shown above (directed into inner tip of nose for 1st cycle and posterior for 2nd cycle)
1st Illumination Cycle 2nd Illumination Cycle
Treatment Site
Tissue Colonized with
Pathogenic Bacteria
Irrigation
Apply Photosensitizer
that binds to bacterial surfaces
Illumination
Illuminate the
Treatment Site Using
Non-Thermal Light Energy
Eradication
“Activated” Photosensitizer creates reactive oxygen species, killing bacteria
How Photodisinfection worksHow Photodisinfection works
11
Advantages of this Approach
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
12
Decolonization ProtocolSurgeries 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
Document Compliance, AE
Perform Surgery
SSI Surveillance
Photodisinfection Therapy
(MRSAid)
1. Microbiological Efficacy, Safety,
and Compliance• Microbiological Efficacy
Growth MSSA reduction
n = 1286 (%)
MRSA reductionn=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 doneN= 3274
SSI surveillance not routinely doneN = 1912
Cases not treated
N = 206Cases treated pre-op
N = 3068
94% compliance
Comparing SSI rates: Treated and Historical
(1) CHG/mupirocin program in place previously (2) CHG bathing program in place previously
Specialty Treated Patients 4-year Historical Group P value OR
SSIs Rate % SSIs (Average) Rate %
Cardiovascular1
19/628 3.0 83/3334 (21) 2.5 0.4373 0.82
Neuro2 2/502 0.4 31/2152(7.75) 1.4 0.0764 3.65
Orthopedics1 (all)
6/892 0.7 50/2844 (12.5) 1.8 0.0251 2.64
Spine 18/475 3.8 136/1606 (34) 8.5 0.0009 2.35
Thoracic 1/431 0.2 14/1357 (3.5) 1.0 0.1478 4.48
Vascular 3/140 2.1 25/1094(6.25) 2.3 0.9152 1.07Total 49/3068 1.6 339/12,387
( 85)2.7 0.0004 1.73
42% reduction
Impact: Financial
Service Cases Avoided Case Cost* Cost AvoidanceNeurosurgery 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: ReadmissionsParameter Project Period Average previous
two yearsAverage number of readmissions/Fiscal
period
1.25/pd 4.04/pd
Average days stay 16.5 16.5 days
Readmissions/fiscal year
15 48.5
Days Stay x Cost/dy 15 x 16.5 x $500/day =$123,750
48.5 x 16.5 x $500/day =
$400,125Cost Avoidance $276,375
Patient Days saved 552
Impact: Cost Avoidance
1. LPNs able to treat 5176 patients/yr2. 3608 were cases routinely followed for SSI outcomes3. 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
**Conditional logistic regression analysis of the matched data with treatment as the only covariate: coefficient = -1.44, z = -3.65 p=0.0026
Propensity Score Analysis: 1:4 MatchingTreated Untreated Total P-Value Stand d
Number of Patients 704 188 892Age 59.6 (± 1.2 ) 59.3 (± 2.5 ) 59.6 (± 1.1 ) 0.832 0.15Gender (Male) 329 (46.7%) 92 (48.9%) 421 (47.2%) 0.622 0.04ASA (3-5) 433 (61.5%) 118 (62.8%) 551 (61.8%) 0.917 0.02Scheduled Case 623 (88.5%) 160 (85.1%) 783 (87.8%) 0.211 0.1Cancer Suspected/Proven 113 (16.1%) 32 (17%) 145 (16.3%) 0.379 0.14Surgery Time 152.1 (± 8.3 ) 149.2 (± 17.8 ) 151.5 (± 7.6 ) 0.771 0.21Median Time 120 111 118Cases Greater than 2h 351 (49.9%) 87 (46.3%) 438 (49.1%) 0.412 0.07T time: cases higher than 75 percentile 141 (20%) 40 (21.3%) 181 (20.3%) 0.685 0.03Type of Service Cardiovascular 136 (19.3%) 39 (20.7%) 175 (19.6%) 0.68 0.04 Neurological 117 (16.6%) 29 (15.4%) 146 (16.4%) 0.74 0.03 Orthopedic 198 (28.1%) 52 (27.7%) 250 (28%) 0.927 0.01 Spine 104 (14.8%) 25 (13.3%) 129 (14.5%) 0.726 0.04 Thoracic 123 (17.5%) 36 (19.1%) 159 (17.8%) 0.593 0.04 Vascular 26 (3.7%) 7 (3.7%) 33 (3.7%) 1 0Infected
13 14 27Not
applicable1
Not applicable1
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 TeamSurgery: Bas Masri Gary Redekop
Perioperative Services: Debbie Jeske Claire JohnstonKelly Barr Shelly ErricoAnna-Marie MacDonald Tammy ThandiLorraine Haas Pauline GoundarLucia Allocca Dawn BreedveldSteve Kabanuk
Infection Control: Elizabeth Bryce Chandi PandithaLeslie Forrester Diane LoukeTracey Woznow
Medical Microbiology: Diane RoscoeTitus Wong
Patient Safety: Linda Dempster
Ondine Biomedical: Shelagh Weatherill et al
Special Thanks: microbiology technologists, and perioperative staff
Thank you
Ultraviolet Room Disinfection
Elizabeth BryceOn 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
The R-D RAPID DISINFECTOR: Advanced Technology for Reducing Pathogens
in Patient Environments
August 20, 2013Steriliz, LLC.
Similar technology but:
Allows repositioning of the machine
Only one setting for all organisms
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
Tru-D MRSA BedKill at <7.2 x 100 CFU
RD MRSA BedKill at >7.2 x 103 CFU
UVC + Decluttering and Equipment Cleaning Campaign: Impact
38
375
263
0
50
100
150
200
250
300
350
400
Pre Post
Tota
l Num
ber
of C
ases
Total CDI Acquired at VGH (Pre & Post Implementation)
Sep 2012 - Dec 2013Jun 2011 - Aug 2012
↓ 30%
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