Difference Makers in Infection Control

Infection Prevention

By: Jared Bilski

Published: 6/11/2020

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In the wake of the COVID-19 pandemic, look to innovative technologies to keep patients safe.


One positive that's come out of the COVID-19 pandemic is a renewed focus on proper infection control practices. Facilities everywhere are ramping up their protocols and looking to cutting-edge technologies to help eradicate or prevent surgical site infections. Forward-thinking infection preventionists are also finding novel ways to use this technology specifically to combat COVID-19. Yale New Haven (Conn.) Health is a prime example.

"Once we realized there may be a critical shortage of N95 respirators in the near future, we immediately thought of using our hydrogen peroxide technology to safely reprocess respirators," says Nancy Havill, MT (ASCP), MHA, CIC, infection prevention manager at Yale New Haven Health.

Airborne hydrogen peroxide in the form of a mist or vapor is typically delivered via specialized machines during terminal cleanings of ORs. The machines "fog" hydrogen peroxide vapor or mist into the air, which covers every surface in the enclosed space.

When the coronavirus pandemic struck and N95 masks were in short supply, Ms. Havill's team got to work and tested the effectiveness of hydrogen peroxide vapor as a reprocessing method for used masks. "We developed an experiment involving heavily contaminated N95 masks with three different types of aerosolized bacteriophages that would mimic a heavy viral load and that were also safe for humans to handle," says Ms. Havill. "When the process was over, we tried to recover live bacteriophages from the respirators, and we didn't recover any. Hydrogen peroxide completely reverts back to oxygen and water, so there are no harmful residues."

Yale New Haven's detailed N95 reprocessing system starts in a negative pressure room, so the facility doesn't contaminate any other clinical areas. Staff members who work in the room don full PPE. Contaminated masks are sorted and hung individually by paperclips on three-by-five-foot racks that hold up to 250 masks. The racks are wheeled into a room where a hydrogen peroxide machine sits ready for use. After the room is completely sealed off, the masks are treated with hydrogen peroxide mist for 25 to 30 minutes. The room is then degassed and aerated.

"We put a load stick on every bag of reprocessed masks that includes the date it was sterilized and the load it was in," says Ms. Havill.

"We keep track of every load in the event there was a need to recall any respirators." Yale New Haven Health has safely reprocessed more than 20,000 respirators, according to Ms. Havill.

Cleaning the OR air

EASY ACCESS Air purification systems offer a safeguard against disruptions to OR laminar airflow.

Effectively treating OR surfaces and even staff footwear with UV-C light has traditionally garnered the lion's share of attention when it comes to infection prevention technology. Many facilities are now looking to technologies that address another problem area: the OR air.

COVID-19 has only increased growing interest in air purification technologies. For instance, Twin Cities Orthopedics (TCO), an orthopedic care provider with locations throughout Minnesota and western Wisconsin, recently purchased air purification machines as a direct result of the pandemic. "As soon as the pandemic began, we purchased the units because we knew extra steps were needed to ensure the safest environment possible," says Owen O'Neill, MD, an orthopedic surgeon at TCO.

The units also emit UV light, which kills virtually 100% of viruses and bacteria in the air, according to Dr. O'Neill. "We started using the machines as soon as the governor opened us up for elective cases on May 11," he says.

Although the air in TCO's ORs is exchanged 24 times per hour, the purification machines provide increased effectiveness in airflow and recirculate the air to achieve an additional 12 air exchanges per hour.

Some air purification/filtration systems are portable units that can be wheeled next to the OR table to provide sterile airflow across patients and instruments as well as overhead fixtures, pull air into the filtration system, treat it with UV-C light and push it back into the room.

"Some systems have combined UV-C technology with HEPA filtration to create a reduction in both viable and non-viable particulates," says Charles Edmiston, Jr., PhD, CIC, FIDSA, FSHEA, FAPIC, a professor of surgery and director of the surgical microbiology research laboratory for the Medical College of Wisconsin in Milwaukee.

Dr. Edmiston expects a surge in the use of innovative air filtration/purification technologies in the next five to 10 years, but acknowledges cost could be a major obstacle.

The safety of your patients is the ultimate standard. — Owen O'Neill, MD

"Work with vendors to develop a cost benefit analysis, documenting the yearly cost savings associated with preventing surgical site infections in selective operating rooms or for selective surgical services associated with the use of the proposed air filtration/purification technology," says Dr. Edmiston.

Ultimately, the decision to invest in an air purification system comes down to the patient. "Look at the safety of your patients as the ultimate standard," says Dr. O'Neill. "Anything that lowers the risk of infection is worth the investment."

Limiting transmission risks

EXTRA EFFORT Current evidence suggests nasal decolonization should be a standard treatment for all patients.   |  Kate Johnston/St. Francis Hospital

Another infection prevention protocol that may get a boost due to COVID-19 is nasal decolonization, which is generally performed to prevent surgical site infections in Staphylococcus aureus ?carriers undergoing joint replacements. TCO has been regularly swabbing the nares of total joints patients with a povidone-iodine solution as part of its infection prevention bundle.

"The risk of infection is decreased by eliminating staph that exists in some patients as carriers," says Dr. O'Neill. "It also allows us to treat patients with Methicillin-resistant strains of staph. Infections caused by these pathogens are particularly difficult to treat."

There's a very compelling argument to be made for performing nasal decolonization on all patients in the era of COVID-19. With the coronavirus's extremely high rate of asymptomatic patients, facilities should treat every patient as a carrier of COVID-19. Because the coronavirus is effectively inactivated through just a brief exposure to agents such as isopropyl alcohol, chlorhexidine and low concentrations of povidone-iodine (like the formulation Dr.O'Neill uses), it makes sense to take the extra step to swab patients' nares, which takes only minutes to complete, before all elective procedures. Although there is no direct link between nasal decolonization and a reduction in viral transmission, patient decolonization can be part of a multifaceted infection control program built on evidence-based strategies.

Enhanced endoscope care

Difference makers in infection control must include the tools and technologies that improve the effectiveness of endoscope cleaning, a notoriously difficult and complex process.

"There are more than 100 steps involved in the high-level disinfection of endoscopes," says Linda Beaver, RN, MSN, MHA, administrator at Gateway Endoscopy Center in St. Louis. "Automating any parts of the process reduces the possibility of human error and can only benefit patients, which is always the ultimate goal."

Luckily, there's no shortage of innovative automated options to bolster proper endoscope reprocessing: borescopes that let staff examine internal channels for residual bacteria, cleaning verification systems (ATP testing, for example), pressurized rinse technology, closed and labeled containers for transport to the reprocessing area and specialized drying cabinets that ensure internal channels remain dry during storage. Your facility now has plenty of options to augment staff performance with automated technology. To determine the technologies that are right for you, there are several steps you can take.

"First, look at reprocessing guidelines and recommendations issued by national associations," says Alison Sonstelie, BS, CHL, CRCST, supply chain operations manager at Sanford Health in Fargo, N.D., and president of NoCoast Consulting. "Next, develop a cost analysis, which should include the useful life of the equipment, the repair expenses and the cost of treating infections. That creates a story about why this technology is so important for your facility to invest in."

Perhaps the most important part of the decision-making process, says Ms. Sonstelie, is finding out how willing your vendor is to go above and beyond for you. "We always look for a partnership with vendors," she says. "We look for the vendors that offer education and are willing to come in and conduct regular in-services."

Rising stakes

The coronavirus has highlighted the importance of perfecting infection control's basic practices and has caused many facilities to reevaluate difference-making technologies that augment the performance of their hardworking staff. Whether you're considering adding an automated endoscope reprocessing tool, an air purification system, or one of the options in whole room disinfection (or N95 reprocessing!), there are plenty of new solutions you can use to protect your patients from exposure to infection-causing pathogens, including the newest threat that has forced surgical facilities to step up their fight against infection-causing bacteria and viruses. OSM

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