Addressing problems set by Pseudomonas

IHEEM's recent seminar in Birmingham, 'Dirty Little Secrets', not only focused on the key priorities for keeping surgical instruments clean and sterile (HEJ--April 2012), but also featured a timely presentation by Dr Jimmy Walker, principal investigator, Decontamination, HPA Microbiology Services, at the Health Protection Agency, in which the highly experienced microbiologist shared his expertise on what appears to be becoming an increasingly prevalent problem for healthcare estates and engineering personnel--how to ensure that levels of Pseudomonas, a waterborne bacterium potentially particularly harmful to immunocompromised patients, and often found in hospital water supplies, are rapidly detected, kept to a minimum, and, wherever possible, eliminated.

Microfibre barrier laundry adds value

London's Guy's and St Thomas' NHS Foundation Trust has installed a complete barrier laundry system from Electrolux Professional at its St Thomas' Hospital location for specialist washing of an estimated 7,000 microfibre cloths and 5,000 microfibre mops each day from both the St Thomas' and Guy's Hospital sites. Since the installation, as Electrolux Professional national account manager Kurt Fryer reports, the "cost-effective" equipment's high performance has seen laundry staff achieve a significant increase in productivity.

Characteristics of positive working relationships between nursing and support service employees

Developing greater synergies will become increasingly necessary as the pressure on the health-care industry continues to increase. This research looks at the required characteristics to create positive working relationships with clinical staff in a health-care organization from the perspective of nonclinical staff. Ten different U.S. hospitals participated in this qualitative study with over 200 individual participants. A recipe for successful relationship building from a nonclinical perspective is included.

Quantitative assessment of airborne exposures generated during common cleaning tasks: a pilot study

BACKGROUND

A growing body of epidemiologic evidence suggests an association between exposure to cleaning products with asthma and other respiratory disorders. Thus far, these studies have conducted only limited quantitative exposure assessments. Exposures from cleaning products are difficult to measure because they are complex mixtures of chemicals with a range of physicochemical properties, thus requiring multiple measurement techniques. We conducted a pilot exposure assessment study to identify methods for assessing short term, task-based airborne exposures and to quantitatively evaluate airborne exposures associated with cleaning tasks simulated under controlled work environment conditions.

METHODS

Sink, mirror, and toilet bowl cleaning tasks were simulated in a large ventilated bathroom and a small unventilated bathroom using a general purpose, a glass, and a bathroom cleaner. All tasks were performed for 10 minutes. Airborne total volatile organic compounds (TVOC) generated during the tasks were measured using a direct reading instrument (DRI) with a photo ionization detector. Volatile organic ingredients of the cleaning mixtures were assessed utilizing an integrated sampling and analytic method, EPA TO-17. Ammonia air concentrations were also measured with an electrochemical sensor embedded in the DRI.

RESULTS

Average TVOC concentrations calculated for 10 minute tasks ranged 0.02 - 6.49 ppm and the highest peak concentrations observed ranged 0.14-11 ppm. TVOC time concentration profiles indicated that exposures above background level remained present for about 20 minutes after cessation of the tasks. Among several targeted VOC compounds from cleaning mixtures, only 2-BE was detectable with the EPA method. The ten minute average 2- BE concentrations ranged 0.30 -21 ppm between tasks. The DRI underestimated 2-BE exposures compared to the results from the integrated method. The highest concentration of ammonia of 2.8 ppm occurred during mirror cleaning.

CONCLUSIONS

Our results indicate that airborne exposures from short-term cleaning tasks can remain in the air even after tasks' cessation, suggesting potential exposures to anyone entering the room shortly after cleaning. Additionally, 2-BE concentrations from cleaning could approach occupational exposure limits and warrant further investigation. Measurement methods applied in this study can be useful for workplace assessment of airborne exposures during cleaning, if the limitations identified here are addressed.

Quantitative assessment of medical waste generation in the capital city of Bangladesh

There is a concern that mismanagement of medical waste in developing countries may be a significant risk factor for disease transmission. Quantitative estimation of medical waste generation is needed to estimate the potential risk and as a basis for any waste management plan. Dhaka City, the capital of Bangladesh, is an example of a major city in a developing country where there has been no rigorous estimation of medical waste generation based upon a thorough scientific study. These estimates were obtained by stringent weighing of waste in a carefully chosen, representative, sample of HCEs, including non-residential diagnostic centres. This study used a statistically designed sampling of waste generation in a broad range of Health Care Establishments (HCEs) to indicate that the amount of waste produced in Dhaka can be estimated to be 37+/-5 ton per day. The proportion of this waste that would be classified as hazardous waste by World Health Organisation (WHO) guidelines was found to be approximately 21%. The amount of waste, and the proportion of hazardous waste, was found to vary significantly with the size and type of HCE.

Mycobacterium avium complex organisms predominantly colonize in the bathtub inlets of patients' bathrooms

Medical treatment of pulmonary Mycobacterium avium complex (MAC) disease does not always provide curative effects and is frequently hampered by recurrence. This suggests the presence of a reservoir for MAC in the environment surrounding patients. We previously reported the recovery of MAC isolates from the residential bathrooms of outpatients. In the present study, to ascertain the colonizing sites and the possibility of an MAC reservoir in the bathrooms of patients, we tested the recovery and the genetic diversity of MAC isolates from 6 sites of specimens, including 2 additional sampling sites, inside the showerhead and the bathtub inlet, in the residential bathrooms of patients with pulmonary MAC disease. MAC isolates were recovered from 15 out of the 29 bathrooms (52%), including specimens from 14 bathtub inlets and 3 showerheads. Nearly half of these bathrooms (7/15) contained MAC strains that were identical or similar to their respective clinical isolates Additionally, in 5 out of 15 bathrooms, polyclonal colonization was revealed by pulsed-field gel electrophoresis. The results imply that colonization of MAC organisms in the bathrooms of MAC patients occurs predominantly in the bathtub inlets, and there is thus a risk of infection and/or reinfection for patients via use of the bathtub and other sites in the bathroom.

A patient's journey through the operating department from an infection control perspective

The path a patient negotiates through an operating department is shaped by its design and layout, which should be determined by infection control requirements to ensure the safety of both patients and practitioners. How this is achieved is discussed in relation to an operating department in a local trust, together with how infection control, and therefore the prevention of surgical site infection, is achieved through hospital policies and key practices within a theatre by theatre practitioners and surgeons.

Isolation precautions to prevent the spread of contagious diseases

This article explores the use of isolation precautions to prevent the spread of infection. The standard infection control precautions, which should be undertaken routinely with all patients, and the additional measures which should be adopted when a patient has a specific infection, are discussed. The use of single room accommodation for patients with infections is debated.

Development of a waste management protocol based on assessment of knowledge and practice of healthcare personnel in surgical departments

BACKGROUND

Good healthcare waste management in a hospital depends on a dedicated waste management team, good administration, careful planning, sound organization, underpinning legislation, adequate financing, and full participation by trained staff. Hence, waste management protocols must be convenient and sensible.

AIM OF STUDY

To assess the knowledge and practice related to waste management among doctors, nurses, and housekeepers in the surgical departments at Al-Mansoura University Hospital, and to design and validate a waste management protocol for the health team in these settings.

SUBJECTS AND METHODS

This cross-sectional study was carried out in the eight surgical departments at Al-Mansoura University Hospital. All health care personnel and their assistants were included: 38 doctors, 106 nurses, and 56 housekeepers. Two groups of jury were included for experts' opinions validation of the developed protocol, one from academia (30 members) and the other from service providers (30 members). Data were collected using a self-administered knowledge questionnaire for nurses and doctors, and an interview questionnaire for housekeepers. Observation checklists were used for assessment of performance. The researchers developed the first draft of the waste management protocol according to the results of the analysis of the data collected in the assessment phase. Then, the protocol was presented to the jury group for validation, and then was implemented.

RESULTS

Only 27.4% of the nurses, 32.1% of the housekeepers, and 36.8% of the doctors had satisfactory knowledge. Concerning practice, 18.9% of the nurses, 7.1% of the housekeepers, and none of the doctors had adequate practice. Nurses' knowledge score had a statistically significant weak positive correlation with the attendance of training courses (r=0.23, p<0.05). Validation of the developed protocol was done, and the percent of agreement ranged between 60.0% and 96.7% for the service group, and 60.0% and 90.0% for the academia group.

CONCLUSION AND RECOMMENDATIONS

The majority of the doctors, nurses, and housekeepers have unsatisfactory knowledge and inadequate practice related to health care waste management. The knowledge among nurses is positively affected by attendance of training programs. Based on the findings, a protocol for healthcare waste management was developed and validated. It is recommended to implement the developed waste management protocol for the surgical departments in the designed hospital, with establishment of waste management audits.

Intensive care unit environmental cleaning: an evaluation in sixteen hospitals using a novel assessment tool

Despite isolation precautions and enhanced hand hygiene product use, the transmission of healthcare-associated pathogens remains a major problem. Recent studies have confirmed that microbial contamination of the environment in intensive care units (ICUs) can lead to colonisation and infection of patients. Although environmental disinfectants have been used to minimise the spread of microbial pathogens, suboptimal cleaning may limit the effectiveness of such activities. In order to evaluate the thoroughness of cleaning near-patient surfaces, a transparent, easily cleanable and environmentally stable solution was developed that fluoresces when exposed to UV light. The solution was used to mark a standardised group of frequently touched objects in ICU patient rooms following discharge cleaning. These sites were then evaluated after at least two patients had occupied the room and at least two terminal cleanings had been completed. Evaluation of 2320 objects in 197 patient areas disclosed that 57.1% of the standardised sites were cleaned following discharge of the room's occupant in the 16 ICUs studied. Although high rates of cleaning (>80%) were found for toilet seats, sinks and tray tables, consistently low rates of cleaning (<30%) were documented for several objects at high risk of becoming contaminated with nosocomial pathogens, including bedpan cleaners, toilet area handholds, doorknobs and light switches.

Identification and control of an outbreak of ciprofloxacin-susceptible EMRSA-15 on a neonatal unit

We report the identification and control of an outbreak of a ciprofloxacin-susceptible strain of UK epidemic meticillin-resistant Staphylococcus aureus (EMRSA)-15 on a neonatal unit (NNU). All babies were screened for MRSA on admission using ciprofloxacin-containing media which did not detect the outbreak strain. The first identified case was a premature baby who developed MRSA bacteraemia with associated tibial osteomyelitis and multiple subcutaneous abscesses. The outbreak strain was subsequently identified in the nasopharyngeal secretions of a second child who was not clinically infected. Screening of all patients on the NNU using non-ciprofloxacin-media identified two other colonised babies. All four patient isolates were EMRSA-15, spa type t022, SCCmec IV, Panton-Valentine leucocidin (PVL) negative, indistinguishable by pulsed-field gel electrophoresis and susceptible to all non-beta-lactam antimicrobials tested. The outbreak strain was cultured from four of 48 environmental sites in a communal milk-expressing room. Unsupervised movement of mothers to and from the milk-expressing room may have contributed to the outbreak. Control measures included cohort isolation of affected babies, improved environmental cleaning, increased emphasis on hand hygiene and education of mothers. Ciprofloxacin-containing media should be used with caution for MRSA screening in settings where ciprofloxacin-susceptible strains (including community-associated MRSA) are increasing in prevalence.

Uninvited guests pose particular problems

There are often unwelcome visitors in hospitals--some potentially harmful. Extermination is the only solution for some pests but there are alternative measures for others, Health Estate Journal discovers.

Infection prevention and control in pediatric ambulatory settings

Since the American Academy of Pediatrics published a statement titled "Infection Control in Physicians' Offices" (Pediatrics. 2000;105[6]:1361-1369), there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated annually, and enforced. The standard precautions for hospitalized patients from the Centers for Disease Control and Prevention, with a modification from the American Academy of Pediatrics exempting the use of gloves for routine diaper changes and wiping a well child's nose or tears, are appropriate for most patient encounters. As employers, pediatricians are required by the Occupational Safety and Health Administration to take precautions to identify and protect employees who are likely to be exposed to blood or other potentially infectious materials while on the job. Key principles of standard precautions include hand hygiene (ie, use of alcohol-based hand rub or hand-washing with soap [plain or antimicrobial] and water) before and after every patient contact; implementation of respiratory hygiene and cough-etiquette strategies for patients with suspected influenza or infection with another respiratory tract pathogen to the extent feasible; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices and evaluation and implementation of needle-safety devices; appropriate use of personal protective equipment such as gloves, gowns, masks, and eye protection; and appropriate sterilization, disinfection, and antisepsis.

Diagnosis and management of patients with Clostridium difficile-associated diarrhoea

This article outlines the diagnosis, treatment and nursing management of patients with Clostridium difficile-associated diarrhoea.

Standards of clinical waste management in hospitals—A second look

METHODS

The arrangements for bulk clinical waste handling were audited in 16 UK hospitals, one year after an earlier audit that revealed many deficiencies in performance.

RESULTS

Storage of clinical waste carts in areas accessible to members of the public and failure to lock individual waste carts was common. Waste segregation was poor. Many clinical waste carts and the areas dedicated to their storage were in a poor state of repair. Many instances of clinical waste storage apparently in breach of UK health and safety legislation, of fire regulations, and of the hazardous waste regulations were observed.

CONCLUSIONS

The standard of performance in clinical waste management in UK hospitals remains poor, with evidence of neglect of basic hygiene, housekeeping and safety standards. However, codes of practice exist, and despite implementation of the Hazardous Waste Regulations 2006 that provide further control on all wastes management issues, the reality of clinical waste management in some National Health Service (NHS) hospitals continues to be largely inadequate.

Differences in physical workload, psychosocial factors and musculoskeletal disorders between two groups of female hospital cleaners with two diverse organizational models

OBJECTIVES

To clarify if differences in the physical workload, the psychosocial factors and in musculoskeletal disorders can be attributed to work organizational factors.

METHODS

The physical workload (muscular activity of m. trapezius, positions and movements of the head, upper arms and wrists and heart rate) was assessed in 24 female hospital cleaners working in a traditional work organization (TO) and in 22 working in an extended one (i.e. with an enlarged work content and more responsibilities; EO). The psychosocial work environment was assessed as job demand, decision latitude and social support in 135 (TO) and 111 (EO) cleaners, and disorders of the neck and upper extremity by a physical examination.

RESULTS

The EO group was associated with lower physical workload, in terms of heart rate ratio (23 vs 32; P<0.001), head and upper arm positions and movements (right upper arm, 50th percentile, 35 degrees/s vs 71 degrees/s; P<0.001) and wrist movements (20 degrees/s vs 27 degrees/s; P=0.001), than the TO group. The EO group reported higher decision latitude and lower work demand than the TO one, while we found no difference in social support. The prevalence of complaints and diagnoses in neck/shoulders were lower in the EO group (diagnoses 35% vs 48%; P=0.04). Moreover, the prevalence of subjects with at least ten physical finding in elbows/hands was lower in the EO group (10 vs 29; P<0.001).

CONCLUSION

Hospital cleaners have a high prevalence of neck and upper limb disorders and a high physical workload. Comparing two groups of cleaners, with differences in the way of organizing the work, lower physical workload, more beneficial psychosocial factors and a better musculoskeletal health was found in the group with an extended organization. Hence, the differences found can be attributed to the organizational factors.

Monitoring the effectiveness of cleaning in four British hospitals

BACKGROUND

A survey of cleaning effectiveness was conducted in two wards in four acute hospitals in England and Wales. Surfaces were monitored immediately before and after cleaning on three separate occasions using visual assessment, adenosine triphosphate (ATP) bioluminescence, expressed in relative light units (RLUs), and microbiological methods (aerobic colony counts [ACC]), expressed in colony forming units (cfu) per cm(2).

METHODS

Comparison of data from a total of over 3000 assessments showed highly significant differences in failure rates between visual assessment and either ATP or microbiological counts. There was no significant difference in failure rates between ATP and microbiological counts. Using visual assessment, failure rates were significantly lower after cleaning than before. Using ATP or microbiological methods, failure rates were not significantly different after cleaning.

RESULTS

Data obtained using both ATP and ACC, indicated considerable variability after cleaning and that failed surfaces were often well in excess of benchmark values.

CONCLUSIONS

Cumulatively, the results indicate that visual assessment is not a reliable indicator of surface cleanliness or of cleaning efficacy. Concerns also arise about the standards of surface cleanliness achieved after cleaning in the hospitals.

Envelhecimento e capacidade para o trabalho dos trabalhadores de higiene e limpeza hospitalar

As mudanças demográficas ocorridas no Brasil mostram um aumento da população que está envelhecendo e em idade produtiva. Estudo com trabalhadores do Serviço de Higiene e Limpeza de um hospital universitário, não terceirizado, teve por objetivo avaliar a capacidade para o trabalho. Foi utilizado o Índice de Capacidade para o Trabalho, instrumento auto-aplicável, desenvolvido por pesquisadores finlandeses. Foram entrevistados 69 trabalhadores: 21,7% tinham ótima capacidade para o trabalho; 31,9% boa; 31,9% moderada e 14,5%, baixa. As doenças com diagnóstico médico mais freqüentes foram as lesões por acidentes, músculo-esqueléticas e cardiovasculares. O grupo etário de 50 a 60 anos obteve menor Índice de Capacidade para o Trabalho e maior número de doenças, afetando, portanto, a capacidade para o trabalho. Sendo assim, há necessidade do desenvolvimento de programas de promoção à saúde, tendo em vista a recuperação e manutenção da capacidade para o trabalho.

Percutaneous exposure incidents of the health care personnel in a newly founded tertiary hospital: a prospective study

BACKGROUND

Percutaneous exposure incidents (PEIs) and blood splashes on the skin of health care workers are a major concern, since they expose susceptible employees to the risk of infectious diseases. We undertook this study in order to estimate the overall incidence of such injuries in a newly founded tertiary hospital, and to evaluate possible changes in their incidence over time.

METHODOLOGY/PRINCIPAL FINDINGS

We prospectively studied the PEIs and blood splashes on the skin of employees in a newly founded (October 2000) tertiary hospital in Athens, Greece, while a vaccination program against hepatitis B virus, as well as educational activities for avoidance of injuries, were taking place. The study period ranged from October 1, 2002 to February 28, 2005. Serologic studies for hepatitis B (HBV) and C virus (HCV) as well as human immunodeficiency virus (HIV) were performed in all injured employees and the source patients, when known. High-titer immunoglobulin (250 IU anti-HBs intramuscularly) and HBV vaccination were given to non-vaccinated or previously vaccinated but serologically non-responders after exposure. Statistical analysis of the data was performed using Mc Nemar's and Fisher's tests. 60 needlestick, 11 sharp injuries, and two splashes leading to exposure of the skin or mucosa to blood were reported during the study period in 71 nurses and two members of the cleaning staff. The overall incidence (percutaneous injuries and splashes) per 100 full-time employment-years (100 FTEYs) for high-risk personnel (nursing, medical, and cleaning staff) was 3.48, whereas the incidence of percutaneous injuries (needlestick and sharp injuries) alone per 100 FTEYs was 3.38. A higher incidence of injuries was noted during the first than in the second half of the study period (4.67 versus 2.29 per 100 FTEYs, p = 0.005). No source patient was found positive for HCV or HIV. The use of high-titer immunoglobulin after adjustment for the incidence of injuries was higher in the first than in the second half of the study period, although the difference was not statistically significant [9/49 (18.37%) vs 1/24 (4.17%), p = 0.15].

CONCLUSIONS/SIGNIFICANCE

Our data show that nurses are the healthcare worker group that reports most of PEIs. Doctors did not report such injuries during the study period in our setting. However, the possibility of even relatively frequent PEIs in doctors cannot be excluded. This is due to underreporting of such events that has been previously described for physicians and surgeons. A decrease of the incidence of PEIs occurred during the operation of this newly founded hospital.

Secondary individual prevention of occupational skin diseases in health care workers, cleaners and kitchen employees: aims, experiences and descriptive results

OBJECTIVES

Due to increased occupational dermatoses in certain professions such as health care workers (HCW), cleaning and kitchen employees (CKE), measures of prevention and skin protection are of high significance. Skin protection courses focus on educational aims (e.g. improving skin care habits, influencing the participants' attitudes towards health) and medical aims (e.g. optimising diagnostic procedures, complementing individual therapy).

METHODS

Participants are patients who have been suspected to suffer from an occupational skin disease and are insured with the German Accident Prevention & Insurance Association (BGW). Teaching units of the skin protection courses focus on basics of skin functioning and important aspects of occupational skin diseases. Practical parts include information and instructions about the correct implementation of skin protection, skin care and skin cleansing. Every participant is seen by a dermatologist obtaining a precise patient's history and performing a skin examination. All this results in working out individually adapted and professional skin protection strategies.

RESULTS

In total, 791 participants (93 men and 698 women) completed the skin protections courses. Six hundred and sixty-seven patients (mean age: 36.9 years, SD = 11.6) were HCW and 124 patients (mean age: 40.4 years, SD = 10.8) were CKE. In HCW 82.5% (n = 550) and in CKE 86.3% (n = 107) suffered from hand eczema of the atopic, irritant or allergic type. Irritant contact dermatitis as a single diagnosis was the most frequent one in both groups (HCW: 34.5.%, n = 230; CKE: 49.2% n = 61). According to regularly performed evaluations, the participants rated the course as good to excellent. Nearly 80% of the participants had skin lesions while attending the course, in 27% the dermatosis was severe.

CONCLUSIONS

There is a high need for health education, advisory services, diagnostics and additional therapy in occupational dermatology. Prevention of occupational skin diseases and maintenance of health through educational programmes are important complementary measures for dermatological care but still missing in endangered professions.

Occupational exposures among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital

OBJECTIVES

To determine the incidence and related factors of blood and body fluid exposure (BBFE)among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital, Bangkok, Thailand

MATERIAL AND METHOD

A retrospective survey of BBFE among 858 nurses and housekeeping personnel who were working in the year 2004 was done. Data were collected by a self-administered questionnaire

RESULTS

The annual incidence rate of BBFE was 31.9% (by person) and 45.5 exposures per 100 persons (by event). The highest incidence rate was observed in percutaneous exposure. Graduated nurses had the greatest risk of all exposures, but housekeeping personnel had the highest rate ofpercutaneous exposure. The highest incidence of BBFE was observed in the emergency room. Most BBFE occurred after using a medical instrument. 76.9% of BBFE were not reported.

CONCLUSION

The incidence of BBFE among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital was high. Systematic control measures and good organization of the work and workplace should be urgently implemented.