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Quantitative assessment of interactions between hospitalized patients and portable medical equipment and other fomites
ARTICLE IN PRESS American Journal of Infection Control ■■ (2017) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Quantitative assessment of interactions between hospitalized patients and portable medical equipment and other fomites Nuntra Suwantarat MD a, Laura A. Supple BS a, Jennifer L. Cadnum BS b, Thriveen Sankar MBA b, Curtis J. Donskey MD c,d,* a
Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, OH Department of Medicine, Division of Infectious Diseases & HIV Medicine, University Hospitals of Cleveland, Cleveland, OH c Geriatric Research, Education, and Clinical Center, Cleveland VA Medical Center, Cleveland, OH d Case Western Reserve University School of Medicine, Cleveland, OH b
Key Words: Portable equipment Fomites
In an observational study, we demonstrated that hospitalized patients frequently had direct or indirect interactions with medical equipment and other fomites that are shared among patients, and these items were often contaminated with health care–associated pathogens. There is a need for protocols to ensure routine cleaning of shared portable equipment. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Efforts to improve environmental disinfection in health care facilities typically focus primarily on surfaces in patient rooms that are frequently touched by health care workers and patients (eg, bed rails, bedside tables).1 Portable equipment that is shared among patients (eg, medication carts, vital signs equipment, wheel chairs, electrocardiogram machines) can also be a potential source of pathogen transmission.1-8 Therefore, current guidelines recommend that medical equipment that comes into contact with intact skin is cleaned and decontaminated after each patient use.8 In clinical practice, nursing staff and ancillary staff are often given responsibility for cleaning portable equipment because they use such equipment while working with patients. However, Havill et al8 reported that portable equipment was often not cleaned according to written protocols between each patient use. In a recent study, Huslage et al9 quantitatively assessed the frequency of health care worker contact with different surfaces in hospital rooms in the intensive care unit (ICU) and on general medical-surgical wards. Based on the frequency of contact, surfaces were categorized as high, medium, or low touch. 9 Such
* Address correspondence to Curtis J. Donskey, MD, Geriatric Research, Education, and Clinical Center 1110W, Cleveland VA Medical Center, 10701 East Blvd, Cleveland, OH 44106. E-mail: [email protected] (C.J. Donskey). Funding/support: Supported by a Merit Review grant from the Department of Veterans Affairs to C.J.D., (BX002944) and the Agency for Healthcare Research and Quality to C.J.D. (1R1845020004-01A1). Conflicts of interest: C.J.D. reports having received research grants from Ecolab, Merck, GOJO, Clorox, and Altapure. All other authors report no conflicts of interest relevant to this article.
information is useful for understanding the potential for different sites to transmit pathogens and for development of protocols to improve cleaning. Here, we conducted a similar quantitative assessment of direct and indirect contact between patients and portable medical equipment and other fomites that are shared among patients. In addition, we performed a culture survey to determine the frequency of contamination of shared equipment with health care–associated pathogens. METHODS The Louis Stokes Veterans Affairs Medical Center is a 215-bed acute care facility with a 10-bed surgical ICU and a separate 16bed medical ICU. Each hospital room has dedicated vital signs equipment, including pulse oximeters attached to the wall at the head of the bed. During a 5-month period, a single observer quantified interactions between hospitalized patients on 6 medicalsurgical wards and in the ICUs with portable equipment and other fomites that were either taken inside the room or stopped immediately outside the door followed by patient contact. Interactions required direct or indirect contact between the patient and surfaces in the room and the portable equipment or other fomite. Contact was considered direct if the equipment or fomite directly contacted the patient or environment and indirect if there was no direct contact but personnel touched the equipment or fomite and then touched the patient. All observations were performed between 8 AM and 5 PM during week days. The frequency of interactions between different types of fomites per room per hour was calculated for the medical-surgical wards and the ICUs.
0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2017.05.003
ARTICLE IN PRESS 2
N. Suwantarat et al. / American Journal of Infection Control ■■ (2017) ■■-■■
To determine the frequency of contamination of portable equipment with health care–associated pathogens, 2-pronged BBL CultureSwabs (Becton Dickinson, Cockeysville, MD) premoistened with sterile normal saline were used to collect cultures from a convenience sample of portable equipment and fomite surfaces on the 6 medical-surgical wards and in the ICUs. The equipment and fomites were cultured during periods when they were not in use. No information was available on when the items had last been cleaned. For large objects, 5- × 10-cm areas were cultured focusing on areas that are commonly touched; for smaller objects, the entire surface area was cultured. The cultures were processed for methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile using previously reported methods.10 RESULTS A total of 380 interactions between portable equipment or other fomites and patients were recorded during 144 room hours of observation (2.6 interactions per patient per hour). There were 316 interactions during 96 room hours for medical-surgical wards (3.3 interactions per patient per hour) and 64 interactions during 48 room hours in the ICUs (1.3 interactions per patient per hour). Fortythree of the 380 (11%) interactions occurred in rooms of patients under contact or droplet precautions. Of the 380 interactions, 156 (42%) involved equipment or fomites that made direct contact with the patient or surfaces in the room, including 128 of 316 (41%) on the medical-surgical wards and 28 of 64 (44%) in the ICU. Figure 1 shows the frequency of direct or indirect contact between patients and environment and shared portable medical equipment and fomites on the medical-surgical wards and in the ICUs. For both the medical-surgical wards and the ICUs, medication carts were the items that most frequently interacted with patients. In the ICUs, the next most frequent objects interacting with patients were cleaning carts, x-ray machines, and wheelchairs. On the medical-surgical units, the next most frequent objects interacting with patients were wheelchairs, food trays, laundry carts, and cleaning carts. For medication, laundry, cleaning carts, and oxygen tanks, all the interactions were indirect (ie, contact between hands of personnel and the item followed by touching of patients
Table 1 Frequency of recovery of health care–associated pathogens from portable equipment and fomites on medical-surgical wards and in intensive care units Portable equipment and fomites Medication carts Wheelchairs ECG machines Food trays Laundry carts Bladder scanners Portable x-ray machines Weight scales Doppler ultrasound machines Glucometers Transfer gurneys Vital sign machines Total
MRSA
VRE
Clostridium difficile
2/31 (7) 1/12 (8) 1/8 (13) 0/7 (0) 3/5 (60) 0/3 (0) 1/3 (33) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 8/80 (10)
1/31 (3) 0/12 (0) 1/8 (13) 0/7 (0) 2/5 (40) 2/3 (67) 0/3 (0) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 6/80 (8)
1/31 (3) 0/12 (0) 0/8 (0) 0/7 (0) 1/5 (20) 0/3(0) 0/3 (0) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 2/80 (3)
NOTE. Values are the no. of positive samples/no. sampled (%). ECG, electrocardiogram; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci.
or environmental surfaces in the room). For wheelchairs, food trays, transfer gurneys, electrocardiogram machines, x-ray machines, glucometers, bladder scanners, weigh scales, commodes, vital signs equipment, and Doppler ultrasounds, all interactions involved direct contact between the equipment and the patient or the environment. Table 1 shows the frequency of recovery of health care–associated pathogens from portable equipment and fomites. Of 80 total items cultured, 12 (15%) were contaminated with ≥1 of the health care– associated pathogens, with MRSA and VRE being cultured most frequently. DISCUSSION Many studies have demonstrated that shared portable medical equipment is often contaminated with health care–associated pathogens.1-8 In some studies, such contamination has been linked to transmission of pathogens.3,7 Our results expand on these previous reports by providing a quantitative assessment of direct and indirect contact between patients and portable medical equipment
Fig 1. Frequency of direct or indirect interactions between patients and shared portable medical equipment and fomites on 6 medical-surgical wards and 2 intensive care units. The equipment and fomites were either taken inside the room or stopped immediately outside the door followed by patient contact. Contact was considered direct if the equipment or fomite directly contacted the patient or environment and indirect if there was no direct contact but personnel touched the equipment or fomite and then touched the patient. ECG, electrocardiogram.
ARTICLE IN PRESS N. Suwantarat et al. / American Journal of Infection Control ■■ (2017) ■■-■■
and other fomites that are shared among patients. We found that hospitalized patients frequently had interactions with portable medical equipment and other fomites that are shared among patients. Although many items of equipment made direct contact with patients (eg, wheelchairs, electrocardiogram machines, bladder scanners), indirect interactions were also common (eg, medication carts contacted by hands of personnel with subsequent touching of patients). Twelve percent of the portable equipment cultured was contaminated with MRSA, VRE, or C difficile. Our findings suggest that there is a need for protocols to ensure effective cleaning of shared portable equipment. Our study has some limitations. We only monitored equipment use in 1 hospital. Findings might differ in other settings. For example, because dedicated vital signs equipment was present in each room, it is likely that our results underestimate the potential for interactions with portable vital signs equipment in many other facilities. The policy in our facility requires that medical equipment that comes into contact with intact skin should be cleaned and decontaminated after each patient use. However, we did not assess the frequency of cleaning and disinfection of portable equipment. Havill et al8 have reported that portable equipment was often not cleaned according to written protocols in their facility. Moreover, Havill et al8 highlighted the fact that cleaning of portable equipment is often not included in monitoring of cleaning and is often delegated to nursing staff members with many other responsibilities.
3
References 1. Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control 2013;41:S12-9. 2. Dumford DM 3rd, Nerandzic MM, Eckstein BC, Donskey CJ. What is on that keyboard? Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains. Am J Infect Control 2009;37:15-9. 3. Livornese LL Jr, Dias S, Samel C, Romanowski B, Taylor S, May P, et al. Hospitalacquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112-6. 4. Peretz A, Koiefman A, Dinisman E, Brodsky D, Labay K. Do wheelchairs spread pathogenic bacteria within hospital walls? World J Microbiol Biotechnol 2014;30:385-7. 5. Faires MC, Pearl DL, Ciccotelli WA, Straus K, Zinken G, Berke O, et al. A prospective study to examine the epidemiology of methicillin-resistant Staphylococcus aureus and Clostridium difficile contamination in the general environment of three community hospitals in southern Ontario, Canada. BMC Infect Dis 2012;12:290. 6. Levin PD, Shatz O, Sviri S, Moriah D, Or-Barbash A, Sprung CL, et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest 2009;136:426-32. 7. Falk PS, Winnike J, Woodmansee C, Desai M, Mayhall CG. Outbreak of vancomycin-resistant enterococci in a burn unit. Infect Control Hosp Epidemiol 2000;21:575-82. 8. Havill NL, Havill HL, Mangione E, Dumigan DG, Boyce JM. Cleanliness of portable medical equipment disinfected by nursing staff. Am J Infect Control 2011;39: 602-4. 9. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3. 10. Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis 2010;10:197.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Quantitative assessment of interactions between hospitalized patients and portable medical equipment and other fomites Nuntra Suwantarat MD a, Laura A. Supple BS a, Jennifer L. Cadnum BS b, Thriveen Sankar MBA b, Curtis J. Donskey MD c,d,* a
Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, OH Department of Medicine, Division of Infectious Diseases & HIV Medicine, University Hospitals of Cleveland, Cleveland, OH c Geriatric Research, Education, and Clinical Center, Cleveland VA Medical Center, Cleveland, OH d Case Western Reserve University School of Medicine, Cleveland, OH b
Key Words: Portable equipment Fomites
In an observational study, we demonstrated that hospitalized patients frequently had direct or indirect interactions with medical equipment and other fomites that are shared among patients, and these items were often contaminated with health care–associated pathogens. There is a need for protocols to ensure routine cleaning of shared portable equipment. Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
Efforts to improve environmental disinfection in health care facilities typically focus primarily on surfaces in patient rooms that are frequently touched by health care workers and patients (eg, bed rails, bedside tables).1 Portable equipment that is shared among patients (eg, medication carts, vital signs equipment, wheel chairs, electrocardiogram machines) can also be a potential source of pathogen transmission.1-8 Therefore, current guidelines recommend that medical equipment that comes into contact with intact skin is cleaned and decontaminated after each patient use.8 In clinical practice, nursing staff and ancillary staff are often given responsibility for cleaning portable equipment because they use such equipment while working with patients. However, Havill et al8 reported that portable equipment was often not cleaned according to written protocols between each patient use. In a recent study, Huslage et al9 quantitatively assessed the frequency of health care worker contact with different surfaces in hospital rooms in the intensive care unit (ICU) and on general medical-surgical wards. Based on the frequency of contact, surfaces were categorized as high, medium, or low touch. 9 Such
* Address correspondence to Curtis J. Donskey, MD, Geriatric Research, Education, and Clinical Center 1110W, Cleveland VA Medical Center, 10701 East Blvd, Cleveland, OH 44106. E-mail: [email protected] (C.J. Donskey). Funding/support: Supported by a Merit Review grant from the Department of Veterans Affairs to C.J.D., (BX002944) and the Agency for Healthcare Research and Quality to C.J.D. (1R1845020004-01A1). Conflicts of interest: C.J.D. reports having received research grants from Ecolab, Merck, GOJO, Clorox, and Altapure. All other authors report no conflicts of interest relevant to this article.
information is useful for understanding the potential for different sites to transmit pathogens and for development of protocols to improve cleaning. Here, we conducted a similar quantitative assessment of direct and indirect contact between patients and portable medical equipment and other fomites that are shared among patients. In addition, we performed a culture survey to determine the frequency of contamination of shared equipment with health care–associated pathogens. METHODS The Louis Stokes Veterans Affairs Medical Center is a 215-bed acute care facility with a 10-bed surgical ICU and a separate 16bed medical ICU. Each hospital room has dedicated vital signs equipment, including pulse oximeters attached to the wall at the head of the bed. During a 5-month period, a single observer quantified interactions between hospitalized patients on 6 medicalsurgical wards and in the ICUs with portable equipment and other fomites that were either taken inside the room or stopped immediately outside the door followed by patient contact. Interactions required direct or indirect contact between the patient and surfaces in the room and the portable equipment or other fomite. Contact was considered direct if the equipment or fomite directly contacted the patient or environment and indirect if there was no direct contact but personnel touched the equipment or fomite and then touched the patient. All observations were performed between 8 AM and 5 PM during week days. The frequency of interactions between different types of fomites per room per hour was calculated for the medical-surgical wards and the ICUs.
0196-6553/Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2017.05.003
ARTICLE IN PRESS 2
N. Suwantarat et al. / American Journal of Infection Control ■■ (2017) ■■-■■
To determine the frequency of contamination of portable equipment with health care–associated pathogens, 2-pronged BBL CultureSwabs (Becton Dickinson, Cockeysville, MD) premoistened with sterile normal saline were used to collect cultures from a convenience sample of portable equipment and fomite surfaces on the 6 medical-surgical wards and in the ICUs. The equipment and fomites were cultured during periods when they were not in use. No information was available on when the items had last been cleaned. For large objects, 5- × 10-cm areas were cultured focusing on areas that are commonly touched; for smaller objects, the entire surface area was cultured. The cultures were processed for methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile using previously reported methods.10 RESULTS A total of 380 interactions between portable equipment or other fomites and patients were recorded during 144 room hours of observation (2.6 interactions per patient per hour). There were 316 interactions during 96 room hours for medical-surgical wards (3.3 interactions per patient per hour) and 64 interactions during 48 room hours in the ICUs (1.3 interactions per patient per hour). Fortythree of the 380 (11%) interactions occurred in rooms of patients under contact or droplet precautions. Of the 380 interactions, 156 (42%) involved equipment or fomites that made direct contact with the patient or surfaces in the room, including 128 of 316 (41%) on the medical-surgical wards and 28 of 64 (44%) in the ICU. Figure 1 shows the frequency of direct or indirect contact between patients and environment and shared portable medical equipment and fomites on the medical-surgical wards and in the ICUs. For both the medical-surgical wards and the ICUs, medication carts were the items that most frequently interacted with patients. In the ICUs, the next most frequent objects interacting with patients were cleaning carts, x-ray machines, and wheelchairs. On the medical-surgical units, the next most frequent objects interacting with patients were wheelchairs, food trays, laundry carts, and cleaning carts. For medication, laundry, cleaning carts, and oxygen tanks, all the interactions were indirect (ie, contact between hands of personnel and the item followed by touching of patients
Table 1 Frequency of recovery of health care–associated pathogens from portable equipment and fomites on medical-surgical wards and in intensive care units Portable equipment and fomites Medication carts Wheelchairs ECG machines Food trays Laundry carts Bladder scanners Portable x-ray machines Weight scales Doppler ultrasound machines Glucometers Transfer gurneys Vital sign machines Total
MRSA
VRE
Clostridium difficile
2/31 (7) 1/12 (8) 1/8 (13) 0/7 (0) 3/5 (60) 0/3 (0) 1/3 (33) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 8/80 (10)
1/31 (3) 0/12 (0) 1/8 (13) 0/7 (0) 2/5 (40) 2/3 (67) 0/3 (0) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 6/80 (8)
1/31 (3) 0/12 (0) 0/8 (0) 0/7 (0) 1/5 (20) 0/3(0) 0/3 (0) 0/3 (0) 0/2 (0) 0/2 (0) 0/2 (0) 0/2 (0) 2/80 (3)
NOTE. Values are the no. of positive samples/no. sampled (%). ECG, electrocardiogram; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci.
or environmental surfaces in the room). For wheelchairs, food trays, transfer gurneys, electrocardiogram machines, x-ray machines, glucometers, bladder scanners, weigh scales, commodes, vital signs equipment, and Doppler ultrasounds, all interactions involved direct contact between the equipment and the patient or the environment. Table 1 shows the frequency of recovery of health care–associated pathogens from portable equipment and fomites. Of 80 total items cultured, 12 (15%) were contaminated with ≥1 of the health care– associated pathogens, with MRSA and VRE being cultured most frequently. DISCUSSION Many studies have demonstrated that shared portable medical equipment is often contaminated with health care–associated pathogens.1-8 In some studies, such contamination has been linked to transmission of pathogens.3,7 Our results expand on these previous reports by providing a quantitative assessment of direct and indirect contact between patients and portable medical equipment
Fig 1. Frequency of direct or indirect interactions between patients and shared portable medical equipment and fomites on 6 medical-surgical wards and 2 intensive care units. The equipment and fomites were either taken inside the room or stopped immediately outside the door followed by patient contact. Contact was considered direct if the equipment or fomite directly contacted the patient or environment and indirect if there was no direct contact but personnel touched the equipment or fomite and then touched the patient. ECG, electrocardiogram.
ARTICLE IN PRESS N. Suwantarat et al. / American Journal of Infection Control ■■ (2017) ■■-■■
and other fomites that are shared among patients. We found that hospitalized patients frequently had interactions with portable medical equipment and other fomites that are shared among patients. Although many items of equipment made direct contact with patients (eg, wheelchairs, electrocardiogram machines, bladder scanners), indirect interactions were also common (eg, medication carts contacted by hands of personnel with subsequent touching of patients). Twelve percent of the portable equipment cultured was contaminated with MRSA, VRE, or C difficile. Our findings suggest that there is a need for protocols to ensure effective cleaning of shared portable equipment. Our study has some limitations. We only monitored equipment use in 1 hospital. Findings might differ in other settings. For example, because dedicated vital signs equipment was present in each room, it is likely that our results underestimate the potential for interactions with portable vital signs equipment in many other facilities. The policy in our facility requires that medical equipment that comes into contact with intact skin should be cleaned and decontaminated after each patient use. However, we did not assess the frequency of cleaning and disinfection of portable equipment. Havill et al8 have reported that portable equipment was often not cleaned according to written protocols in their facility. Moreover, Havill et al8 highlighted the fact that cleaning of portable equipment is often not included in monitoring of cleaning and is often delegated to nursing staff members with many other responsibilities.
3
References 1. Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control 2013;41:S12-9. 2. Dumford DM 3rd, Nerandzic MM, Eckstein BC, Donskey CJ. What is on that keyboard? Detecting hidden environmental reservoirs of Clostridium difficile during an outbreak associated with North American pulsed-field gel electrophoresis type 1 strains. Am J Infect Control 2009;37:15-9. 3. Livornese LL Jr, Dias S, Samel C, Romanowski B, Taylor S, May P, et al. Hospitalacquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112-6. 4. Peretz A, Koiefman A, Dinisman E, Brodsky D, Labay K. Do wheelchairs spread pathogenic bacteria within hospital walls? World J Microbiol Biotechnol 2014;30:385-7. 5. Faires MC, Pearl DL, Ciccotelli WA, Straus K, Zinken G, Berke O, et al. A prospective study to examine the epidemiology of methicillin-resistant Staphylococcus aureus and Clostridium difficile contamination in the general environment of three community hospitals in southern Ontario, Canada. BMC Infect Dis 2012;12:290. 6. Levin PD, Shatz O, Sviri S, Moriah D, Or-Barbash A, Sprung CL, et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest 2009;136:426-32. 7. Falk PS, Winnike J, Woodmansee C, Desai M, Mayhall CG. Outbreak of vancomycin-resistant enterococci in a burn unit. Infect Control Hosp Epidemiol 2000;21:575-82. 8. Havill NL, Havill HL, Mangione E, Dumigan DG, Boyce JM. Cleanliness of portable medical equipment disinfected by nursing staff. Am J Infect Control 2011;39: 602-4. 9. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-3. 10. Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis 2010;10:197.