“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

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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

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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

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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

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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