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Beyond Bundles, HAI Prevention “Plus Measures” Toolkit Updated 2018

MDRO Multi-Drug Resistant Organism Chapter

© 2016 Sue Barnes, RN, CIC, FAPIC

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Document posted here:

Overview: This toolkit was designed for IPs (Infection Prevention professionals) and other clinicians as a resource/reference to support efforts to amplify/enhance infection prevention and control bundles. In the absence of sustained zero preventable infections of any type, and in the absence of risk to patients, products and practices supported by less than category 1 level evidence (i.e. “Plus Measures”) are often employed to amplify/enhance IP bundles. The “Plus Measures” contained within this toolkit are most commonly supported by what CDC considers category II level evidence (see page 3 for evidence categories). Within this toolkit evidence summaries are provided for each plus measure, in order to reduce the time required for literature searching by IPs, and are updated every two years. These “Plus Measures” including products, have been identified by the author during review of peer reviewed journals, attendance of professional conferences, continuing education courses, networking with clinical experts and industry partners. Consequently, the set of plus measures (including products), represented in this document is not all inclusive or exhaustive. I welcome any suggested additions from colleagues and industry partners (sueabarnes@).

This document was developed by Sue Barnes. Please feel free to use and reproduce this document in the spirit of patient safety, and please retain this note for appropriate recognition.

CDC Evidence Categories ():

• Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

• Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.

• Category IC. Required by state or federal regulations, rules, or standards.

• Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

• Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

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MDRO Multi-drug Resistant Organism Transmission Prevention

(e.g. methicillin resistant Staphylococcus aureus MRSA, vancomycin resistant enterococcus VRE, carbapenemase-producing Enterobacteriaceae CPE, extended spectrum beta lactamase producing bacteria ESBL)

The following standard bundle of prevention measures are recommended by:

The CDC:

And the SHEA Compendium:  

1. Alerts, monitoring and surveillance

2. Antibiotic stewardship

3. Contact precautions for infected and colonized patients

4. Decolonization during MRSA and other outbreaks

5. Decontamination of the environment and equipment

6. Employee education

7. Hand hygiene

If zero preventable infections have not been achieved and/or sustained, consideration might be given to adding one or more of the following “PLUS” prevention measures to your MDRO prevention bundle:

DOUBLE CLICK ON ICONS IN TABLE BELOW TO OPEN EMBEDDED DOCUMENTS – COPY & PASTE LINKS INTO BROWSER

|Plus Measures |Reference |Product order info |Tools |

|Automated alerts and isolation orders |[pic] |N/A |N/A |

|Cell phone and tablet cleaning |[pic] |PhoneSoap UV-C disinfection device for tablets and cell phones: |Sample guidelines for |

|Hand hygiene between patient care and cell phone/tablet use| | |cleaning mobile devices |

| | | |[pic] |

|Gloves should not be worn during device use | | | |

|Clean device daily according to IFU | | | |

|Avoid use in isolation rooms | | | |

MDRO Prevention and Control continued:

|Plus Measures |Reference |Product order info |Tools |

|Cell phone cleaning continued |See above |See above |Sample combination protocol: hand hygiene|

| | | |and cleaning of mobile devices |

| | | |[pic] |

|Decolonization (Nasal) |[pic] |Mupirocin – from pharmacy |Nasal decolonization guidebook |

|antibiotic Mupirocin ointment | |Nozin alcohol nasal antiseptic |[pic] |

|antiseptic: alcohol or iodine-based product | |3M povidone iodine nasal antiseptic | |

| | |Clorox povidone iodine nasal antiseptic Clorox iodine nasal | |

| | |PDI povidone iodine nasal antiseptic PDI iodine nasal | |

|Environmental cleaning |A[pic] B[pic] |Indigo (405nm) and standard white LEDs: Indigo-Clean |Comparison 4 germicidal wipes |

|Automated/semi-automated adjunctive cleaning technology | |indigo- |[pic] |

|e.g. UV light room disinfection, continuous narrow | |UVDI | |

|spectrum light or violet blue light, hydrogen peroxide | | |Environmental Cleaning Assessment |

|vapor, electrostatic technology | |UVC disinfection unit with 3min cycle time and 3 Log reduction C diff |[pic] |

|Bleach, hydrogen peroxide, peracetic acid, other solutions| |spores | |

|for manual environmental cleaning; EPA registered | |   | |

|sanitizer for soft surfaces (e.g. accelerated HP spray) | |Electrostatic sprayer for hard to clean surfaces e.g. wheel chairs, | |

| | |etc. | |

| | | | |

| | |HP wipe and spray with 1-minute contact time | |

| | | | |

MDRO Prevention and Control continued:

|Plus Measures |Reference |Product order info |Tools |

|Environmental cleaning continued |C[pic] |Silver ion-based laundry additive for immediate and |AHE (association for healthcare environment): |

|Cubicle/privacy curtains cleaning with innovations |D[pic] |sustained antimicrobial effect | |

|such as silver ion-based laundry additive to |E[pic] | | |

|industrial laundry rinse cycle, and HP spray on grab | |Soft surface and privacy curtain cleaning products: |ATP Guidelines |

|area between laundering | |[pic] |[pic] |

|Microfiber vs. cotton for cleaning cloths and mops | |Microfiber: | |

|Quality assessment tools such as fluorescent marker | |Cintas: |Room Cleaning Work Flow: |

|solution, ATP, color additive for disinfectants to | |[pic] |

|improve visibility and compliance with contact time | |aning-system/ | |

| | |Contec: | |

| | | |

| | |er-wipes/ | |

| | | | |

| | |Fluorescent marker product | |

| | | | |

| | | | |

| | |Novel color additive for disinfectants “Highlight” | |

| | | | |

MDRO Prevention and Control continued:

|Plus Measures |Reference |Product order info |Tools |

|Fecal Microbiota Transplant (FMT) to reduce MDRO |[pic] |OpenBiome – nonprofit stool bank |FMT Guide FDA: [pic] |

| | | |Patient FAQ: [pic] |

|Hand hygiene by patient – e.g. 3x/day before meals/and |[pic] |Hand wipes – multiple vendors |N/A |

|after BR | |PDI | |

| | |Purell | |

| | |Kleenex | |

| | | |

| | |kleenex/wipes | |

| | | | |

| | |Single use hand sanitizer “Snaps” Purell: | |

| | | |

| | |ang=en | |

|Hand hygiene – additional considerations |[pic] |Automated hand hygiene compliance monitoring systems: |Electronic Hand Hygiene Compliance |

|Automated hand hygiene compliance monitoring systems | |Clean Hands Safe Hands: |Organization: |

|Gaming technology for teaching hand hygiene technique | |DebMed: | |

|Single use hand sanitizer for meal trays, procedure kits | |Proventix: | |

|and healthcare workers | |Hygreen: | |

MDRO Prevention and Control continued:

|Plus Measures |Reference |Product order info |Tools |

|Hand hygiene continued |See above |Gaming technology for teaching: |See above |

|Improved soaps and sanitizers – for superior skin| |HandinScan | |

|health | |SureWash | |

| | |Single use Purell hand sanitizer “snaps”: | |

| | | |

| | |en | |

| | |Ultra Nourishing foam soap | |

| | | | |

|Instrument, equipment cleaning and disposables |[pic] |3M Red Dot prewired monitoring electrodes in 3 electrode or 5 |Disposable EKG lead guidelines |

|Stethoscope cleaning b/w patients | |electrode style (3-day wear time) |[pic] |

|Disposable EKG leads, B/P cuffs, pulse ox probes,| |Advantage medical cables 5 lead (snap or pinch styles available) | |

|stethoscopes | | | |

|Patient bathing |[pic] |Coloplast CHG liquid and bathing wipes: |Decision Algorithm CHG Liquid vs Cloths |

|Use a sufficient number of CHG cloths (5-6) and | |[pic] |

|use both sides of the cloth. | |ection=product-description_3 |Instructions for use Sage CHG cloths |

|6 CHG cloths are equal to 4 ounces of the 4% CHG | |Hibiclens: 2% liquid or foam formula CHG soap |(patients/staff) |

|formulation.  | | |[pic] |

|Wipe tubes, lines, devices | |Sage: 2% CHG cloths (rinse free): |Instructions for use Coloplast: |

| | | |[pic] |

MDRO Prevention and Control continued:

|Plus Measures |Reference |Product order info |Tools |

|Patient bathing continued |See above |Sage: MCare (rinse free non- antiseptic cleaner): |See above |

| | | | |

| | |Theraworx multi-ingredient colloidal silver skin cleanser | |

| | | | |

|PPE proper removal sequence to prevent infection |[pic] |N/A |N/A |

|transmission | | | |

|Reducing contamination of textiles (bed linen, |[pic] |Applied Silver SilvaClean silver ion-based laundry additive to |N/A |

|scrubs, lab coats) mattress covers and shoes | |rinse cycle | |

| | | | |

| | |Copper embedded patient linen | |

| | | | |

| | |UV disinfection device for OR shoes | |

| | | | |

| | |Disposable sheets - breathable and waterproof. Provides protection | |

| | |against leaks, messes, spills and dirt. | |

|Selective digestive decontamination |[pic] |N/A |N/A |

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