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Healthcare associated infections and medical imaging - infection prevention is everybody's business: A case report By Dr D Neil Jones, Staff Consultant Radiologist Flinders Medical Centre, South Australia Description: Case details An imaging study was requested for an inpatient. Radiology staff called the ward to confirm the request, and arrange transport. The patient was transferred to the patient waiting bay area in the Radiology department by a “patient transport” staff member. On review of the patient's accompanying medical notes, it was evident that the patient had a hospital-acquired methicillin resistant staphylococcus aureus (MRSA) infection. The Medical Imaging and Patient Transport staff members were annoyed that nobody had been informed. There was no information about this on the imaging request form (“Alerts” box left blank), nor on the Radiology Information System. Discussion This case study raises several issues. Firstly, effective and timely communication, including clinical handover, is essential1. This includes the intra-hospital transfer of patients, and the Medical Imaging department is a site of frequent patient visitations with multiple interactions involving Imaging staff members (clerical, nursing, radiographic, medical), ward staff, and transport staff. Additionally, patient information/alerts should be uniformly and readily available, for example, through electronic means, to treating healthcare workers2. Sometimes, variable quality information may reside in disparate and non-integrated information systems within the healthcare organization. Imaging referral forms must contain accurate, complete and relevant information. Involvement of the patient in their own healthcare management may also help prompt appropriate clinical action. Secondly, this case study highlights the issue of Healthcare Associated Infections (HAIs)3,4,5 and the Medical Imaging department. A HAI occurs when a patient acquires an infection as a result of receiving healthcare. HAIs acquired in the hospital setting are a major cause of death and increased morbidity for hospital patients worldwide. Multinational point prevalence studies demonstrate a HAI rate of around 8-10%4. It is estimated that there are 200,000 such infections in Australian hospitals annually5. There are also many indirect impacts of HAIs including a reduction in throughput for elective surgery, stress and workload pressure for staff and reduced time to attend to other patients. HAIs can occur in any patient and most commonly include urinary tract, respiratory tract, surgical site (wounds) and blood stream infections. They are the most common complication affecting patients in hospital, and involve bacterial (with or without antibiotic multiresistance) and viral infections. Healthcare workers HAI and medical imaging - infection prevention is everybody's business: A Case Report QUDI eNews, February 2009 © RANZCR - 2009 1 can also be involved. MRSA is the most commonly reported multiresistant organism and is responsible for a significant burden of disease. The prevention and management of such infections is therefore critically important. HAIs are a major and growing issue in the quality and safety of health care in both the hospital and community settings requiring urgent national consideration and action and has been nominated as a priority area by the Australian Commission on Safety and Quality in Health Care (ACSQHC)3. This HAI program aims to build on facility and jurisdictional initiatives to develop a national approach to reducing HAI by identifying and addressing systemic problems and gaps, and ensuring comprehensive actions are undertaken in a nationally coordinated way in both public and private health sectors. There are five key initiatives in the overall strategy: 1. 2. 3. 4. 5. National Hand Hygiene Project6,7 National Infection Control Guidelines National HAI Surveillance System Building Clinician Capacity in this area Antibiotic Utilisation/stewardship In other countries recognition of the impact of HAIs is growing and considerable measures are being taken in this area8,9. HAI and medical imaging: Your role in their prevention There are actions you can take to minimise the risk of your patients acquiring HAIs. These are listed below and adapted from the Tasmanian Infection Prevention and Control Unit document4. Up to 70% of hospital-acquired infections could be prevented if infection control procedures were optimised. 1) Hand hygiene6,7: The highest priority area to reduce the risk of healthcare-associated infections is improved healthcare worker hand hygiene. Improving hand hygiene among healthcare workers is currently the single most effective intervention to reduce the risk of healthcare associated infections. Transfer of microbial pathogens (including MRSA) on the hands of healthcare workers is a key driver of healthcare associated infection. Healthcare workers inadvertently transfer nosocomial pathogens as they move from patient to patient. Colonised patients become the major reservoir of hospitaladapted pathogens, shedding these organisms into their immediate surroundings. The final transition from colonisation to infection occurs by transfer of a colonising organism to a sterile site during medical care or as a result of the breach of primary defences (injury or medical device). The purpose of the National Hand Hygiene Initiative is to develop a national approach to improving hand hygiene and monitor its effectiveness. The initiative is based on the World Health Organisation (WHO) - World Alliance for Patient Safety campaign – "Clean Care is Safer Care" launched in 2005. The ACSQHC plans to launch the program in February 2009. At their December 2008 meeting, Australian Health Ministers endorsed a national approach to the implementation and monitoring of hand hygiene standards and a standardised national audit tool auspiced by the ACSQHC10. The Medical Imaging department is characterized by very frequent patient interactions and contact involving multiple staff groups. Some of these patients or patient groups seen in Medical Imaging are at high risk for HAI. There is a real potential for breakdown of hand hygiene involving such a high-density, high-acuity patient population in frequent contact with health-care workers. Additionally, some imaging is performed outside of the Medical Imaging department in high-risk environments such as ICU. 2) Policies and procedures It is important to be aware of and comply with infection control policies and procedures that reflect current best practice and standards, including sharps disposal. For example, this RaER case study highlights the need for adherence to institutional protocols in relation to the prevention, detection/surveillance, and management of MRSA infection. Procedures and HAI and medical imaging - infection prevention is everybody's business: A Case Report QUDI eNews, February 2009 © RANZCR - 2009 2 practices need to consider and include infection control risks. Aseptic and non-touch techniques must be carried out correctly. Control of the re-use of single use devices must occur. The Medical Imaging environment is a highly relevant one in relation to these issues. Patient procedures are performed routinely and frequently, ranging from peripheral intravenous access and drug/contrast administrations, through to highly complex and invasive interventional and therapeutic interventions. Body fluids are often involved. Nuclear Medicine imaging techniques can involve in vitro laboratory blood product radio-labeling, and patient reinjection of blood products, and serious adverse events have been reported in both processes11,12. 3) Cleaning Clean and decontaminate equipment and your environment appropriately. Sterilise equipment as appropriate. Medical Imaging equipment may harbour potential pathogens, e.g. MRI scanners and ultrasound equipment13,14. 4) Consider your patients Consider the “risk” your patients pose to others in respect to infection control, and manage those patients appropriately. Also consider whether any of your patients are at risk of HAI. 5) 6) Personal protective equipment • Wear personal protective equipment appropriately and correctly • Always perform hand hygiene after removing personal protective equipment. Surveillance • Participate in surveillance of HAIs • Organizational monitoring of infection control standards, compliance (for example, hand hygiene) and infections. In December 2008, all Australian Health Ministers agreed to a national approach to surveillance of Staphylococcus Aureus blood stream infections (including MRSA) and other virulent microorganisms. All hospitals will establish healthcare associated infection surveillance and monitor and report on Staphylococcus Aureus (including MRSA) blood stream infections and Clostridium Difficile infections, through their jurisdiction, into a national data collection10,15. 7) Get informed and promote action Understand the issues of HAI and promote a culture of awareness, patient safety and action. 8) Antibiotics Use antibiotics appropriately. Occasionally, antibiotic prophylaxis is administered in the Medical Imaging/Interventional Radiology department, although this is a relatively minor feature of overall Medical Imaging work practice. Antimicrobial resistance is one of the major threats to the great advances in treatment of infectious disease. The leading example has been the emergence and dissemination of penicillin resistance in Staphylococcus aureus. Hospitals are the major focus for the spread of highly resistant organisms. Antimicrobial resistance increases the morbidity and mortality associated with infections, and contributes to increased costs of care due to prolonged hospital stays and other factors, including the need for more expensive drugs. 9) Immunisation Ensure you are up to date with your immunisations and receive yearly influenza vaccinations. Summary Healthcare Associated Infections are a major public health concern, and all stakeholders are paying serious attention. There is a growing recognition of the safety and quality aspects of HAIs. Medical Imaging departments and staff need to understand these important issues, and actively participate in solutions to reduce the risk to our patients. HAI and medical imaging - infection prevention is everybody's business: A Case Report QUDI eNews, February 2009 © RANZCR - 2009 3 References 1. ACSQHC Clinical Handover (accessed Feb 14, 2009) 2. Kho, A. An effective computerized reminder for contact isolation of patients colonized or infected with resistant organisms Int J Med Inform. 2008 Mar;77(3): 194-8. 3. ACSQH Healthcare Associated Infection (HAI) (accessed Feb 13, 2009) 4. Tasmanian Infection Prevention & Control Unit "Healthcare Associated Infections Information for health professionals" (accessed Feb 13, 2009) 5. ACSQH "Reducing harm to patients from healthcare associated infection: the role of surveillance" (accessed Feb 13, 2009) 6. Hand Hygiene Australia http://www.hha.org.au/ (accessed Feb 13, 2009) 7. ACSQH National Hand Hygiene Initiative (accessed Feb 13, 2009) 8. NHS UK "Healthcare associated infection" (accessed Feb 14, 2009) 9. Public Health Agency of Canada "Healthcare-associated infection practices and resources among provinces and territories in Canada: results of a survey" (accessed Feb 14, 2009) 10. ACSQH Update; Issue 7, December 2008 (accessed Feb 13, 2009) 11. Patel P. et al. 'Hepatitis C Virus Infections From a Contaminated Radiopharmaceutical Used in Myocardial Perfusion Studies' JAMA 2006;296:20052011. 12. Rojas-Burke J. 'Health Officials Reacting to Infection Mishaps'. J Nucl Med 1992 33: 13N-27N. 13. Fowler, C, McCracken D, 'US Probes: Risk of Cross Infection and Ways to Reduce ItComparison of Cleaning Methods'. Radiology 1999; 213: 299-300. 14. Diagnostic Imaging 'Irish radiologists take urgent action to eradicate superbug'. Nov 28, 2006. (accessed Feb 15, 2009) 15. Dendle, C 'Staphylococcus aureus bacteraemias as “signal event” surveillance in a busy hospital' (accessed Feb 13, 2009) HAI and medical imaging - infection prevention is everybody's business: A Case Report QUDI eNews, February 2009 © RANZCR - 2009 4 COPYRIGHT NOTICE: This report is protected by copyright. No part of this publication may be reproduced or copied in any form or by any means without the written permission of the Royal Australian and New Zealand College of Radiologists. For written permission to use the information contained in this report, please contact the RANZCR: [email protected] DISCLAIMER: Responsibility for the content of this report resides solely with the authors. The views and opinions expressed in this report, including key recommendations and findings are strictly the views and opinions of the authors and not officially sanctioned by the Royal Australian and New Zealand College of Radiologists. NOTE: The RaER project was funded by the Australian Commonwealth Department of Health and Ageing under the Quality Use of Diagnostic Imaging Program. HAI and medical imaging - infection prevention is everybody's business: A Case Report QUDI eNews, February 2009 © RANZCR - 2009 5