‘Primum non nocere’

In relation to infection control the word prevention has not been added to the lexicon of healthcare professionals (HCPs). Despite the plethora of literature, evidence, mandatory guidance, and the basic tenant of care espoused by Nightingale that “The very first requirement in a hospital is that it should do the sick no harm.” (1), HCPs often fail to adhere to simple hand-washing and other infection prevention actions. Consequently, healthcare-associated infections (HAIs) continue to develop either as a direct result of healthcare intervention or from being in contact with a healthcare setting (2).

Healthcare-associated infections (HAIs) result in a large health and cost burden worldwide (3, 4). The demand on NHS resources comes from an increasing number of antibiotic-resistant strains of bacteria and from an increasing number of chronically ill or immunologically compromised patients who are susceptible to hospital associated ‘opportunistic’ infections(5). Between 20% and 30% of all HAIs are preventable by improved infection control measures (6,7).

HCPs lack of engagement in prevention are not well explored, but are thought to include:

• Motivational factors – related to behaviourism (8), and ‘guideline fatigue’, whereby new guidance is either ignored or inexpertly implemented, and HCPs no longer explore new ways of working.
• Structural empowerment – the way in which employees perceive their work environment (8); facilities not readily/easily available, ‘make do and mend’ mentality.

Preventing cross infection in leg ulcer care

According to a recent NICE Clinical Knowledge Summary (9), Ensure the ulcer is irrigated at each dressing change with warm tap water or saline, then dried. Strict aseptic technique is not required, as the aim is not to remove surface bacteria, but rather to avoid cross-infection from contamination.

Previously, buckets or cleansing with swabs/cloths have been used to achieve this. However, if not properly decontaminated after use, buckets have the potential to facilitate cross infection. The innovative PathAguard® range of antimicrobial products facilitate a reduction in cross-infection potential. The range includes:

• The PathAguard® ABLiS® (Antimicrobial Basin Liner System): In an era which has seen the emergence of highly resistant pathogenic and persistent microbes, CMC Hygea Ltd. have developed a polypropylene utility basin system for patient hygiene activities in a clinical setting. The system is designed for use with a fitted disposable inner liner. Both PathAguard® ABLiS® and liner are treated with pathogen protection agents designed to reduce infectious risk from cross-contamination, handling and repeated use. It is a simple combination of a basin with a disposable liner both of which are impregnated with Silver Ion Technology. This has a proven kill rate of 99.99% against commonly occurring problematic species of pathogenic bacteria including E. coli, Staph aureus, Pseudomonas aeruginosa, MRSA, VRE and Klebsiella pneumoniae. The design of the system by using a liner reduces patient exposure to cross-infection from reused basins and contributes to overall infection control strategy in any healthcare setting
• The PathAguard® Luca® Single-Use Antimicrobial Leg Ulcer Cleaning Aid (Figure 1). The leg is placed into the sleeve, the cleansing liquid is added and then the sleeve is secured around the leg. The system offers antimicrobial pathogen protection, is safe, hygienic and cost effective, is versatile and can appropriately be used in both the home and healthcare settings

Laboratory results

Both products have undergone extensive laboratory and clinical testing. Those involved in the study share their findings.

R.J. Russell BA Mod, Ph.D. (Associate Professor of Microbiology. Microbiological Test Report – 20/11/14
The results clearly show that there is little, if any, reduction in bacterial counts on standard polypropylene for any of the bacterial species tested. E.coli and Pseudomonas aeruginosa counts were seen to increase slightly but not to any significant degree. This shows that under the ISO 22196 test conditions, high counts of bacteria were able to survive in viable form and were recoverable from standard polypropylene surfaces after 3 days.

Results recorded for the PathAguard® ABLiS® devices showed a marked contrast to those recorded for polypropylene. The survival rates for all bacterial species tested were very significantly less than on polypropylene and this was regardless of whether the bacteria were in contact for 24 hours or 72 hours.

There was no significant difference between the PathAguard® ABLiS® device antibacterial performance if in new and unused state or after 5 months in use.

All PathAguard® ABLiS® device samples were capable of reducing challenge bacterial counts by greater than 99% at 24 hours and by 99.99% at 72 hours.

This antibacterial performance of the PathAguard® ABLiS® device shows definite potential for infection control in clinical usage.

Debra Johnson MPH, BSN, RN, OCN, CIC, Infection Control & Prevention Specialist (US)
We conclude that bath basins are a reservoir for bacteria and that further investigations into bath basins as a potential source of transmissions of HAI are warranted. Increased awareness of bath basins as a possible source of bacterial cross-contamination is necessary, particularly in high-risk patients. In addition, alternative bathing methods should be investigated. Our findings are a call to action to healthcare providers to develop and implement protocols for patients’ exposure to pathogens. I have not changed my mind on bath basins, with the exception of PathAguard® ABLiS®. I am excited to see what it will bring back to patient care in the US.

Dr Roy Sleator BSc, MA, PhD, CBiol, FRSB. Senior Lecturer, Department of Biological Sciences, Cork Institute of Technology, Ireland.
The rise of antibiotic resistant ‘superbugs’, coupled with increasing incidence of nosocomial infections, continues to put significant strain on hospital infection control measures. The single use disposable liner limits exposure of the basin to potentially infective material and also provides an extra physical barrier between the healthcare professional and potentially infective material. This makes decontamination easier by significantly reducing the potential for reusable basins to act as vehicles for the inadvertent transfer of infective agents. The liner also facilitates clean and easy disposal of contaminated materials; significantly reducing the possibility of sloshing and aerosol formation as the basin is transported within the healthcare facility and subsequently when the basin is sanitized. Aerosol formation is a significant cause of infectious disease transmission in health care facilities.

In my estimation, the PathAguard® ABLiS® represents the cleanest, safest, and most effective approach to protecting against healthcare associated infection during hygiene activity.

Conclusion

Strict adherence to infection prevention practices are often compromised by human and environmental factors. Incorporating, this innovative system which reduces possible cross contamination in a twofold manner and (integral antimicrobial action and single use) eliminates many human and environmental factors.

Pentland Medical will be exhibiting the PathAguard® Luca® Leg Ulcer Cleaning Aid and PathAguard® ABLiS® (Antimicrobial Basin Liner System) at the Sepsis trust meeting in Brighton in September.

References

1. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. Dover Publications, England
2. National Institute for Health and Care Excellence (NICE). Infection prevention and control. NICE quality standard [QS61]. Available at: https://www.nice.org.uk/guidance/qs61/chapter/introduction
3. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control. 2005; 33: 501–509. http://www.ajicjournal.org/article/S0196-6553(05)00522-5/abstract
4. McNamara L. Health Care-Associated Infection. Am J Crit Care 2009;18:41. http://ajcc.aacnjournals.org/content/18/1/41.full
5. Public Health England. Healthcare associated infections (HCAI): guidance, data and analysis. March 2016 https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis
6. Council of the European Union. Council recommendation of 9 June 2009 on patient safety, including the prevention and control of healthcare-associated infections (2009/C151/01). Official Journal of the European Union. 3 Jul 2009. Available from: http://ec.europa.eu/health/patient_safety/docs/council_2009_en.pdf
7. European Centre for Disease Prevention and Control/European Medicines Agency (ECDC/EMEA). Joint technical report: The bacterial challenge: time to react. Stockholm:ECDC/EMEA; 2009. Available from: http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf
8. Smiddy MP, O’Connell R, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Inf Control. 2015. 43(3);269-274
9. NICE. Clinical Knowledge Summaries. Leg Ulcer-Venous. 2016. Available at: http://cks.nice.org.uk/leg-ulcer-venous#!scenarioclarification