Maintaining safe office spaces to minimise risks of SARS-CoV-2 transmission.

BACKGROUND: SARS-CoV-2 can be transmitted within offices. Traditional respiratory transmission modes have undergone reassessment and a new paradigm has emerged. This paradigm needs examining prior to identifying control measures to prevent office acquired infections (OAI). METHODS: An ongoing assessment of the SARS-CoV-2 transmission literature, including international public health guidance, began 30/1/2020 and continued to submission 7/2/2022. The evidence for the established respiratory transmission paradigm (either droplet or aerosols) and that of a newly emerging paradigm (aerosol and/or droplets) were explored. Based on the new paradigm control measures needed to minimise OAI were produced. RESULTS: The old paradigm of respiratory transmission of being either droplet or airborne cannot be evidenced. SARS-CoV-2 is emitted in virus laden particles that can be inhaled and/or sprayed on facial mucous membranes (Airborne being the dominant route). Office hygiene measures include: minimising the opportunities for the virus to enter the building. Reducing the susceptibility of people to the virus. Minimising exposure risks within offices, and optimising success in deployment. CONCLUSION: Standard office hygiene precautions are needed to reduce OAI risks from SARS-CoV-2. Efforts should focus on enabling the smooth functioning of the office whilst minimising risks that the virus will transmit therein. This includes: local risk assessments as transmission risks vary based on building design, ventilation, capacity, and ways of working. Additionally, using experts to optimise ventilation systems.

Intravenous drug preparation: the infection risks.

The preparation of intravenous drugs is a common yet inherently dangerous nursing procedure. Potential errors associated with this procedure include incorrect drugs, doses and routes of administration. As a consequence of these recognized risks, a variety of checks are used to optimize safety. This paper explores the literature around infusate contamination, which can cause infusate-related bloodstream infection (IR-BSI). In addition, this paper will discuss the mechanisms of infusate contamination, as well as details of the types of microorganisms that cause contamination and the types of drugs that enable proliferation of microorganisms. Deficits within current guidance are revealed. The paper concludes that IR-BSI is a significant but under-recognized risk to patients. As microbial contamination sufficient to cause IR-BSI is not detectable to the naked eye, those who prepare intravenous drugs must be more aware of contamination risks and how to reduce them.

A comparison of the nationally important infection prevention and control documents in NHS England and NHS Scotland.

BACKGROUND: The devolution of health to Scotland in 1999, led for the first time in the NHS, to different priorities and success indicators for infection prevention and control (IPC). This project sought to understand, compare and evaluate the national IPC priorities and available indicators of success. AIM: To identify the national IPC priorities alongside national indicators of success. METHODS: Critical analysis of nationally produced documents and publicly available infection-related data up to March 2018. FINDINGS: For both NHS Scotland and England the local and national IPC priorities are evidenced by: (1) people being cared for in an IPC-safe environment; (2) staff following IPC-safe procedures; and (3) organisations continuously striving not just to attain standards, but to improve on them. If national agencies that produce data were also charged with using a Continuous Quality Improvement (CQI) model, then there would be further opportunities to detect and improve on successes.

A quality improvement project to standardise decontamination procedures in a single NHS board in Scotland.

BACKGROUND: A project was designed to improve decontamination procedures in our hospitals. This included: improving skills with training provided within clinical areas, simplifying procedures to reduce variation and increasing access to decontamination products. AIM: To make it easy for healthcare workers (HCWs) to do the right thing and for HCWs to be confident that they were doing the right thing. METHODS: A pre-intervention survey of 120 HCWs in 10 wards on three hospital sites identified variations in the products used, variations in precautions taken and deficits in HCWs' capabilities due to unmet training needs. INTERVENTION: We streamlined the available products, provided an education programme and then undertook a second survey involving 133 HCWs in 12 wards. RESULTS: Significant improvements were attained in the reported time taken to clean and disinfect (P < 0.0001) and in HCW capability (P < 0.0001) (reported training received); other improvements in the use of appropriate products and the use of personal protective equipment were evident. The key finding was that a large, previously unrecognised, unmet training need existed; only 44% of HCWs in the pre-intervention survey reported having received training on the topic. CONCLUSION: The utility of a pre-intervention survey is critical to knowing whether any change becomes improvement and to set the priorities for change. By focusing on the process rather than the outcomes, greater improvements can be attained. The assumption that all nurses know how to clean is erroneous.

Chemical disinfectants: Controversies regarding their use in low risk healthcare environments (part 1).

In recent years, the number of disinfectants designed to decontaminate healthcare environments and reusable, non-invasive care equipment (NICE) has increased markedly, making the selection of the most appropriate disinfectant a somewhat daunting prospect. In addition to the microbial challenge, there are numerous factors to consider including: efficacy; range and speed of activity; stability of the ingredients; compatibility of the disinfectant with surfaces; inactivation of the disinfectant by organic matter; method of application; convenience; health and safety concerns; and cost. While the microbial challenge continues to evolve, and novel disinfectants continue to emerge, guidance updates have been notably absent. Most healthcare surfaces belong to a UK-defined category of 'low risk' for which guidance dictates 'cleaning and drying is usually sufficient'. This paper assesses the evidence and arguments regarding the use of disinfectants for low-risk healthcare surfaces. A novel subcategorisation of 'low risk' is presented to provide a more specific up-to-date disinfectant needs assessment.

Outbreak Column 22: How to manage an outbreak.

This outbreak column uses the Health Protection Scotland (HPS) Outbreak Process and Algorithm to examine and reflect on a published outbreak report. The report involved an extensively drug-resistant Acinetobacter baumannii in an oncology unit. High-reliability theory is then used to reflect on how the outbreak was managed and consider how best to improve local outbreak prevention, preparedness, detection and management. The conclusion of this exercise is that if the possibility of an era of untreatable infections caused by antibiotic-resistant organisms is to be significantly postponed, Infection Prevention and Control Teams must improve their ability to get others to prevent cross-transmission in the absence of recognised risks.

Outbreak column 21: Tuberculosis (TB): Still a nosocomial threat.

This outbreak column explores the epidemiology and infection prevention guidance on tuberculosis (TB) in the UK. The column finds that, at present, national guidance leaves UK hospitals ill-prepared to prevent nosocomial TB transmission. Reasons for this conclusion are as follows: (1) while TB is predominantly a disease that affects people with 'social ills', it has the potential to infect anyone who is sufficiently exposed; (2) nosocomial transmission is documented throughout history; (3) future nosocomial exposures may involve less treatable disease; and (4) current UK guidance is insufficient to prevent nosocomial transmission and is less than that advocated by the World Health Organization and the Centers for Disease Control and Prevention.

Vessel Health and Preservation Framework: Use of the outcome logic model for evaluation.

BACKGROUND: Vascular access is an important part of many patient care management plans, but has unwanted risks. A working group led by the Infection Prevention Society (IPS) produced a Vessel Health and Preservation (VHP) Framework. Based on current evidence, a framework was developed for frontline staff to assess and select the best vascular access device to meet the individual patient's needs and to preserve veins for future use. METHODS: Using the Outcome Logic Model, we conducted an evaluation of the short- and medium-term outcomes with regards to the impact and success of the VHP Framework. RESULTS: This evaluation found that many respondents were aware of the framework and were using it in a range of different ways. Participants saw the framework as being most beneficial to help decisions on device choice and peripheral vein assessment. However, the framework has not fully reached its intended audience. DISCUSSION: Many positive outcomes were reported as a result of using the VHP Framework including improving clinical practice as it relates to the VHP elements. However, further work is required to find the tools to extend the reach of the framework and assist healthcare teams to be able to fully implement it within their clinical settings.

Effectiveness of national and subnational infection prevention and control interventions in high-income and upper-middle-income countries: a systematic review.

Evidence-based guidance for national infection prevention and control (IPC) programmes is needed to support national and global capacity building to reduce health-care-associated infection and antimicrobial resistance. In this systematic review we investigate evidence on the effectiveness of IPC interventions implemented at national or subnational levels to inform the development of WHO guidelines on the core components of national IPC programmes. We searched CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS databases for publications between Jan 1, 2000, and April 19, 2017. 29 studies that met the eligibility criteria (ie, economic evaluations, cluster-randomised trials, non-randomised trials, controlled before-and-after studies, and interrupted time-series studies exploring the effective of these interventions) were categorised according to intervention type: multimodal, care bundles, policies, and surveillance, monitoring, and feedback. Evidence of effectiveness was found in all categories but the best quality evidence was on multimodal interventions and surveillance, monitoring, and feedback. We call for improvements in study design, reporting of research, and quality of evidence particularly from low-income countries, to strengthen the uptake and international relevance of IPC interventions.

Outbreak Column 20: are outbreaks man-made disasters that display intertwined errors of human judgement and behaviour?

Man-made disasters are reported to have five intertwined errors of human judgement and behaviour. As outbreaks are essentially man-made disasters, the cited intertwined errors of engineering overreach, smooth sailing fallacy, insider view, risk-seeking incentives and social-herding were looked for in five notable outbreaks of Clostridium difficile infection. Engineering overreach was found to be the most identifiable error. The purpose of this reflective exercise was to turn hindsight into foresight and determine the intertwined levels of safety behaviour needed to prevent any future pathogen emerging to produce healthcare disasters.

Transmission of Salmonella enteritidis after endoscopic retrograde cholangiopancreatography because of inadequate endoscope decontamination.

We report a historic nosocomial outbreak of Salmonella enteritidis affecting 4 inpatients who underwent endoscopic retrograde cholangiopancreatography. The cause was attributed to inadequate decontamination of an on-loan endoscope used over a weekend. This report highlights the risks of using on-loan endoscopes, particularly regarding their commissioning and adherence to disinfection protocols. In an era of increasing antibiotic resistance, transmission of Enterobacteriaceae by endoscopes remains a significant concern.

Needleless connectors: the vascular access catheter's microbial gatekeeper.

Needleless connectors (NCs) are essential devices which connect to the end of vascular catheters and enable catheter access for infusion and aspiration. There are various different designs which make it difficult for purchasers to identify the features which present the least risk and greatest safety. The NC is the microbial gatekeeper for vascular catheters; how it is disinfected pre access determines if, and how many, organisms enter and how quickly biofilm will form. This paper will consider these design variations and how differences in antiseptic testing methods have made it difficult to determine the best antiseptic practice pre access. One specific design characteristic is considered: the fluid pathway. The NC's fluid pathway creates a flow which can be either direct to produce a laminar flow or indirect which creates a turbulent flow. At present, the evidence does not support there being an advantage for a specific fluid pathway design in reducing infection risks.

Outbreak column 19: needleless connectors (NCs) tales from nine outbreaks.

A critical review of historical outbreak reports that are still influencing practice today is presented. These outbreak reports were used as evidence in support of guideline recommendations and of the US Food and Drug Administration's (FDA) advisory notice requiring post-product surveillance for needleless connectors (NC) which have a positive displacement. Guideline recommendations were subsequently changed but not before other authorities had issued recommendations based on the original. All the above led some purchasers to look for different NC designs. The conclusions are that the evidence, as reported, does not support there being an increased risk from positive displacement NCs. Identified in this review were unsubstantiated claims, incompleteness in reporting of specifics, opinions considered as evidence and unexplored outbreak-provoking explanations.

The Where is Norovirus Control Lost (WINCL) Study: an enhanced surveillance project to identify norovirus index cases in care settings in the UK and Ireland.

BACKGROUND: Norovirus outbreaks have a significant impact on all care settings; little is known about the index cases from whom these outbreaks initiate. AIM: To identify and categorise norovirus outbreak index cases in care settings. METHODS: A mixed-methods, multi-centre, prospective, enhanced surveillance study identified and categorised index cases in acute and non-acute care settings. RESULTS: From 54 participating centres, 537 outbreaks were reported (November 2013 to April 2014): 383 (71.3%) in acute care facilities (ACF); 115 (21.4%) in residential or care homes (RCH) and 39 (7.3%) in other care settings (OCS). Index cases were identified in 424 (79%) outbreaks. Of the 245 index cases who were asymptomatic on admission and not transferred within/into the care setting, 123 (50%) had been an inpatient/resident for 4 days. Four themes emerged: missing the diagnosis, care service under pressure, delay in outbreak control measures and patient/resident location and proximity. CONCLUSION: The true index case is commonly not identified as the cause of a norovirus outbreak with at least 50% of index cases being misclassified. Unrecognised norovirus cross-transmission occurs frequently suggesting that either Standard Infection Control Precautions (SICPs) are being insufficiently well applied, and or SICPs are themselves are insufficient to prevent outbreaks.

Outbreak Column 16: Cognitive errors in outbreak decision making.

During outbreaks, decisions must be made without all the required information. People, including infection prevention and control teams (IPCTs), who have to make decisions during uncertainty use heuristics to fill the missing data gaps. Heuristics are mental model short cuts that by-and-large enable us to make good decisions quickly. However, these heuristics contain biases and effects that at times lead to cognitive (thinking) errors. These cognitive errors are not made to deliberately misrepresent any given situation; we are subject to heuristic biases when we are trying to perform optimally. The science of decision making is large; there are over 100 different biases recognised and described. Outbreak Column 16 discusses and relates these heuristics and biases to decision making during outbreak prevention, preparedness and management. Insights as to how we might recognise and avoid them are offered.

Outbreak column 17: Situational Awareness for healthcare outbreaks.

Outbreak column 17 introduces the utility of Situation Awareness (SA) for outbreak management. For any given time period, an individual or team's SA involves a perception of what is going on, meaning derived from the perception and a prediction of what is likely to happen next. The individual or team's SA informs, but is separate to, both the decisions and actions that follow. The accuracy and completeness of an individual or team's SA will therefore impact on the effectiveness of decisions and actions taken. SA was developed by the aviation industry and is utilised in situations which, like outbreaks, have dynamic, i.e. continuously changing problem spaces, and wherein a loss of SA is likely to lead to both poor decision-making and actions with potentially fatal consequences. The potential benefits of using SA for outbreaks are discussed and include: (1) retrospectively to identify if poor decision-making was a result of a poor SA; (2) prospectively to identify where the system is weakest; and (3) as a teaching tool to improve the skills of individuals and teams in developing a shared understanding of the here and now.

Outbreak column 18: The undervalued work of outbreak: prevention, preparedness, detection and management.

There are oft-quoted studies which advise that between 1% and 10% of healthcare-associated infections (HAIs) present as healthcare-associated outbreaks (HAOs). Examination of these studies showed they lacked validity due to a low sensitivity to detect HAO, and because they pre-date both advanced healthcare systems and the emergence of recent nosocomial pathogen challenges. The accepted inference: that as there are so few HAOs the focus of surveillance programmes should be on endemic and not epidemic infections (outbreaks), is therefore called into question. Current estimates of HAI burden are derived from Point Prevalence Surveys (PPS) which are neither designed to nor are capable of detecting HAOs. We considered the extensive Infection Prevention and Control Team (IPCT) work to prevent and prepare for perennial and novel HAOs and suggest that at present this endeavour is largely unseen, underestimated and undervalued. Any HAI burden estimate needs to comprise a more complete HAI summary than PPS data. This can only be done with a more inclusive surveillance system that has a wider focus than just prevalent infections. There is a real risk of redirection of the IPCT resource from outbreak prevention and preparedness work towards HAI that are counted: such a change could only further increase HAO risks.