Hospital Water: Is it a Source for Nosocomial Infections? Copyright 2002, Robert Garcia, BS, MMT(ASCP), CIC
Causative Agent Reservoir Susceptible host Portal of exit Portal of entry Mode of Transmission The Chain of Infection. Components of the Infectious Disease Process.
Water as a Reservoir of Nosocomial Pathogens • Organisms such as Pseudomonas aeruginosa, Serratia marcescens, and Acinetobacter calcoaceticus can replicate in relatively pure water • May be present in drinking water that has acceptable limits of safety (<1 coliform bacterium/100 mL)
P. aeruginosa Infections due to Hospital Water Sources • >12 reports indicating transmission and development of infection from contaminated hospital water • Trautmann M, Michalsky T, et al. Tap water colonization with Pseudomonas aeruginosa in a surgical intensive care unit and relation to Pseudomonas infections of ICU patients. Infect Control Hosp Epidemiol 2001;22:49-62.
Burn Infections • Tap water has been cited as the source for serious wound and sepsis • Kolmos HJ, Thuesen B, et al. Outbreak of infection in a burn unit due to Pseudomonas aeruginosa originating from contaminated tubing used for irrigation of patients.
Infections from Hospital Sinks • Many reports have identified the presence of gram-negative bacteria in hospital sinks • Organisms may survive for >250 days on sink surfaces • Simor AE, Ramage L, et al. Molecular and epidemiologic study of multiresistant Serratia marcescens infections in a spinal cord injury rehabilitation unit. Infect Control Hosp Epidemiol 1988;9:20-27.
Tip of the Iceberg • More than 40 citations of water as a source of nosocomial infections • Anaissie et al estimate that >1,400 deaths occur each year due to waterborne nosocomial pneumonia due to P.aeruginosa alone • Anaissie EJ, Penzak SR, Dignani C. The hospital water supply as a source of nosocomial infections. A plan for action. Arch Intern Med 2002;162:1483-92.
“…In such settings, hospital water may have contaminated environmental surfaces (eg, sinks, drains, and whirlpool baths), medical equipment (eg, by rinsing tube feed bags, endoscopes, respiratory equipment, etc., with tap water), or health care providers, leading ultimately to patient exposure.” • - Anaissie EJ, et al. The hospital water supply as a source of nosocomial infections. A plan for action. Arch Intern Med 2002;162:1483-92.
How are Patients Exposed to Hospital Water? • Handwashing (cross-contamination) • Bedpans • Enteral feedings • Respiratory equipment • Drinking • Showering • Bed bathing
Basin Bath Drawbacks • High consumption of resources • Negative impact on nursing and patients • Damaging effects on the skin • Contamination risks with basins & water • Real economics of basins
Why Should Hospitals Care? • Most of your patients skin is at risk • Cost of skin breakdown in U.S.: $13 Billion • Nosocomial contamination may lead to nosocomial infection • Cost of nosocomial infection: $5.9 Billion • JCAHO Patient Safety Quality Indicators • Patient ‘barometer’ for their quality of care Source: Stone P. et al, Outcomes of ICU Working Conditions, Nov 2001
Nursing Shortage vs. Patient Outcomes JCAHO Expert Panel Report “Insufficient staffing not only adversely impacts health care quality and patient safety, it also compromises the safety of nurses themselves” Source: Joint Commission on Accreditation of Healthcare Organizations, August 2002
Damage to the Skin • Soaps can strip the acid mantle, raise the pH and compromise the epidermis • Washcloths introduce friction because they are harsh and rough • Drying soap and rough washcloths are fragile skin’s worst enemy Sources: Friers, S.A. Ostomy, Wound Management June 2001 Bryant R. A. Ostomy, Wound Management June 2001 Wysocki A. Acute and Chronic Wounds 2nd Edition 2000
Whose Skin Are We Talking About? • Your Patient • Majority are elderly • Most have pruritic skin condition • Epidermis and dermis are thinner • Skin has reduced barrier function • Reduced skin elasticity • Poor epidermal turnover • Lowered sebum production • Loss of subcutaneous fat and muscle Source: Thomas MD, D., Clinical Journal of Medicine, Cleveland
Pressure Ulcers • 1.6 million cases per year in acute care • Varied settings: • medical wards • surgery and operating rooms • intensive care units • rehabilitation centers • long term and home care
Prevalence of Pressure Ulcers • Reported rates to be between 3% and 11% • Two large studies: • 9.2% (148 hospitals) 1 • 7% (116 hospitals) 2 1. Meehan M. Multisite pressure ulcer prevalence survey. Decubitus 1990;3:4-14. 2. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.
Cost Impact: Hospitals • Unadjusted mean costs: • With Pressure ulcers - $37,288 • Without pressure ulcers - $13,924 • Adjusted for admission predictors and nosocomial infections: • With pressure ulcers - $29,048 • Without pressure ulcers - $13,819 Allman RM, Goode PS, Burst N, et al. Pressure ulcers, hospital complications, and disease severity: Impact on hospital costs and length of stay. Adv Wd Care 1999;12:23-30.
Basinborne Contamination Study • Hospital personnel do not perceive basin bath water as significantly contaminated • 100% of the samples in the study were positive for bacterial growth, 60.8% were gram negative • The bacterial count in basin water was so high it was similar to the bacterial count in the urine from patients with UTI’s • Employees, wearing contaminated gloves used during the procedure, were observed to touch many environmental surfaces. • Basin water may serve as a reservoir of antibiotic resistant organisms Source: Shannon R et al., Patient Bath Water as a Source of Nosocomial Microbiological Contamination: An intervention Study using Chlorhexidine. J Healthcare Safety Infect Control, 1999;3:180-84.
Basinless Bathing • Removes the risk of basin contamination • Removes the risk of waterborne contamination • 8 washcloths to reduce transfer of organisms • Mild cleanser helps maintain skin’s natural barrier • Single-use helps reduce environmental/cross contamination • No water spills reduce slips & fall potential Better Science and Patient Safety
$6.84 per bath What’s the Real Cost of Basin Bathing? Energy, Water & Sewer $.10 Nursing $5.11 Laundry Processing $.98 Materials $.65 Source: Total Delivered Cost Analysis Database from U.S. hospitals 1997 - 2002, Sage marketing data on file.
Solid Economics $5.11 Nursing Time $6.84 total $3.68 total $1.83 Nursing Time $1.73 $1.90 $.98 Laundry &Linens Basinless Bath $1.10 to $1.90 $1.10 $.10 Water,Sewer,Energy $.65 Materials Basin Bath Cost Basinless Cost Source: Total Delivered Cost data analysis of U.S.hospitals 1997-2002
Time is on Your Side Original Price $5.50 • New Concept $5.00 $4.00 $3.00 $2.00 $1.00 • High Distribution Margins H o s p i t a l p r i c e • One or Two Product Choices $3.75 • Manufacturing Efficiencies The Cost of Basinless Bathing • GPO Contracts $2.25 $2.05 • Multiple Product Choices $1.90 $1.10