Let there be Light New light-based technologies to

“Let there be Light”: New light-based technologies to prevent infections Elizabeth Bryce Regional Medical Director, Infection Prevention and Control

The Goals of Infection Prevention and Control • Protect Patients • Protect Staff & Visitors • Do this in a cost effective manner

The Role of Infection Control Research Consultation Surveillance Education Policy and Procedure Standards and Guidelines

Topics for Today • Immediate Pre-operative decolonization to prevent surgical site infections • Use of Ultraviolet C to disinfect patient rooms

Immediate Preoperative Decolonization Therapy Reduces Surgical Site Infections: A multidisciplinary quality improvement project Dr. Elizabeth Bryce On behalf of the Vancouver General Hospital Decolonization Team Vancouver, British Columbia, Canada 5

Pre-operative Decolonization: Background • Most surgical site infections (SSIs) arise from the patient’s own bacteria • Decreasing the bacterial load on the skin and nose prior to surgery can decrease the risk of surgical site infections (SSIs) = DECOLONIZATION • Traditional decolonization consist of antiseptic soap (chlorhexidine) +/- intranasal antibiotics (mupirocin) • Compliance with chlorhexidine + mupirocin poor • Resistance to mupirocin is an issue

Our Innovative Approach Nasal Photodisinfection Chlorhexidine Wipes • Methylene blue applied to nares • Two – 2 minute pulses of red light • applied to limbs and torso the night prior to or day of surgery

Chlorhexidine Washcloths • Alcohol-free washcloth impregnated with CHG • FDA and Health Canada approved • Used below the neck day of or night prior to surgery • Left on the skin (not rinsed off) • Equivalent to 4% CHG on skin http: //www. sageproducts. com/lit/20778 C. pdf

MRSAid™ Treatment Protocol 1 2 3 4 1 st Illumination Cycle 2 nd Illumination Cycle 1. Connect nasal illuminator tips to laser cable port via fiber-optic connector 2. Illuminate for 2 minutes with tips placed as shown above (directed into inner tip of nose for 1 st cycle and posterior for 2 nd cycle)

How Photodisinfection works Treatment Site Irrigation Tissue Apply Colonized with Photosensitizer Pathogenic that binds to Bacteria bacterial surfaces Illumination Eradication Illuminate the Treatment Site Using Non-Thermal Light Energy “Activated” Photosensitizer creates reactive oxygen species, killing bacteria

Advantages of this Approach • Targets both gram positive and negative bacteria • Eradicates antibiotic resistant bacterial strains • Does not generate bacterial resistance • No/minimal effect on human tissues • Rapid action – maximally effective in minutes • Increased compliance 11

VGH SSI reduction decolonization QI project Objectives: 1. To determine if immediate preoperative decolonization using nasal photodisinfection therapy + CHG wipes reduces SSI rates in elective non-general surgeries. 2. To assess the feasibility of integration of a decolonization program in the pre-operative area 12

Decolonization Protocol Surgeries included: • cardiac, thoracic, ortho-recon, ortho-trauma, vascular, neuro/spine, and breast cases. Surgeries excluded: • open fractures, dirty/contaminated cases, duplicate cases, cases in 6 week introductory period CHG within 24 h Nasal Culture Photodisinfection Therapy (MRSAid) SSI Surveillance Perform Surgery Document Compliance, AE

1. Microbiological Efficacy, Safety, and Compliance • Microbiological Efficacy Growth MSSA reduction n = 1286 (%) MRSA reduction n=51 (%) Heavy 105/109 (96. 3%) 8 /10(80%) Moderate 348/383 (90. 9%) 13/16 (81. 3%) Scant 598/794 (75. 3%) 18/25 (72%) Total 1051/1286 (81. 7%) 39/51 (76. 4%) *unpaired data was excluded ** reduction defined as complete or partial bioburden reduction

1. Microbiological Efficacy, Safety, and Compliance • Safety: – All adverse events were tracked and reported – 7 cases of transient, mild burning sensation in throat after application of methylene blue – Total adverse event rate of 7/5691 = 0. 123%

SSI Data - Extraction Cases during study period and study hours N=5176 SSI surveillance routinely done N= 3274 Cases treated pre-op N = 3068 94% compliance SSI surveillance not routinely done N = 1912 Cases not treated N = 206

Comparing SSI rates: Treated and Historical Specialty Treated Patients SSIs 4 -year Historical Group Rate % SSIs (Average) P value OR Rate % Cardiovascular 19/628 3. 0 83/3334 (21) 2. 5 0. 4373 0. 82 Neuro 2 Orthopedics 1 (all) 2/502 6/892 0. 4 0. 7 31/2152(7. 75) 50/2844 (12. 5) 1. 4 1. 8 0. 0764 0. 0251 3. 65 2. 64 Spine Thoracic Vascular Total 18/475 1/431 3/140 49/3068 3. 8 0. 2 2. 1 1. 6 136/1606 (34) 14/1357 (3. 5) 25/1094(6. 25) 339/12, 387 ( 85) 8. 5 1. 0 2. 3 2. 7 0. 0009 0. 1478 0. 9152 0. 0004 2. 35 4. 48 1. 07 1. 73 1 (1) CHG/mupirocin program in place previously (2) CHG bathing program in place previously 42% reduction

Impact: Financial Service Cases Avoided Case Cost* Cost Avoidance Neurosurgery 6 $25, 000 $150, 000 Cardiovascular 3 $30, 000 $90, 000 Orthopedics 8 $33, 000 $ 264, 000 Spine 15 $30, 000 $450, 000 Vascular 2 $20, 000 $ 40, 000 Thoracic 1 $10, 000 $ 10, 000 Total 35** $1, 040, 000 *Case Cost provided by A. Karpa Financial Planning and Business Support **Cases were rounded down by “ 1”

Impact: Readmissions Parameter Project Period Average previous two years Average number of readmissions/Fiscal period Average days stay 1. 25/pd 4. 04/pd 16. 5 days Readmissions/fiscal year Days Stay x Cost/dy 15 48. 5 15 x 16. 5 x $500/day =$123, 750 48. 5 x 16. 5 x $500/day = $400, 125 Cost Avoidance $276, 375 Patient Days saved 552

Impact: Cost Avoidance 1. LPNs able to treat 5176 patients/yr 2. 3608 were cases routinely followed for SSI outcomes 3. If remaining 1912 cases had a similar SSI rate reduction (0. 016) , 31 additional infections prevented. 4. $20, 000/SSI x 31 = $ 611, 840 avoided costs Total Cost Avoidance: $1, 040, 000 + $276, 375 + $611, 840 = $1, 928, 215

Comparing Treated and Untreated Patients in Intervention Period • 206/3274 (6. 3%) of patients routinely followed for SSI surveillance were not treated during the intervention period • 49/3268 (1. 6%) treated patients had a SSI • 17/206 (8. 3%) of untreated patients had a SSI • Propensity score analysis with 1: 4 matching performed

Propensity Score Analysis: 1: 4 Matching Untreated 188 Total 892 P-Value Stand d Number of Patients Age Treated 704 59. 6 (± 1. 2 ) 59. 3 (± 2. 5 ) 59. 6 (± 1. 1 ) 0. 832 0. 15 Gender (Male) 329 (46. 7%) 92 (48. 9%) 421 (47. 2%) 0. 622 0. 04 ASA (3 -5) 433 (61. 5%) 118 (62. 8%) 551 (61. 8%) 0. 917 0. 02 Scheduled Case 623 (88. 5%) 160 (85. 1%) 783 (87. 8%) 0. 211 0. 1 Cancer Suspected/Proven Surgery Time 113 (16. 1%) 32 (17%) 145 (16. 3%) 0. 379 0. 14 149. 2 (± 17. 8 ) 151. 5 (± 7. 6 ) 111 118 0. 771 0. 21 Median Time Cases Greater than 2 h T time: cases higher than 75 percentile Type of Service Cardiovascular 152. 1 (± 8. 3 ) 120 Orthopedic Spine Thoracic Vascular Infected 87 (46. 3%) 438 (49. 1%) 0. 412 0. 07 141 (20%) 40 (21. 3%) 181 (20. 3%) 0. 685 0. 03 136 (19. 3%) 39 (20. 7%) 175 (19. 6%) 0. 68 0. 04 117 (16. 6%) 198 (28. 1%) 29 (15. 4%) 52 (27. 7%) 146 (16. 4%) 250 (28%) 0. 74 0. 927 0. 03 0. 01 104 (14. 8%) 25 (13. 3%) 129 (14. 5%) 0. 726 0. 04 123 (17. 5%) 26 (3. 7%) 36 (19. 1%) 7 (3. 7%) 159 (17. 8%) 33 (3. 7%) 13 Neurological 351 (49. 9%) 14 27 0. 593 1 Not applicable 1 0. 04 0 Not applicable 1 **Conditional logistic regression analysis of the matched data with treatment as the only covariate: coefficient = -1. 44, z = -3. 65 p=0. 0026

Conclusions Reduction in surgical site infections by 42% Takes 10 minutes: easily integrated into workflow Safe and has excellent patient compliance (94%) Cost-effective ($1. 3 million in cost avoidance)

The Team Surgery: Bas Masri Gary Redekop Perioperative Services: Debbie Jeske Kelly Barr Anna-Marie Mac. Donald Lorraine Haas Lucia Allocca Steve Kabanuk Claire Johnston Shelly Errico Tammy Thandi Pauline Goundar Dawn Breedveld Infection Control: Elizabeth Bryce Leslie Forrester Tracey Woznow Medical Microbiology: Diane Roscoe Titus Wong Patient Safety: Linda Dempster Ondine Biomedical: Shelagh Weatherill et al Chandi Panditha Diane Louke Thank you Special Thanks: microbiology technologists, and perioperative staff

Ultraviolet Room Disinfection Elizabeth Bryce On behalf of the Innovation Award Team January 9, 2013

Background • Contaminated environments increase risk of transmission of HAIs • Prior room occupancy by a pt with an antibiotic resistant organism (ARO) increases risk to subsequent pts • Novel disinfecting systems could minimize this risk particularly of Clostridium difficile infection

Clostridium difficile • Clostridium difficile infection (CDI): most common cause of nosocomial diarrhea, with an incidence of 3 -8 cases per 1000 hospital admissions. • Symptoms: from mild or moderate diarrhea to severe complications such as pseudomembranous colitis, toxic megacolon, septic shock, renal failure, and mortality.

Ultraviolet surface disinfection • Used in laboratories for years • New literature demonstrates its value as an adjunct to cleaning • Demonstrated to reduce CD spores, MRSA, VRE within hospital rooms • Ability to integrate the technology into workflow needs to be evaluated

The technology Smart. UVC aka Tru. D • UVC light automatically delivers lethal UV doses required for each room using a 3600 sensor • Two settings: Bacterial and sporicidal • Evaluated already in USA for effectiveness • 9 hospital cross over study re outcomes in USA underway

Similar technology but: Allows repositioning of the machine Only one setting for all organisms The R-D RAPID DISINFECTOR: Advanced Technology for Reducing Pathogens in Patient Environments August 20, 2013 Steriliz, LLC.

Is it Safe? Yes, there are sensors that shut machine off if door opened. Additional barriers are across door. UV light doesn’t penetrate through glass

http: //www. vickers-warnick. com/news/uv-disinfecting-lights-brought-to-new-york-state-hospital-to-control-c-diff-outbreaks/

Project Proposal • Use equipment on isolation rooms with priority on floors with most Clostridium difficile cases • Use it on the ORs, endoscopy suite and equipment depot at night • Use it as required during outbreaks • Assess its effectiveness microbiologically • Assess it’s impact on bed turn around time • Assess user satisfaction

Results • Both machines effective: one machine has slightly better microbial kill in the presence of protein under lab conditions • Both machines effectively remove organisms in patient rooms • Machine B is preferred by users • Machine B has a faster disinfecting time

RD MRSA Bed Kill at >7. 2 x 103 CFU Tru-D MRSA Bed Kill at <7. 2 x 100 CFU

UVC + Decluttering and Equipment Cleaning Campaign: Impact ↓ 30% 38

What’s next? • Business case to purchase the machines • Incorporation into regular work flow • Monitor outcomes not only with C. difficile but with other organisms • If efforts can be sustained, roll out to other regional facilities