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Draft revised Australian Guidelines for the Prevention and Control of Infection in Healthcare submission

ID: 
17
Personal Details
This submission reflects the views of
Organisation Name: 
WSLHD - Westmead Hospital
Specific Questions
1. Introduction: 

Scope - 

add Hospitals, day procedure units, office-based practice, long-term care facilities, remote area health services, home and community nursing and emergency services.

These materials are available to download from the NHMRC website. - are these available in other languages? If not wouold recommend

2. Basics of infection prevention and control: 

2.2 Table 1 would question if the word spray is most apropriate language for infection prevention

2.3 How does patient-centred care relate to infection prevention and control?

Important to add whilst patient centred care is paramount ensuring appropriate Infection Prevention and control to minimise spread of infection especially with communicable diseases must be te overriding factor and should not be jepordised.

2.3.1 Information about PPE rquired by visitors/carers should be provided

Whilst we state is ok to ask healthcare worker about various aspects we should provide some educational tips/tools in the manual for staff on how to answer /deal with being asked.

3. Standard and transmission-based precautions: 

3.1.1 Hand Hygiene Recommendation1 - research evidence seems redundant even to state.

Rational I would be inclduing more recent reflective data to support

Practical Info - fix large gap in between sections

"Follow facility policy on cuts and abrasions, fingernails, nail polish and jewellery" - woud benefit direction around these points as they are some of greatest contentions in the work place - ie recommendation for not wearing and risk and evidence/research

Would also write a statement about cloth bangles religious or not would not be recommended

Recommendation 2 - what about simple personal hygiene - offering hand hygiene before meals, after meals, before and after pan use, access of suggested hand wipes on patiet meal trays to facilitate this

It’s okay to question healthcare workers about their hand hygiene practices - if this is a repeating them and need to equip our staff on responses or how to handle - as a carer for many years and many admission on top of my IPC expertise I did ask and the response I would not like to see any one else receive we say ask our staff but we don't really arm them with the correct skills/tools to handle

Recommendation 3 - have completely dismissed the use of ABHR and chlorhex as a residual - the many benefits these may have. I would have concern this is aigned with conflict of product and recommendations. In the real world where many staff are faced with many infectious issues they need to know the products they have access to are superior and not just sufficient. I feel the Guide is missinga huge part of potential products here

I would also suggest there is evidence supporting this

"Some studies have noted that gel formulations have generally significantly less antimicrobial activity than liquid alcohol-based hand rub formulations, even if the total alcohol content is similar [36] [21] [35]." should foams also be added to this comment here

Recommendation 4 It is good practice that alcohol-based hand rubs that meet the requirements of European Standard EN 1500 are used for all routine hand hygiene practices. - suggest changing this statement - The use of ABHR is the preferred method, should also state in evidence why and hand washing is still effective

This statement is also out of line with health infrastructure and building of hospitals and the increase of handwash basins - there is a dosconnect between guidelines and practices - ABHR should be an adjunct, may be the preferred but should not dismiss Hand washing in the way the guideline currently stands to do so

Sequence for putting on PPE - add for standard precautions

Pictures of PPE Mask - the second picture illustrates fit checking on a duckbill mask ? does not fit when illustrating PPE for standard precautions which is a surgical mask

This section discusses the routine use of PPE as part of standard precautions. Specific PPE used when transmission-based precautions are applied is discussed in Section 3.2. - this describes this sextion but it is confusing as  PPE for standard precautions and TRansmssion precautions are mixed in this section - suggest putting only PPE associated with standard precautions - also does not discuss the different levels of masks for protection withi standard precautions

Table 3 would dispute the use of aprons for contact precautions as does not adequately cover or protect the wearer

Concerns for wek recommendations on Recommendations 7 & 8 what impact this will have on compliance - this needs to be explained clearer

Table 6 - example of venepuncture - this is only the case if the prepared site is not palpated prior to insertion otherwise asepsis is breached and needs to be more clearly detailed

sterile gloves would add venepuncture to maintain asepsis where the site is needing t be palpated once it has been skin prepped

should add under gloves new technologies and different gloves available as long as meet ARTG

3.1.3 Single Use Vials & Multi dose Vials - Is this enough to cover the risk associated with provesses in allergy testing?

3.1.4 Weak Recommendation implies is not recommended would suggest change in terminology: the below implies not recommending!

Weak recommendation
15. It is suggested that site decontamination should occur after spills of blood or other potentially infectious materials. 


Spills of blood or other potentially infectious materials should be promptly cleaned as follows:

  • wear gloves and other PPE appropriate to the task;

Recommendation 17 & 18 - in the absence of evidence does not mean that there is no evidence. I feel the recommendations here are based on writers inexperience or lack of experience with such novel processes that are in fact proving to reduce environmental contamination. and in turn reducing prevalence in some patient populations I feel the panel may not be well equiped to comment completely AGAINST and would recommend this be rewritten in the face of limited written evidence however some units may be showing improvements. These strong statements are biased in the face of inexperience. The real situation - management of MROs is extremely difficult in the patient setting, environmental contamination is a major factor, the need to implement advanced environmental cleaning/decontamination forever increasing, this includes contemporary use of surface disinfectants, I would argue may not also be as well evidenced but have long term historical use. Vapourised hydrogen peroxide may in fact prove beneficial as an adjunct to traditional cleaning  as part of an enhanced method for terminal cleaning - facilities should have a matrix for cleaning that includes different levels and the ability to enhance with both traditional methods and new. Hydrogen peroxide itself is well evidence with activity against organisms. The delivery of being vapourised may be newer however is the delivery of choice to combat currently  CPE, C Diff and also enhanced decontamination for Ebola I would argue this section requires additional thought and rewrite to ensure facilities where use is part of a bundle approach and seeing reductions in prevalence as aresult can continue to use and hopefully write up experience. Interesting expert opinion is used in support of other areas in the document in the absence of evidence yet a clear AGAINST unsubstantiated in this section due to lack of practicle experience and perhaps bias. Concernd this will inevitably place patients and environments at risk. Is also on ARTG. Would also argue there are some articles

Recommendation 19
Possible similar argument with UV, Whilst my experience with UV is less the issues around UV may be associated with contact time etc again well evidenced in science and so some of these pointers could be written - not sure again this positions the panel to be able to write AGAINST given its stance on other areas throughout doc in the face of lack of evidence This is also not consistent

Without introduction of such novel environmental decontamination there is little to no advancement/change in this space - no other introduction of chemical has been required to stand up to the same level of evidence being asked here and certainly not listed so strongly as AGAINST These systems are also registerd with ARTG which is a requirement especially in relation to their claims

3.1.7 Could add some pictures of cough etiquette

3.1.8 Key parts that remain protected (ie with protective cap insitu) remain aseptic unless an event occurs, for example if dropped on floor despite having protective cap insitu is no longer  protected and should be discarded - This needs to be detailed as staff in practice think if this key part is protected with cap and falls on the floor is ok to attach to central line as remains protected! Tis should not be the case

3.1.9 As there is currently no national definition of clinical waste in Australian, healthcare facilities, including community healthcare settings, need to conform to relevant  reword to make sense As there is currently no national definition of clinical waste in Australia, healthcare facilities, including community healthcare settings, need to conform to relevant

3.2

Summary - should add patients treatment should not be adversely affected by implementation of transmission based precautions

Recommendation 24 - the use of gloves for contact precautions should be risk assessed and applied when contact with patient or environemnt and not just routine on entry - when this ocurs 5 moments of hand hygiene is not performed and multiple tasks are undertaken as hand hygien is not performed inside the room. This is obviously difficult to measure but observed first hand over a period of  approx 12 months of being a carer in isolation. There is also recent studies supporting this same notion - excess use of gloves increases risk to patient.

From a patient perspective glove use rotuinely in this situation is less for protection of the patient as it does not translate to adherence of 5 moments. Critical moments such as moments 2 are not adhered to once inside the room - a particluar problem for immunocompromised patients / transplant patuent. In addition if gloves are placed on routinely before entry and then the door is touched to enter gloves would need to be removed, Hand hygiene performed then regloved inside the room. This needs further thought. Potential negaitive impact on patient care

3,2,3 Droplet Precautions does not detail difference in mask levels as per the standards

3.2.4 Suggest using P2/N95 to reflect products in the market place could offer some explaination of different regulatory bodies however mask use and diseases for use reflect same

3.3.1 recent article from CDC on how long contact precautions should be applied should be reflected

recommendation 32 - issue with routine gloves on entry for same reasons as listed above

Also does not cover additional requirements during Influenza season

Table 16 - suggest  arange of potential common recommendations for neonates

I find the recommendations as set out confusing and may not be helpful in informing an Infection Prevention and Control program

Table 21 Use sterile saline for wound cleansing up to 2 days after surgery  - ? is this evidenced based? or expert opinion

RECOMMENDATION 37 Key info statement is really not backed up and does not offer a solution, Evidence is week and use of chlorhex is in fact drug of choice in some instances - it also states evidence cannot be applied to clinical setting

Replacement of PIVC - my understanding is these studies and outcomes are also reliant on dedicated teams monitoring these aspects

6. Appendix 2: 

? missing from the document

6.3  Table and document content need to be consistent  Contact precautions and glove use Standard Precaution (as required) - gloves & gowns to be worn when there is potential of contact with blood or body substances. Mouth & eye protection to be worn when there is potential of exposure to splashes or sprays to mucosa. body of document should align with this table and not routine on entry to room

 

Vaccinatins should also reflect local/state policies

6.9 Suggest adding the delivery of enhanced environemntal decontamination methids here anedotal evidence controling prevelance

8. Glossary / Abbreviations and Acronyms: 

A little disapointing - completed a whole section of feedback and then hit final submission, said I did not have access and did not save most recent additions

Page reviewed: 24 September, 2019