Clean Sweep
By Dan Harvey
Radiology Today
Vol. 19 No. 7 P. 22

Infection control in radiology is an ever-evolving effort.

On April 18, The Joint Commission outlined the challenges in efforts to reduce health care–associated infection (HAI) associated with medical equipment and devices. In radiology, this includes MRI, ultrasound, X-ray, and CT. Previously, organizations such as The Joint Commission, World Health Organization, and Centers for Disease Control and Prevention independently developed recommendations that eventually formed best practices for reducing HAI.

Many radiology departments have elements of control in place for the following:

• hand hygiene: among other risks are hand exposure to patients' bodily fluids;
• contact isolation: for patients infected with epidemiologically concerning microorganisms, as infections can be transmitted by both direct and indirect contact;
• airborne isolation: guidelines are similar to above;
• droplet isolation: as with airborne and contact isolation, radiology departments are notified in advance of patient status;
• safe injection: for procedures where contrast agents are injected, sterilization is required;
• personnel and patient protective measures: eg, gloves worn during procedures that present potential for exposure to patient bodily fluids—personal protective equipment is made available in radiology sections including vascular, neuroradiology, pediatrics, CT, MR, ultrasound, genitourinary, and nuclear medicine;
• equipment management: all equipment—eg, MRI table, MRI scanner, MRI tube—requires cleaning and disinfection between each patient use; and
• high-level disinfection or sterilization: especially for all reusable equipment exposed to mucous membranes.

These recommendations pertain to patients and providers. While patients get the lion's share of attention, when it comes to infection control, infection control practitioners are as much concerned about health care workers.

Facilitywide Effort
Among The Joint Commission's many other best practice recommendations, they suggest that a health care facility or system should assign a dedicated individual to oversee programmatic infection elimination. A good example of how a best practice program is effectively put in place involves Baptist Health South Florida. The health system opened its state-of-the-art Miami Cancer Institute in January 2017. Before the new center opened, Baptist Health hired Jammie Klim, MPH, to plan, coordinate, and execute the implementation of Miami Cancer Institute's Infection Control Program. Klim's official title is infection control preventionist.

"Essentially, I am responsible for preventing HAI," Klim says. "Treatment of infection is often more difficult with our population because their immune systems are weakened." She adds that it is very much a data-driven effort. "This involves investigative data analysis to determine which sections have the most potential of being immunity-compromised locations."

After she assumed her new role and before the center opened, she performed an in-depth risk assessment study. When she was finally able to walk down the tiled corridors and become intimate with her new surroundings, Klim conducted a baseline study to evaluate each of the center's departments, including radiology. Armed with data-driven analysis, she endeavored to ensure the highest level of infection prevention. To advance that goal, the program makes staff aware of flagged areas that are potentially compromised, along with potential causes. Staff are then educated on how best to deal with potential infection.

Klim reveals which areas are most vulnerable to infection: "Wherever we do contrast injection and ultrasound procedures is where we see potential for infection. With ultrasound, transducers actually touch the patient. In fact, all equipment that is touched must be disinfected. So it's not just transducers; it's also equipment that includes scanners and tubes."

One of the top goals of the program is to ensure that patients presenting with an illness don't compromise the rest of the patient population, she says. From her experience with Miami Cancer Institute, Klim offers these evidence-based observations:

• Hand hygiene is no longer just a concern; it is one of the most significant areas of compliance.
• Hygiene consciousness extends to the equipment, technology, and procedures.
• Deployment of sophisticated cleaning substances, eg, not water-based, will "zap the room."
• Postprocedural "deep" cleaning and disinfecting is not a daily chore but a responsibility.

Essentially, postprocedural disinfection is more than a "new broom-sweeping clean."

Beyond analyzing numbers, Klim observes daily and weekly procedures and performs quarterly infection control site visits that provide data for the center's annual infection control risk assessment. This leads into further data analysis: The approach is designed to identify what needs to be worked on in the upcoming years as improvement evolves, patient volumes increase, and analytic examinations uncover overlooked risk factors.

"A successful program isn't just about maintenance. It's about improvement," Klim says. As such, she's developed an analytic tool wherein newly entered data determine specific focus areas for the next year.

New Approach to an Old Problem
It has been suggested that, in the future, best practices will involve not just how equipment is maintained but also what equipment is purchased and implemented. Driving this line of thought are concerns related to IR and ultrasound. Skyline Medical has introduced an FDA-approved, automated, direct-to-drain medical fluid disposal solution called the Streamway System designed to eliminate manual handling of waste fluid.

Within radiology departments, the largest generators of biohazardous waste fluid are paracentesis and thoracentesis procedures. Using imaging guidance, a long needle and catheter are inserted into the abdominal or thoracic cavities in order to withdraw anywhere from one to 10 liters of fluid from a patient. Patients requiring this type of treatment are typically suffering either from organ failure or some type of disease, most commonly liver disease.

Traditional methods for collecting and disposing of medical fluids in imaging departments involve manual handling of glass evacuated bottles. A heavy volume draw might require five to 10 bottle changes and provide multiple opportunities for breakage, leakage, and exposure risk.

"Each bottle represents a risk," says David Dauwalter, Skyline Medical's director of product management. "When a mishandled bottle is dropped and shatters, you see shards of sharp glass covered with patient waste. It's not a pretty sight. Eliminating the use of glass bottles is a significant benefit of the Streamway System.

"Minimization of exposure is maximized," Dauwalter says. Safe handling and disposal processes don't just protect the health care professionals; they also improve patient safety and the patient experience.

"When a health care professional knows that there are high levels of protection, they then know that they can focus on their job, doing it correctly, knowing there is no risk for exposure," Dauwalter explains. "They can focus all of their attention on the patient."

Another benefit may be residual or, perhaps, secondary, but no less important. It involves visual—in this case, a patient's—perception.

"Patients and visitors using the hallways can be put off by witnessing the transportation of carts carrying containers marked by the biohazard label," Dauwalter says. A biohazard label can be as disturbing as the skull-and-crossbones seen on antiquated iodine bottles, he says. "Automatic waste disposal sends both the risk and the need to create awareness of potential risk right down the drain."

Probing Ultrasound Questions
There has been ongoing discussion about patient and staff safety, disinfection, and where automation figures into the larger picture. This discussion is particularly relevant to the disinfection of ultrasound probes. Keith Kobey, MBA, senior vice president of Nanosonics, Inc, North America, says even the best-intentioned health care facilities need direction regarding this highly complex task.

"Frankly, many hospitals don't exactly know what to do when it comes to high-level disinfection," Kobey says. "We help customers accomplish high-level disinfection by making it automatic."

That effort is embodied with the company's trophon EPR product, which offers an automated solution for ultrasound probe disinfection.

"We readily admit that it is a niche product," Kobey says. "The technology enables disinfecting of the handle of the probe. The technology makes it possible to disinfect all types of ultrasound probes, even surface transducers."

Kobey provides some background about product development, which included consideration of numerous studies that provided evidence about infection.

"These studies revealed just how dirty the probes can potentially be and the extent of the risk of subsequent cross-contamination," he says. "We followed the Spaulding Classification, which classifies all devices as [noncritical], semicritical, or critical, and most ultrasound probes can be found within [the semicritical to critical] range. Critical probes come into contact with blood and were previously just 'wiped off.'"

During the product development process, the company determined that ultrasound is unique and most hospitals don't know exactly how to clean the probes. The trophon automation methodology helps to provide a better understanding of disinfection, but automation technology isn't meant to blind the user; rather, it is meant to reveal.

"We make customers aware of what they have to be most concerned about," Kobey says. "We're just saying that trophon is automatic, so why don't you make it part of your best practice? Do high-level disinfection on every probe before it is used on the next patient. Further, the technology doesn't have to be in a special area; it can be right in the exam room."

As with Skyline Medical's technology, Nanosonics' technology is also meant to protect staff as much as it protects patients.

"Historical evidence reveals that previous cleaning methods with harsh chemicals proved detrimental to the health of hospital staff," Kobey explains. "Respiratory problems related to harsh chemicals have been revealed." Further, he offers a reminder that's perhaps as harsh as the chemicals that were previously deployed. "The chemicals used in previous ways were being poured down into the drain."

The immediate word that his observation conjures is "environment." And that leads to a consideration of the complete name of the trophon technology: trophon EPR. The EPR acronym stands for environmental probe reprocessor.

"Environment, however you wish to define it, is something we take very seriously," Kobey says.

He's not just talking about general environmental consideration, although that's a large part of the company's concern. He's also talking about an immediate health care environment that can impact staff or patients. So how does that relate to trophon technology?

"We describe it as supercharged and sonicated," Kobey says. Although those terms sound like copywriting hyperbole, there is a scientific basis, Kobey explains. "Here's what I mean. Ultrasonic vibration generates sonically activated, supercharged, ultrafine hydrogen peroxide mist. Consider it like dry fog. The free radicals disperse, disrupt, and kill bacteria, fungi, and viruses. This all takes place in a seven-minute cycle within a closed-door chamber. It is completely automated."

But, again, automatization doesn't divorce itself from the user. Instead, in the best of human hands, it becomes an intimate relationship.

A Matter of Trust
Public perception is an important consideration for an infection control program—and within the mindset that fosters technological developments focused on program success. Reports about infection rates in general, or within a specific facility, inform the general public's level of trust. Public trust, in turn, informs a patient's choice about which facility to choose. This thinking insinuates itself into the equation of a business decision.

However, as efforts by facilities such as Miami Cancer Institute, individuals such as Klim, and companies such as Skyline Medical and Nanosonic indicate, it's not just business—infection control and elimination are about taking things to the next level of trust.

— Dan Harvey is a freelance writer based in Wilmington, Delaware.