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Search & destroy tactics success15th of September 2010
For some years the Dutch guidelines on infection prevention and the country's method of dealing with MRSA outbreaks have been held up as an example to the healthcare profession around the world. Hygiene for Health editor Michelle Marshall visited the Leiden University Medical Centre in the Netherlands to meet Thea Daha, an infection control specialist for the Dutch Working Party on Infection Prevention.
Thea Daha is recognised as a leading authority on infection control throughout the Netherlands, and increasingly around the world as she is frequently invited to share her knowledge and experience with other healthcare professionals. Originally trained as a nurse before specialising in infection control, Daha is a key figure in the Dutch Working Party on Infection Prevention (WIP). Based at the Leiden University Medical Centre close to Amsterdam she has been instrumental in developing the comprehensive guidelines covering infection control and hygiene in healthcare facilities, and in implementing the so-called 'search and destroy' tactics for dealing with outbreaks of MRSA.
Funded by the Dutch government, WIP was founded in 1981 under the initiative of the Dutch Society of Infectious Diseases - it was made up of experts from the Dutch Society of Infection Control Practitioners and the Dutch Society of Medical Microbiology. The aim was to set up an information and advice centre and to develop up-to-date and scientifically based guidelines for infection prevention in hospital settings. "Nursing staff were the first infection control professionals," Daha explained. "But at that stage each hospital made its own standards and there was no communication or common ground at a national level.
"Everything changed when the Study on the Efficacy of Nosocomial Infection Control - the SENIC Project - which took place in the USA from 1970-1976 concluded that 32 per cent of infections could be prevented by well-organised infection surveillance and control," continued Daha. "That's when more formalised systems started to be introduced and WIP started its work."
Having first established guidelines for hospitals only, WIP extended its remit and now covers the entire healthcare sector - nursing homes, dental practices, care in the home, GPs surgeries. New guidelines have also been added as new diseases have occurred: MRSA and SARS for example. Daha explained: "The plan was to update guidelines every five years but that’s very difficult now because we have 150 of them in place. The guidelines are not actually law because of course they have to be adapted to local conditions, but they do encourage a consistent approach across the whole country.”
The guidelines have been compiled on a number of different levels, starting with general precautions concerning:
• Personal hygiene
• Hand washing
• Accidental blood contact
• Cleaning, disinfection and sterilisation.
They then go into further, department-specific detail:
• Operating theatres
• Eye department
• Dermatology, and so on.
The detail finally goes into procedure-specific guidelines and MO-specific precautions (MRSA, Tuberculosis etc).
The Documentation Centre for WIP is housed in Leiden's university hospital, and from there Daha also runs a national advice centre, which healthcare professionals from around the Netherlands can call upon to seek guidance on their specific hygiene and infection control issues.
WIP is in absolutely no doubt what a crucial role effective cleaning regimes have in the control of infection and with that in mind specific guidelines have been published as to how procedures should be carried out. "Cleaning is absolutely crucial in the prevention of spreading infection because it gets rid of the living habitat for the micro-organism," Daha explained. "Hand-in-hand with that is prudent use of disinfectant – but it’s vital to realise that if you can’t clean, you can’t disinfect. First you must clean, then disinfection follows."
There is a guideline relating to the cleaning of rooms and furniture, for example, covering wet, dry and damp cleaning; vacuum cleaning; the use of microfibre cloths; detergent use; maintenance of cleaning tools and equipment. A comprehensive schedule of cleaning and disinfection in the various hospital areas has also been formulated.
The policy of cleaning, disinfection and sterilisation has been carefully considered and WIP advocates prudent use of disinfectant in Dutch hospitals. "Over-use of disinfectant can give a false sense of security about cleanliness and hygiene," explained Daha. "So it must be used with care and knowledge. Indiscriminate use is absolutely no good at all.”
Research carried out by various institutions has concluded that good cleaning practice is sufficient in most cases, even within healthcare environments, and disinfection is not always necessary. "So now our guideline states that no disinfection is needed where sterilisation is necessary, for example, and none is needed when cleaning is sufficient."
The definition of disinfection in the Dutch guideline is: The irreversible inactivation of micro-organisms on inanimate surfaces as well as intact skin and mucous membranes. Disinfection is aimed at minimising the risk of transfer of microorganisms. So when should an area be disinfected? Daha explained: "We only use disinfectants when the risk of patient-to-patient transmission is high and when there are fast-spreading high risk micro-organisms. Hands are only disinfected to avoid transmission of micro-organisms and at pre-operative stage to avoid post-operative infection. Then there’s instrument disinfection.
"It must not be forgotten there are some negative aspects to using disinfectants. For example, they often also kill 'good' bacteria as well as harmful ones. They can also cause harmful side effects to people if not used properly - the eyes, airways, skin and mucous membranes are particularly vulnerable. That means they must be used under strict conditions only and with the right personal protective equipment for the cleaning staff.
"In deciding whether disinfection is appropriate it’s essential to take a view of the situation and ask, can the pathogen we are tackling live outside the body, and how likely is it to reach the skin? There are actually not many highly dangerous pathogens."
In the Netherlands any product used for disinfection in hospitals must gain government approval. "If it's not tested it cannot be used," said Daha. "This applies only to biocides. At the moment the only disinfectants approved for use are alcohol and chlorine. Otherwise it’s detergent use.
"Other disinfectants do exist of course but manufacturers often just don’t submit them for testing because the process is so expensive. That makes the situation extremely restrictive here in the Netherlands."
For healthcare disinfection, the ideal formula needs to be non-toxic, fast working (between one and two minutes), have comprehensive labelling, not be dangerous in any way, and have no smell. "That’s why I’ve come to the conclusion the perfect formula simply does not exist," Daha concluded.
Hand hygiene in healthcare applications is covered by a guideline in the Netherlands, loosely based on the 5 Moments for Hand Hygiene devised by the World Health Organisation (WHO):
1. Before patient contact.
2. Before an aseptic task.
3. After body fluid exposure risk.
4. After patient contact.
5. After contact with patient surroundings.
Thea Daha has strong opinions about hand hygiene's place in infection prevention. "I do believe that in many cases there is a little too much focus on hand hygiene. It is of course vital, but it’s not everything. Clean hands are important, but a clean environment is equally important - each and every aspect counts just as much."
Having put such enormous effort into compiling such detailed standards, the next major challenge is spreading the message to staff on the front line in hospitals around the country and making sure everyone is following them. At LUMC that is the responsibility of infection prevention advisor Stephanie Zuurveen. She explained: "Our job is to ensure the correct protocols of the hospital guidelines are being followed wherever possible. The biggest challenge for us here in such a large hospital is getting to know everything that’s happening and communicating all protocols to the staff."
Education is of course a key element so an E-learning module has been devised to ensure all personnel understand hygiene procedures. Each member of staff must embark on this programme and complete the test at the end to demonstrate they have understood what they have been taught. There is also a section on how to clean - particularly when dealing with bodily spillages and other hazardous waste.
Zuurveen also explained cleaning within many hospital areas is contracted out and admitted that can sometimes prove problematic. "We do not speak directly to the cleaning staff so it is not always easy to ensure they are working to the standards we have set." Thea Daha agreed there is room for improvement in the way communication with cleaning staff is carried out and more needs to be done to ensure they are following the same protocols as hospital personnel.
Sterilisation of devices
Beyond the everyday cleaning tasks in a hospital, there is the more specialist area of medical device sterilisation. At LUMC this is the responsibility of Drs Mariette Jungblut and she explained there must be a registered person in every Dutch hospital who is responsible for controlling the process of sterilisation, as well as auditing and monitoring all medical instruments. This area of hospital hygiene comes with its own particular challenges.
"The invasive surgical instruments and flexible endoscopes are the most difficult to deal with," she said. "For example with endoscopes they have to first be cleaned by hand, using small brushes, before going into a machine to be disinfected and sterilised.
"Sometimes this is carried out by the nurses and doctors themselves because the sterilisation assistant is not always available. So we are working on developing a protocol whereby everyone involved knows how it should be done. It’s an ongoing process which we are working towards."
Here again E-learning will prove to be invaluable, according to Jungblut. "The systems we are developing represent major change in that there is simply not enough awareness about the endoscope requiring special cleaning. And the manufacturers give no special instructions to make this clear.
"More attention must be given in the manufacturing process to how instruments can be kept clean. New technologies should be developed with cleaning in mind but at the moment that does not happen enough. People need control and protocols, they ask for this. And what guidelines do exist are not always easy to understand – often being far too technical in the way they are written - so our role is to put them into a more understandable form."
Search and Destroy
It is perhaps for its 'Search and Destroy' approach to MRSA that the Netherlands' infection control policies have become most well known. The first guidelines were implemented in 1988, as Thea Daha explained. "MRSA was fairly well controlled until the more vigorous strain hit the UK. Search and Destroy works on the principle that we look for MRSA in the most likely people to have it, if we find it we put them in isolation and medicate as necessary. We also test any staff who have come into contact with them."
Every patient who is admitted to a Dutch hospital is categorised in line with their MRSA risk. The risk categories are:
1. Proven MRSA carrier.
2. High risk of being carrier. That could be a patient who has had a stay in a foreign hospital of more than 24 hours, for example, has open wounds or a catheter.
3. Moderately increased risk. This could be a dialysis patient who has been treated abroad for example.
4. No increased risk.
As well as the proven MRSA carriers, high risk patients go into isolation until the results of cultures are known. Nurses wear protective clothing when in contact with them.
Daha continued: "If we find a patient on a ward has MRSA we screen absolutely everyone who has come into contact with them and treat them if we find anything. For our staff this means two days at home together with medication."
In the event of an outbreak the ward closes completely and only reopens after all patients and healthcare workers are tested negative, the ward is disinfected and non-disinfected material, such as paper, is destroyed.
The measures taken in Dutch hospitals may appear to be extreme, and they have been criticised as being too expensive. In the short term it may be costly to manage isolation rooms, with all the additional equipment, cultures and laboratory costs involved. Daha's response to that is simple: "In the longer term it is far more expensive to manage an outbreak of MRSA, just in the cost of more expensive antibiotics alone." And the success of the Dutch model is proved just by the fact it has now been used as the basis for standards in a number of other countries.
Thea Daha is passionate about the ongoing work in the Netherlands by WIP. "We are working to protect our future and prevent the spread of most virulent micro-organisms. The fact is we are in a situation globally where more infections are occurring – neonates, more older people, people travelling around the world, more adventurous eating habits, developments in medical technology (sometimes disinfection is difficult), and of course the increased resistance to antibiotics by certain pathogens.
"Looking ahead is absolutely vital - we must ask, what's coming next? We can always be sure there will be another ‘superbug’ to challenge us. We cannot emphasise enough the importance of infection prevention is key because if a dangerous pathogen is not allowed to spread, there is no infection. Cleanliness and hygiene play a pivotal role in that process."