2_Graveto_J_p78490_1

Fomites: from colonization to the risk of
infection on tourniquets in Nursing Practice
1
Faculty Name
João Graveto, RN, MS, PhD
Conflicts of interesse
None
Employer
Nursing School of Coimbra
Sponsorship/Commercial Support
None
Faculty Name
Pedro Miguel Silva, RN
Conflicts of interesse
None
Employer
Nursing School of Coimbra
Sponsorship/Commercial Support
None
Faculty Name
Marta dos Santos Costa, RN
Conflicts of interesse
None
Employer
Nursing School of Coimbra
Sponsorship/Commercial Support
None
2
3
Nosocomial Infections 
Massive problem in Health
Institutions
Risk Factores to acquire hospital
infections:
Endogenous
Exogenous
Vale and Dinis (2011) define fomites as a surface or object, porous or
non-porous, contaminated with pathogen microorganism, acting like
a vehicle to transfer infections.
These objects are daily use in the hospital environment
and their use becomes a risk as they may cause an
infection to the patients.
4

The focus of this research  Tourniquets

We should look to the reused tourniquets like a fomite,
because these kind of tourniquets are the more used in hospital
daily practice.
Tourniquets are used in the more common and invasive
procedure in the hospitals (cannulation and for getting blood
samples).
5


Integrative Literature Review (ILR) according to
Cochrane Handbook.
Aim:
 To understand the occurrence of fomites in hospital
environment, specifically on tourniquets;
 To know actions and strategies to decrease
complications involved in tourniquets using;
The Research was made between 2010 and 2015. The chosen
methodology was the PI[C]OD.
6
Concepts
P
I
Participants
Interventions
O
Outcomes
D
Design
Who was
been studied?
Keywords
Nurses and Heath care
workers.
Interventions to prevent
contamination of
tourniquets;
What as been
Interventions to prevent
done?
transmissions of several
pathogen microorganism
presents on tourniquets.
Results,
Good practices that
effects or
reduced infections rates
consequences
associated with fomites;
.
Types of
Descriptive, quantitative
researches
and experimental
included.
Researches .
Fomite,
tourniquet,
infection,
nurs*.
7
The research question who guided this research is:
Which are the practices related to tourniquets handling [I]
(known as objects with high risk of contamination), used
by nurses or health care workers [P], with consequences
in prevention of nosocomial infections [O]? ´
To perform the ILR it was previously established criteria's for
inclusion and exclusion of the Researches .
8
Selection Criteria
Inclusion
Exclusion
Researches dated between 1st of January Research dated before the 1st of
Research es
Participants
Interventions
Outcomes
Design
January 2010;
2010 to 19th of May 2015;
Articles in other languages;
Articles in Portuguese, Spanish and
Articles without full text;
English;
Articles related to pediatrics area.
Full text articles.
Nurses;
Heath care workers that use tourniquets.
Prevention;
Procedures;
Autonomous and interdependent
Nursing actions;
Lack of specify information about
Effective measures proven;
the theme.
Awareness of the risk infection to
fomites;
Contributions to acquire good practices
to prevent infection.
Results about the Nursing practice and
other heath care workers;
Non-conclusive results.
Aplicability of the interventions.
Descriptive, quantitative and
Results withou research
9
methodology.
experimental Researches .
Inclusion and
Exclusion Criteria
Applied
(n= 66)
Identification
Included
Eligibility
Screening
Researches identified through
database searching and
Portuguese Institutional and
International Repositories
(n= 168)
Excluded
Articles
(n= 57)
Seleted Articles
(n= 9)
Included
Articles
(n= 5)
Excluded
Articles
(n= 4)
10
Authors
S1 E1
Title
Authors
Pinto, A.; Phan, T.; Sala, G.; Cheong, E. Siarakas, S. & Gottlieb, T
(2011, September 5).
'Reusable venesection tourniquets: a potention source of hospital
transmission of multiresistant organisms'.
Kim, J. Y.; Anh,H.; Lee, E. & Chae, H.B. (2014, December).
S2 E2
Title
'Anesthesiologist's hand hygiene and disinfection of reusable rubber
tourniquet with alcohol swabs before intravascular cannulation.'
Authors
Sahu, S. K.; Tudu, B. & Mall, P. K. (2015, February).
Title
‘Microbial colonisation of orthopaedic tourniquets: A potential risk for
surgical site infection'.
Mehmood Z.; Mubeen S.M.; Afzal M.S. & Hussain Z. (2014
September).
'Potential risk of cross-infection by tourniquets: a need for effective
control practices in pakistan'.
Thompson, S.M.; Middleton, M.; Farook, M.; Cameron-Smith, A.;
Bone, S. & Hassan, A. (2011, August).
S3 E4
Authors
S3 E6
Title
Authors
S4 E7
Title
‘The effect of sterile versus non-sterile tourniquets on microbiological
11
colonization in lower limb surgery’
S1 E1  Authors: Pinto, A.; Phan, T.; Sala, G.; Cheong, E.
Siarakas, S. & Gottlieb, T (2011, September 5).
• Sydney Teaching
Hospital;
• Collected 100
samples of
reusable
tourniquets from
differents
hospitals wards;
• Divided in two
moments.
1st Moment
• The colonisation rate from 100 tourniquets were 75 %.
• Tourniquets
2nd Moment
colonized with
were
more than one
microorganisms.
• 61% of reusable tourniquets were colonized with
various species of microorganisms that aren´t
associated with skin flora but with the hospital
environment.
Authors estimate that 6% of hospitalized patients will acquire a
hospital infection.
12
S2 E2  Kim, J. Y.; Anh,H.; Lee, E. & Chae, H.B.
(2014, December).
• Research done by the
infection control team;
• In 30 operation rooms and 2
differents hospital buildings;
• They cut tourniquets in two
different pieces;
• The first half part was
disinfected with alcoholic
solution 83% and washed
with distilled water;
• The second half part were
pressed against a culture
solution;
• It was applied forms to
professionals in order to
understand hand hygiene
when tourniquets are used.
Conclusions
• The disinfected tourniquets had no
microorganisms.
• Before the application of alcoholic
solution,
tourniquets
were
contaminated.
Forms
• 37% of the team do hand-washing
with soap and alcohol before the
cannulation;
• 44% do hand-washing occasionally;
• 19% of the team don't do any of these
procedures.
13
S3 E4  Sahu, S. K.; Tudu, B. & Mall, P. K. (2015,
February).
• Research conducted at the
Microbiology ans Orthopedic
departments of a tertiary
hospital;
• 16 samples from
orthopedic reusable
tourniquets – labeled from
1 to 16;
• The inner and outer areas of
tourniquets were identified
with proximal and distal
extremity;
• The odd numbers: half were
imbibed with salvone
solution ans the other with
sterillium solution;
• The pair numbers didn’t
have any treatment.
Conclusions
• All tourniquets were colonized with
microorganisms, with 15 to 68 per area;
• The inner (1459 colonies) and proximal
(1382 colonies) areas were more
contaminated than the outer (1030
colonies) and distal (1107 colonies) areas.
After treatment with antiseptic the
number of colonies reduce:
• 92,18% with Salvone;
• 95,70% with Sterillium.
14
S3 E6  Mehmood Z.; Mubeen S.M.; Afzal M.S. &
Hussain Z. (2014 September).
• Research done in
Pakistan;
• Swabs made from
100 tourniquets: 40
from public
hospitals and 60
from private
hospitals;
• Harvesting carried
out on both sides of
tourniquets from the
distal and proximal
regions.
Outcomes
From 100 samples, 51 had bacteria colonies:
• 23/40 samples from public hospitals;
• 28/60 samples from private hospitals.
Staphylococcus aureus Methicillin resistant
(MRSA):
• More prevalent in public hospitals (18, 2%);
• Less prevalent in private hospitals (16,6%).
S. aureus:
• 12 samples from private hospitals;
• 10 samples from public hospitals.
It was detected microorgnisms in 18/20 samples (90%) from elastic
tourniquets and 33/80 samples (41%) from rubber tourniquets.
15
In the same Research (S3 E6)
Questionnaire conducted to health professionals
• 96% of health professionals agreed that the hospital staff and
fomites may spread infections;
• 44% (43 professionals) agreed that tourniquets can be a source of
infection;
• 27% of the participants agreed that tourniquets contained blood
spots;
• 2/3 mentioned that the tourniquet need to be clean before use;
• 25% agreed that the tourniquet should be washed before use.
16
S4 E7  Thompson, S.M.; Middleton, M.; Farook, M.;
Cameron-Smith, A.; Bone, S. & Hassan, A. (2011, August).
• Research conducted
in two general
hospitals belonging to
the National Health
System;
• Collected 34
samples of
tourniquets nonsterilized and 36
tourniquets
sterilized;
• Samples were placed
on agar plates.
From 34 samples of non-sterilized
touniquets, 23 were contaminated with various
microorganisms (63% from the non-sterilized
tourniquets).
From 36 samples of sterilized tourniquets,
none had associated contamination.
17
From the risk of contamination to infection
Nosocomial
Infections
Pinto, et al. (2014) (S1,
E1), estimates that 6% of
hospitalized users will
acquire nosocomial
infections
An increase of
approximately
1,7%
Data presented in
2008 the range was
between 5% and
10%
The Program of
Prevention and
Control of
Infections reveals a
prevalence of
11,7%
18
Pinto, et al. (2014) (S1, E1) and Sahu, Tudu and Mall
(2015) (S3, E4)
Both Researches refere that inanimate
objects existing in the hospital
environment, are a source of transmission
of microorganisms, contributing to the
increased of nosocomial infections.
19
Tourniquet as a possible source of transmission
Thompson et al. (2011) (S4, E7), Kim,
Anh, Lee, and Chae (2014) (S2, E2),
Sahu, Tudu, and Mall (2015) (S3, E4),
Mehmood, Mubeen, Afzal and
Hussain (2014) (S3, E6) and Pinto et
al. (2011) (S1, E1)
Pinto et al. (2011) (S1, E1)
and Sahu, Tudu, and Mall
(2015) (S3, E4)
BUT…There is a
colonization by
bacteria and fungi,
belonging to skin
flora.
Theese authors report that tourniquets are
not disiNnfected or cleaned between use
and they do not know if they have ever
been replaced, reason to consider them a
source of nosocomial infections.
The contamination of tourniquets are
majority attributed to hands of health
professionals and not to the contact with
patients (S1, E1) and that 61% of reusable
tourniquets were colonized with species of
microorganisms that weren’t associated
with normal skin flora (S3, E4).
Kim, Anh, Lee, and
Chae (2014) (S2,
E2)
20
Microorganisms found in the included Researches
Microorganisms
Staphylococcus aureus
Methicillin resistant
(MRSA)
S. aureus
Staphylococcus spp
coagulase-negative
Bacillus spp.
Pseudomonas spp.
Enterococcus spp.
Articles/Researches
S1, E1; S3 E4; S3, E6
S2, E2; S3, E6; S4, E7
S1, E1; S3, E4; S4, E7
S1, E1; S3, E4; S4, E7
S1, E1; S3, E4; S4, E7
S1, E1; S3, E4
21
S1 E1
Tourniquets as a possible
source of infection
Microorganisms found
Used in various patients
17% of tourniquets – bacteria colonization
corresponding to the skin flora.
without control of the
contamination state.
S2 E2
Tourniquets rarely replaced.
At non-disinfected tourniquets, it is detected
MRSA or VRE.
S3 E4
No desinfection after use.
At tourniquets non-sterilized MRSA and VRE
was detect. It was also found Staphylococcus spp.
and Staphylococcus spp coagulase-negative.
S3 E6
Used irrespective of infection
status.
Tourniquets non-sterilized detected with MRSA
and VRE.
The prevalence of MRSA in public hospitals is
higher than that in private hospitals.
The prevalence of S. aureus in private hospitals is
higher than that in public hospitals.
Bacteria colonies is higher in reusable tourniquets
than in disposable tourniquets.
S4 E7
Tourniquets rarely clean.
Non-sterilized tourniquets – infected with
microorganisms.
22
Prevention measures and solutions
LIMITATIONS
• Shortage of professionals with specialized
training;
• lack of Proper and adequate facilities of
administrative support;
• Supporting infrastructure.
23
Pinto et al. (2011) (S1, E1)
Kim, Anh, Lee, and Chae
(2014) (S2, E2)
Sahu, Tudu, and Mall
(2015) (S3, E4)
Mehmood, Mubeen, Afzal
and Hussain (2014) (S3,
E6)
Thompson et al. (2011)
(S4, E7)
Disposable tourniquets
• Personal hygiene;
• Disinfection and sterilization of
various materials (including tourniquets).
Antiseptics and disinfectants
Lack of knowledge of health
professionals
• Sterilized or disposable tourniquets;
• Guidelines formulation for control of
infection.
24




We should have prevention as a main concern;
Disinfection and cleaning of reusable
tourniquets is one solution ;
Another solution is the use of disposable
tourniquets;
Do a correct hand hygiene.
Important:
The implementation of these strategies as a set of
preventive measures and standards should be applied
by a committee of infection control to improve the
quality of care and hospital hygiene
25






Tourniquets are objects with the ability to become contaminated
(fomites) and thus act as a vehicle of transmission of pathogenic
microorganisms.
Responding to the research question: the use of reusable
tourniquets, associated with common practice, may be a risk to the
safety of patients, in hospital hygiene, making fomites a risk of
transmission of microorganisms.
The viable solutions, consist in the use of disposable tourniquets and
clean, disinfect or sterilize reusable tourniquets after their use.
It is important to continue updating our knowledge and its
mobilization to the clinical practice of nursing.
The results of ILR can contribute to the encouragement of debate and
research in this area.
Other researches are suggested in order to investigate practices and
to improve the knowledge that nurses has about use of tourniquets
in clinical practice with the aim to prevent and control hospital
infections.
26
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Fomites: from colonization to the risk of
infection on tourniquets in Nursing Practice
28