Post Category → Quality of care

A sleuth story Patricia Cornwall would appreciate

Microbes, a Pharmacy Clean Room, Waste Bins, ATP, and a keen-eyed pharmacist

Recently I was part of a trio who presented an intriguing case-study of a microbiological contamination issue in a pharmacy clean room – it took months to solve, and ATP proved an excellent tool.

Tyler Weaver, Josh Guinter (Children’s Hospital of Philadelphia) and I delivered our paper entitled “Resolving microbial contamination of reusable waste bins in a pharmacy clean-room” at the Sept Association for the Healthcare Environment (AHE) conference in Pittsburg PA.

We are soon to publish – in meantime click here to view our PowerPoint presentation.

The story in a nutshell…

  Within a hospital, a Pharmacy Clean Room (PCR) is where sterile medications are prepared for patients – it is an “inner sanctum” with restricted access and is regularly tested for microbes to ensure all surfaces are scrupulously decontaminated to an ISO Standard – at a level higher than operating rooms.

A recent failure in a PCR resulted in 753 patients being infected with 64 deaths across 20 USA states.

The problem

  • PCR work-surfaces are required to be regularly tested for microbes. Two tests in PCR exceeded allowable level – triggering immediate action
  • Surfaces and ducts were scrupulously cleaned – but tests failed a second time. Several weeks of investigations proceeded
  • Then a keen-eyed pharmacist noticed a gown-tie moving as it hung from a waste bin in the PCR
  • Tie-movement meant air-flow; airflow meant bugs could waft in air – perhaps bin was source?
  • The reusable bins were tested, found to have very high microbial counts, and bin-vendor A was asked to remedy

The remedy

  • Microbe tests are expensive, so bins were ATP-tested as surrogate (ATP detects microbes and other living cells)
  • Bin-vendor A could not reduce ATP count to target-level  of <250 Relative Light Units (RLU) – aver of highest counts was 14,844 RLU
  • Second vendor (Vendor B) supplied bins for testing – all passed – aver of highest counts was 103 RLU – hospital changed to Vendor B for PCR.
  • No further PCR work-surface tests failed.

The explanation

  • Vendor A supplied bins “nested”. Entrapped moisture in bottom bin enabled microbial growth
  • When pushed into bin, discarded gowns created “piston effect” liberating microbial aerosol which wafted onto PCR work-surface
  • Vendor B wash process had higher level of bin decontamination. Bins supplied individually, not nested.
  • In 4 years: bins have exceeded ATP threshold of 250 RLU occasionally, and none since Aug 2015; no failures in PCR work-surface microbe tests have occurred.

Take Home Messages

  • Vendors of reusable bins have differing wash, drying  and delivery processes. Ask for details of processes and ATP-test (particularly if for PCR use).
  • ATP testing using a threshold of 250 RLU is a useful adjunct for checking QA of external waste bins used in PCR

What patients wish for in hospitals

Let me sleep, and Oh, please knock on my door when entering.

Becker’s Hospital Review alerted me to the work of Peter Pronovost of  The Johns Hopkins. He recently reviewed patient surveys and with Jane Hill compiled the top ten wishes of hospital inpatients.

  1. Let me sleep. Do not take vitals throughout the night or draw blood between 10 p.m. and 6 a.m. unless it is critical. If it is critical, please make sure I understand. My sleep helps me recover and feel better.
  2. Keep the noise levels down at the nurses’ station. This is so important – especially at night when my sleep is needed. Turn off the TV, radio, computer screen, etc., at night in my room, so there’s not a glare or noise that can disturb my sleep.
  3. Don’t lose my personal belongings. Take an inventory and label everything with my name and medical record numberso my personal belongings do not get misplaced. These belongings are an extension of me and make me feel more at ease. Taking care of my stuff feels like you are taking care of me.
  4. Knock on the door before entering. This shows respect for me as an individual and my privacy. Introduce yourself to me, and shake hands or make eye contact when you do this. Call me by my preferred name (formal or first name).
  5. Please keep my white board current and up to date. It gives me a quick reference of who is caring for me and my daily plan. Provide a notebook at the bedside so I can keep all my important papers, cards from my health care team and other staff, etc. in one place. Please make sure my name and my location (nursing unit, room number and room phone) are listed on the front.
  6. Update me and my family if you notice changes in my condition. Keep communication open. Please keep me informed of delays. It lessens my anxiety during an already stressful time.
  7. Keep my room clean – mop the floors every day, wipe surfaces to prevent the spread of germs, empty my wastebasket and keep my bathroom really clean so it even smells clean. If you are my housekeeper, please introduce yourself to me and say hello. I like to know who is taking care of me.
  8. Listen to me and engage me in my care. Use plain language, and make sure I understand my plan of care.
  9. Please orient me to my room and the hospital, so I know where important things are located, how to work the television, how to order food and when my linens may be changed. I am a guest here and don’t know these things, yet these are important to me.
  10. Please maintain professionalism in ALL areas of the hospital. While you may be on your break, you are still a hospital employee and a reflection of the hospital. How I perceive you is often how I perceive the hospital and care that I am receiving.

The original article was published by US News & World Report – Health.