Thanks to Anne Savage – Senior Staff Nurse, ICU, Royal Berkshire NHS Foundation Trust – and Rachel Crisford, ICU Lead Nurse, Royal Berkshire NHS Foundation Trust – for this contribution to Hospital Hub…
Rigorous infection prevention is essential in all hospital settings, but is critical in intensive care units (ICU). Any potential risk of a seriously ill patient acquiring a healthcare associated infection (HAI) must be minimised. There is evidence that patients admitted to ICU with an HAI have a worse clinical outcome (higher mortality and length of stay), and are more severely ill on admission than patients without [Nuvials, 2015]. Studies have found that 5% – 15% of hospitalised patients acquire an HAI and between 9% to 37% of those admitted to intensive care units have an HAI [Hacque, 2018]. A study looking at infections in ICU patients found that 26.4% of infections were HCAIs [Nuvials, 2015].
Healthcare associated infections may be defined as ‘infections occurring in a healthcare setting that were not present prior to a patient entering that care setting,’ [NICE, 2017].
Estimates of HAI prevalence vary and the most recent National Institute for Health and Care Excellence (NICE) data estimates a prevalence in hospitals in England of 6.4% [NICE, 2014]. However, more recent modelling estimates that in 2016/2017 in NHS hospitals in England there could have been 834,000 HCAIs, which may have cost the NHS £2.7 billion, accounted for 28,500 patient deaths and led to an additional 7.1 million occupied hospital bed days (equivalent to 21% of the annual number of all bed days across all NHS hospitals in England) [Guest, 2020].
HAIs are caused by a wide range of microorganisms and some of these are carried by the patients themselves. The most common HAIs include respiratory infections particularly pneumonia and infections of the lower respiratory tract [NICE, 2014]. HAIs are often caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. diff) and Escherichia coli (E. coli) [NICE, 2014]. 25% to 30% of UK population is positive for skin or nasal carriage of Staphylococcus [Jeans, 2018].
The Intensive Care Unit at Royal Berkshire NHS Foundation Trust has 15 level 3 beds (for patients requiring ventilation) and a flexible number of level 2 High Dependency beds, contingent on patient need. Around 900 patients a year are treated on ICU and there are just over 100 nurses on the ICU rota.
There is evidence that preventive washing with an antimicrobial body wash reduces the likelihood of some HAIs occurring [Gastmeier, 2016; Spencer, 2013; Messler, 2019]. As part of a rigorous infection prevention policy, the ICU at Royal Berkshire NHS Foundation Trust started using octenisan wash mitts in 2014 for the routine skin cleansing of all patients. The mitts replaced washing with a disposable bowl, soap and towels.
Working closely with the Trust’s Infection Control team, it was agreed that the octenidine impregnated mitts would become an element of agreed Best Practice on the Unit. Unless a patient refuses the mitts, their use is mandatory for daily patient cleansing. Every patient admitted to ICU is prescribed octenisan wash mitts on their drug chart. There are ten mitts in each pack and one is used for each limb. Patients may be ‘washed’ more than once a day, depending on their particular needs. Being able to put a hand inside the mitt makes it easier to thoroughly clean the patient, even in difficult to reach areas. For example, washing under a patient’s arms was difficult with soap and water and usually involved wet bedclothes, but is easy to perform with the mitts.
All staff are trained in the correct use of wash mitts and are highly positive about their use, commenting on their ‘ready to use convenience’ and ‘time saving’ qualities. Some patients come into ICU in an unkempt state and cleansing the skin to keep it clean is an integral part of patient care.
Patient feedback about the mitts has also been excellent, for example, patients with pyrexia like the cooling sensation on their face. If a patient prefers a warmer mitt, there is a warming container which can be used for the mitts prior to use. Unlike washing solutions, which require a leave-on period and then rinsing, the mitts do not need to be rinsed and the skin dries quickly. Also, they are gentle on the skin.
Octenidine is a broad spectrum antimicrobial and to date, has not shown any decrease in antimicrobial efficacy to multi-resistant bacteria [Siebert, 2010]. There have been no reports of the development of resistance to octenidine and no side effects have been described [Lachapelle, 2014]. Octenidine has a residual antimicrobial effect on the skin, which lasts for at least 24 hours, which may result in a better preventative outcome [Brill, 2015].
There is evidence to suggest the potential effectiveness of octenidine in ICUs to lower HAIs [Gastmeier, 2016; Spencer, 2013; Messler, 2019]. Clinical studies examining the use of an octenidine based antimicrobial body wash in ICU have found a 76% reduction in the acquisition of multi-drug resistant organisms [Spencer, 2013]. There was a significant reduction in ICU-acquired blood-stream infections and MRSA in medical ICUs after implementation of an octenidine-based antimicrobial for decontamination [Gastmeier, 2016]. Nosocomial incidence density of 7.55 (pre-intervention) was reduced to 2.61 (post-intervention) per 1000 patient days [Messler, 2019]. Nosocomial infections were significantly reduced from 13 cases to 1 case after intervention [Messler, 2019].
Additional data on patient decontamination in ICUs also indicates further advantages of preventive washing. A 2011 study concluded that all decontamination strategies in ICU improved health outcomes as well as cutting costs of healthcare provision [Robotham, 2011]. Universal decontamination was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions [Huang, 2014].
A 2017 study investigated the impact when routine MRSA decontamination in ICU was discontinued. There was a 250% increase in bacteraemia cases across the whole hospital. Six months after reinstating routine decontamination in ICU, cases showed a significant decrease. The researchers concluded that ‘routine decolonization for MRSA in a large ICU setting is an effective strategy to reduce the spread and incidence of MRSA across the whole hospital’ [Bradley, 2017].
The clinical evidence and our own experience means that the ICU team at the Royal Berkshire will continue to use wash mitts for all patient cleansing, as part of our overall infection control strategy.
References
Bradley CW, Wilkinson MA, Garvey MI. The Effect of Universal Decolonization with Screening in Critical Care to Reduce MRSA Across an Entire Hospital. Infect Control Hosp Epidemiol. 2017;38(4):430-435. doi:10.1017/ice.2017.4
Brill FHH, Radischat N, Goroncy-Bermes P, Siebert J. Residual antiseptic efficacy of octenidine dihydrochloride versus chlorhexidine gluconate in alcoholic solutions. Antimicrob Resist Infect Control. 2015;4(Suppl 1):P33. Published 2015 Jun 16. doi:10.1186/2047-2994-4-S1-P33
Gastmeier P, Kämpf KP, Behnke M, Geffers C, Schwab F. An observational study of the universal use of octenidine to decrease nosocomial bloodstream infections and MDR organisms. J Antimicrob Chemother. 2016;71(9):2569-2576.
Guest JF, Keating T, Gould D, et al Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England BMJ Open 2020;10:e033367. doi: 10.1136/bmjopen-2019-033367
Haque M, Sartelli M, McKimm J, Abu Bakar M. Healthcare-associated infections – an overview. Infect Drug Resist. 2018;11:2321-2333.
Huang SS, Septimus E, Avery TR, et al. Cost savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial. Infect Control Hosp Epidemiol. 2014;35 Suppl 3:S23-S31.
Jeans E, Holleyman R, Tate D, Reed M, Malviya A. Methicillin sensitive staphylococcus aureus screening and decolonisation in elective hip and knee arthroplasty. J Infect. 2018;77(5):405-409.
Lachapelle JM. A comparison of the irritant and allergenic properties of antiseptics. Eur J Dermatol 2014;24:3–9.
Messler S, Klare I, Wappler F, et al. Reduction of nosocomial bloodstream infections and nosocomial vancomycin-resistant Enterococcus faecium on an intensive care unit after introduction of antiseptic octenidine-based bathing. J Hosp Infect. 2019;101(3):264-271.
NICE, Infection prevention and control Quality Standard [QS61], April 2014 www.nice.org.uk/guidance/qs61
National Institute for Health and Care Excellence (NICE). Healthcare associated infections: prevention and control in primary and community care, Clinical guideline [CG139], 2017. https://www.nice.org.uk/guidance/cg139
Nuvials X, Palomar M, Alvarez-Lerma F, et al. Healthcare associated infections. Patient characteristics and influence on the clinical outcome of patients admitted to icu. envin-helics registry data. Intensive Care Med Exp. 2015;3(Suppl 1):A82. Published 2015 Oct 1.
Robotham JV, Graves N, Cookson BD, et al. Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation. BMJ. 2011;343:d5694.
Siebert J. octenidine – a new topical antimicrobial agent for wound antisepsis. J Wound Technology. 2010;7: 66-68
Spencer C, Orr D, Hallam S, Tillmanns E. Daily bathing with octenidine on an intensive care unit is associated with a lower carriage rate of methicillin-resistant Staphylococcus aureus. J Hosp Infect. 2013;83(2):156-159.
