Hospital Privacy Curtains --What's hanging around?
The patient environment can harbour potential pathogens making it a possible source for cross-transmission to the hands of healthcare workers, patients and their visitors (Cheng et al., 2015).
Some of the most common hospital-acquired pathogens survive on dry surfaces, such as privacy curtains, for many months. A literature review by Kramer, Schwebke & Kampf showed that most gram-positive bacteria such as Vancomycin Resistant Enterococcus (VRE), Staphylococcus aureus, including Methicillin resistant Staphylococcus aureus (MRSA), and Streptococcus pyogenes survive for months on dry surfaces, as do many gram-negative species such as Escherichia coli, and Pseudomonas aeruginosa.
Mycobacteria including Mycobacterium tuberculosis and spore forming bacteria including Clostridium difficile can also survive for months as can fungal pathogens like Candida albicans.
Most viruses from the respiratory tract such as coxsackie and influenza can persist on surfaces for only a few days but those from the gastrointestinal tract, such as rota virus, and astrovirus persist for up to two months (Kramer, Schwebke & Kampf 2006).
Non-sanitised fabric surfaces are potentially a continuous source of pathogen transmission and come into ready contact with healthcare workers, patients, and visitors, therefore posing a risk of cross-contamination.
A research study by Mody and Gibson (2019) from the University of Michigan looked at the pathogen loading of patient privacy curtains, presenting their findings at the European Congress of Clinical Microbiology and Infectious Diseases in April this year. The study aimed to better inform curtain hygiene protocols.
The prospective cohort study across six skilled nursing facilities, or rehabilitation rooms, obtained bacterial culture samples from several sites on each patient's body as well as from 'high-touch' surfaces in the patient's room. Samples were taken upon admission, after 14 days, 30 days and then monthly up to six months. A total 1521 samples from 625 rooms were obtained from the edge of privacy curtains where they are touched most often.
The study found that 22 per cent of cultures taken from privacy curtains tested positive for multi-drug resistant organisms (MDROs) with contamination rates varying from 11.9 to 28.5 per cent across the different facilities. Of these cultures, 13.8 per cent were contaminated with VRE; 6.2 per cent with resistant gram-negative bacilli (R-GNB); and 4.9 percent with MRSA.
In 15.7 per cent of cases, patients and their privacy curtain were concurrently colonised with the same multi drug-resistant organism (MDRO).
Ohl, Schweizer, Graham, Heilmann, Boyken and Diekema (2012) from the University of Iowa conducted a longitudinal study to determine the prevalence and time course of bacterial contamination on privacy curtains after laundering. Over a three-week period, swab cultures were obtained twice weekly from the leading edge of 43 curtains in 30 rooms in two intensive care units and a medical ward. Contamination with Staphylococcus aureus, MRSA, Enterococcus, VRE or aerobic gram-negative rods was determined.
Ninety-two percent of curtains placed during the study showed contamination within one week; 95 per cent demonstrated contamination on at least one occasion, including 21 per cent with MRSA and 42 per cent with VRE. Eight curtains yielded VRE at multiple time points, suggesting frequent recontamination.
The study concluded that privacy curtains are rapidly contaminated with potentially pathogenic bacteria and interventions are required to reduce curtain contamination. The immediate implication of this study showing substantial bacterial contamination of privacy curtains is that healthcare workers should complete hand hygiene after touching curtains and before touching the patient.
Mahida, Beal, Trigg, Vaughan and Boswell (2014) described the investigation and control of an outbreak of group A Streptococcus (GAS) infection in an ear nose and throat ward which revealed 10 out of 24 fabric curtains were contaminated with the same strain. This was the first outbreak report to demonstrate patient curtains as the potential source for GAS cross-transmission, with implications in relation to hand hygiene and the frequency of curtain laundering.
Hand hygiene and targeting privacy curtains for disinfection
While nurses and medical staff understand the importance of hand hygiene in preventing the spread of infection, achieving full compliance still remains a challenge. Patients and visitors generally have a lower level of awareness and curtains in reality come into contact with staff, patients and visitors alike.
Disposable privacy curtains have been marketed over the past few years as a passive infection prevention strategy. Most brands claim some form of anti-microbial activity. This may be due to the polypropylene surfaces that inhibit pathogen growth or to various antibacterial technologies employed.
Monash Health in Australia tested silver-impregnated curtains hung in the intensive care unit in 2014 and found these to have excellent antimicrobial and sporicidal activity for up to six months (Kotsanas, Wijesooriya, Sloane, Stuart,& Gillespie, 2012). Recent reformulations have extended one antimicrobial and sporicidal product (Endurocide Aberdeenshire, Scotland) curtain life up to two years and this was tested in a subsequent study by the Monash team (Kotsanas & Gillespie 2016).
Effectiveness of antimicrobial sporicidal curtains
Kotsanas and Gillespie (2016) tested the zone of inhibition and contact inhibition against a range of microorganisms including gram negative: extended-spectrum[beta]-lactamase Escherichia coli, Stenotrophomonas maltophilia, carbapenemase-producing Klebsiella pneumoniae, and Pseudomonas aeruginosa; and gram positive: methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecium, and coagulase-negative staphylococci), Candida albicans, and spores of Clostridium difficile. Excellent results were achieved for both the zone of inhibition and contact inhibition when tested at baseline, six, 12, 18, and 24 months with no visible loss of activity.
The curtains are composed of extruded 0.5 mm thick polypropylene. They are impregnated with a blend of quaternary ammonium chlorides and repellent negatively charged silicone as well as being fire retardant. The biostatic and biocidal properties also prevent bacteria from penetrating or multiplying on the curtain.
Kotsanas and Gillespie (2016) also conducted a cost benefit analysis for replacing standard fabric curtains with the newer formulation (Endurocide) sporicidal and antimicrobial curtains. When the cost of laundering, hanging and removing fabric curtains on a regular three month cycle is considered, there is a significant cost saving involved in using the Endurocide curtain with a two year life.
The Monash 2016 study concluded that the curtains provide sporicidal and antimicrobial protection to all patients, staff and visitors accessing the patient area as well as endorsing and promoting the implementation of the new formulation Endurocide privacy curtains from both a cost-effectiveness and safety perspective (Kotsanas & Gillespie, 2016).
The patented sporicide used on the brand of curtains in this trial contains an active ingredient that attacks the cell wall and kills the pathogen. This is not a mode of action a pathogen can become resistant to and is completely different to that of carbapenem antibiotics. The sporicide is also electrostatically bonded to the surface of the fabric. This creates static that grabs hold of the pathogen so it cannot be released and passed on. The sporicide then quickly kills it (Endurocide, 2018).
Recycling of sporicidal disposable curtains
As of 2019 New Zealand has an onshore recycle option where the curtains are melted, pelletised and the plastic pellets re-sold to be made into other plastic products. Curtain recycling is organised through existing hospital waste channels. This means that affording patients a less infected environment by means of sporicidal disposable curtains is a sustainable option.
There is a growing recognition that the hospital environment is strongly implicated in the transmission of healthcare-related infections. Privacy curtains that separate patient care areas in most hospitals are a potentially important site of contamination given the frequency that they are touched by patients, visitors and hospital staff. Strategies to inhibit curtain contamination and potential transfer of bacteria from curtains to patients on a continuous basis is required. The use of disposable antimicrobial and sporicidal privacy curtains offers a tool in combating the transmission of MDRO.
Cheng, V.C., Chau, P.H., Lee, W.M., Ho, S.K., Lee, D.W., So, S.Y.... et al., (2015). Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients and visitors. J Hosp Infect: 90:220-5. DOI:10.1016/j.jhin.2014.12.024.
Endurocide (2018). Antimicrobial and sporicidal curtains. Available from: http://www.endurocide.com/infection-control/hospital-curtains/antimicrobial-and-sporicidal-curtains/.
Kramer,A., Schwebke,I., Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases 6:130. doi:10.1186/1471-2334-6-130 https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-6-130
Kotsanas,D. & Gillespie E. (2016). Disposable antimicrobial and sporicidal privacy curtains: Cost benefit of hanging longer. American Journal of Infection Control, Vol. 44, Issue 7, p854-855 doi.org/10.1016/j.ajic.2016.01.009. Retrieved from https://www.clinicalkey.com.au/service/content/pdf/watermarked/1-s2.0-S019665531600047X.pdf?locale=en_AU
Kotsanas, D., Wijesooriya, W.R., Sloane, T., Stuart, R.L., Gillespie, E.E. (2014). The silver lining of disposable sporicidal privacy curtains in an intensive care unit. Am J Infect Control; 42:366-70. doi: 10.1016/j.ajic.2013.11.013.
Mahida, N., Beal, A., Trigg, D., Vaughan, N., Boswell, T. (2014). Outbreak of invasive group A Streptococcus infection: contaminated patient curtains and cross-infection on an ear, nose and throat ward. J Hosp Infect; 87:141-4. DOI: https://doi.org/10.1016/j.jhin.2014.04.007
Mody, L., Gibson, K.(2019). Privacy curtains used in healthcare worldwide are a potential source of drug-resistant bacteria transmission to patients. Public release: European Society of Clinical Microbiology and Infectious Diseases. Retrieved from https://www.eurekalert.org/pub_releases/2019-04/esocpcu040919.php
Ohl, M., Schweizer, M., Graham, M., Heilmann, K., Boyken, L., & Diekema, D. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control 2012; 40:904-906 doi:10.1016/j.ajic.2011.12.017 https://www.clinicalkey.com.au/service/content/pdf/watermarked/1-s2.0-S0196655312000703.pdf?locale=en_AU
By Kendyl Carikas and Shona Matthews
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|Title Annotation:||infection control|
|Author:||Carikas, Kendyl; Matthews, Shona|
|Publication:||The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation|
|Date:||Jun 1, 2019|
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