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Skin care products: why staff know-how is mandatory.

It sounds like something out of a bad science fiction movie: cross- contamination, antibiotic-resistant bacterial strains, even killer viruses. But to the front-line nursing home staff, especially those caring for subacute patients, these infection control nightmares are part of an everyday reality. That reality has given rise to an unprecedented need for a working knowledge of skin care, wound healing and infection control on the part of every caregiver.

Government agencies respond with regulations and guidelines, nursing homes update and refine infection control protocols - and the skin care industry continues to develop products ranging from the simple to the highly sophisticated. All of this, though, comes up against the unfortunate fact that some health care workers still don't take the simplest of precautions to prevent the spread of dangerous pathogens, despite their often dire consequences.

What's the solution? Recently, four skin care product manufacturers offered their views on some key questions.


Paul Alper, Vice President and General Manager, Provon Medical Group

Cathy Garvin, RN, ET, Professional Services Manager, Sween Corp.

Don Jenkins, PhD, Technical Director, Summit Industries

Randy Schwartz, Product Manager, Sherwood Medical

1) What are the key infection control issues in nursing homes today?

Alper: It's been well documented that our ability to resist infection decreases as we age. Unfortunately, there are very few published studies on infection control in long-term care facilities. What research has been done cites infection rates in the range of 10 to 30% at any given time. But at the same time, HCFA reports that 24.7% of the country's 15,000 Medicaid-participating LTC facilities do not comply with isolation techniques intended to prevent nosocomial infections.

There is no doubt that there is a clear need for standardized infection control programs in long-term care facilities. We know, for example, that hand washing is the most important procedure in the prevention of nosocomial infections. Yet most studies show that physicians rarely wash their hands more than 25% of the time when they should, and the number of nurses who do so rarely exceeds 50%. This is true even when they know they're being observed and when they know the patient is infected.

Unfortunately, hand washing behavior is as difficult to modify as smoking or over-eating. In a study published in the December, 1994 issue of the American Journal of Infection Control, Alvaran, Butz and Larson point out that education alone isn't likely to change behavior, and a multi-faceted approach to behavioral intervention is needed. That includes organizational and social structures that facilitate, enhance and enforce compliance.

A related issue is the need to effectively control and reduce the risk of transmitting serious pathogenic microorganisms such as methicillin-resistant Staphylococcus aureus (MRSA), C. difficile, and enterococcus, each of which can be transmitted on the hands of caregivers. There's a real need for skin antiseptics that can claim efficacy against those pathogens.

Garvin: The issues we tend to hear the most about these days are related to HIV and resistant microorganisms such as MRSA, C. difficile and tuberculosis. Now that subacute care has come to the nursing home, these problems are by no means the exclusive domain of acute care facilities. Even so, we still hear infection control nurses saying that staff simply doesn't take the time to wash their hands, despite a general concern about how to care for patients infected with these microorganisms in these settings.

Jenkins: High up on the list - probably first - is the need to guard against infection that's introduced through medications or medication handling. By law, every batch of cream, ointment, etc., is checked for microbiologic contamination before it's released. The possibility of contamination in use depends, therefore, upon the training and skill of the staff.

To reduce that risk, some nursing homes have a "no-jar policy," or at least permit the use of medication jars only when the jar is used exclusively for a single patient. This is because contaminants can be introduced into the jar with a tongue depressor or whatever means is used to retrieve the ointment, especially if that implement is placed in the jar repeatedly after patient contact. Proper procedure - such as removing the ointment with a tongue depressor, placing it on a piece of gauze and using the gauze to apply the ointment to the wound - will reduce the risk of contamination. The key is education about such methods and compliance with them.

Schwartz: Nursing homes have to deal with a large number of problems related to staph, fungal infections and other "bugs." That's part of the territory when you're dealing with people who are incontinent and bedridden. All of this becomes quite a challenge for clinicians, especially when skin breakdown, due to any number of causes, further increases the risk of infection.

2) How is the skin care industry responding to the needs that arise from these issues?

Alper: While we can't influence all aspects of behavior, there are some that we can. Staffers cite product harshness as a reason for not washing their hands. Provon formulates its products for exceptional mildness, in addition to efficacy, in order to help motivate care providers to use them. We also provide inservice training and awareness literature that help support and reinforce that behavior.

With that in mind, we've recently introduced two new products designed to encourage high-frequency hand-wash-ing (PROVON[R] Brand Medicated Lotion Soap with Triclosan and PROVON[R] Brand Health Care Personnel Hand Wash). Each meets what we feel are the key criteria for selecting products for the health care setting: they've passed rigorous in vitro and in vivo efficacy studies and independent dermatologist testing as well as having been proven effective against MRSA, C. difficile and enterococcus. We also offer a skin care library with a comprehensive hand washing awareness and compliance program that includes videos, a leader's guide and reminder stickers and posters.

Because maintaining intact skin is so critical to reducing the risk of infection, we've also introduced a no-rinse, deodorizing perineal wash with broad spectrum antibacterial activity (PROVON[R] Brand Antibacterial Perineal Wash) and PROVON[R] Brand Moisturizing Perineal Barrier, a one-step, dry-to-the-touch formula that combines the moisturizing and barrier function in a single product.

Garvin: Our skin care line includes products for incontinence, hand washing, bathing, moisturization and wound care. Our hand washing system includes ISAGel, an instant hand sanitizer, and Sween Soft Touch, an antimicrobial hand wash. We also promote the use of a moisturizer along with the hand washing products to keep caregiver skin intact.

In general, the industry's products are high quality and as innovative as they can be. The real challenge is to find an effective way to introduce them into a particular health care setting, to incorporate them into existing protocols and standards, and to make sure the products are positioned and used correctly. That's where education comes in.

Jenkins: Lantiseptic has a high lanolin content and acts as an emollient protective ointment that lets the natural healing process proceed without the inhibitions that come from excessive dryness or excessive moisture. The product is indicated for raw or irritated skin, for stage 1 and 2 pressure ulcers and as a moisture barrier for incontinent patients.

Because packaging plays an important role in reducing the risk of infection and cross-contamination, the ointment is available not only in jars, but in tubes and half-ounce foil packets as well. Caregivers using the tubes find it easy to extrude a bit of extra ointment and wipe it off with a tongue depressor. In this way, they're getting rid of the ointment surface that might become contaminated through handling, unlike using a jar, in which you can't really get rid of the surface once it's been touched.

The half-ounce packets are intended for single use to eliminate the possibility of contaminating the container. Of course, the tubes and the single-use packets are a bit higher in price for a given quantity of ointment, but in return you're gaining an increased element of safety.

Schwartz: The industry has come out with a variety of effective products, but proper use is still the "take-home message." From a wound care standpoint, we're dealing with both contamination and infection. Most chronic wounds are contaminated but not necessarily infected, so the idea is to control the contamination to prevent progression to infection. This way of thinking is evident even in the new AHCPR treatment guidelines, which recommend an initial two-week prophylactic course of treatment with a topical antibiotic to control contamination.

Interestingly, one of the products they recommend for that purpose is silver sulfadiazine, a product we manufacture for the burn market. While it's not indicated for chronic wounds, many nursing home clinicians are using it "off-label" because of its broad-spectrum antimicrobial activity.

A large number of products, such as hydrocolloids and our composite dressing, called Viasorb, maintain the moist environment needed for optimal wound healing, but also provide an anti-bacterial barrier. Along those lines, we also manufacture a biosynthetic dressing called Inerpan, which is a co-polymer of two amino acids. It offers a full bacterial barrier, while allowing the body to take advantage of its own healing mechanisms. The amino acids in the dressing bond to the amino acids in the wound. Because the dressing doesn't adhere to healthy tissue, it begins to slough off as the wound begins to heal. For this reason, the dressing can be left on the wound for extended periods, reducing the discomfort, the labor and the risk of contamination associated with frequent dressing changes.

Amazing as it seems, the number one products used in wound care are still gauze and tape, neither of which does anything to control contamination or enhance wound healing. This is yet another reason why education is still our greatest need. To that end, we have 74 representatives in the field conducting inservices. We also offer inservice videos and a CEU program on basic wound care.

3. What does the future hold with respect to product development in these areas?

Alper: We do extensive market research to identify the needs of long-term care facilities and we have several proprietary product development projects underway. The targets are clearly cost-effective products that combine mildness and efficacy with the ability to maintain healthy, intact skin for caregivers and residents. We will also continue our attempts to develop effective education and training programs to support our skin care systems.

Garvin: Unfortunately, we can't develop "a magical product that will make it all go away." What we can do is make products that work well within the appropriate protocols. But we also need to inservice and assist the staff in making sure that our products are incorporated into appropriate protocols.

Jenkins: At Summit, we've talked about developing a water-based gel-type wound treatment using any of the various gelling agents. That's obviously one of the directions wound treatment is taking.

But it's important to understand that wound healing and skin care is constantly evolving, as are the concerns of practitioners about infections, antiseptics, antibacterials and so on. This can even be seen in the name of our product, Lantiseptic. It was first used 20 years ago to convey the idea of a lanolin-based antiseptic ointment. Today, if you go to a meeting with ET nurses and utter the word "antiseptic," you're met with a chorus of "boo's". The betadine and alcohol-based products still have a place, but our understanding of wound healing has come to be based on the concept that anything that kills the undesirable microorganisms is going to kill the healthy cells that promote healing as well.

There are no antiseptics that are appropriately selective and, indeed, normal wound healing involves high bacteria levels. Today, the focus is on good circulation to the affected area and on the understanding that the wound itself is a virtual hotbed of microorganisms that are not only not harmful, but, for the most part, are essential parts of the normal healing process. That is why, today, the role of the 8-hydroxyquinoline in Lantiseptic is to assure that there is no growth of microorganisms in the ointment. The product acts as a protective emollient and we make no claims of disinfecting the wound itself.

In essence, we're dealing with a delicate balance: we need to allow the microorganisms needed for wound healing to do their job while, at the same time, prevent those microorganisms from coming into contact with anyone other than the patient with whom they've originated. I think we'll continue to walk that tightrope over the coming years.

Schwartz: The research seems to show that better control of wound contaminants leads to faster-healing wounds. It's important to remember that, once wounds become infected, they can be very slow to heal, if they heal at all. So, in the future, I think we'll see active biologic products that offer some sort of anti-bacterial activity. I think we'll also see more naturally-acting materials, such as the collagen products that are picking up interest now, along with more types of dressings that can remain on the wound for longer periods of time.
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Title Annotation:nursing homes
Author:Bruck, Laura
Publication:Nursing Homes
Article Type:Panel Discussion
Date:Apr 1, 1995
Previous Article:Interim exceptions to RCLs.
Next Article:Shift work: its challenges and management.

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