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Patient Safety Tip of the Week
September 12, 2023
Radiology and Hospital-Acquired
Infections
It seems we are
always writing about patient safety issues and radiology (see full list below).
Most of them have nothing to do with radiology, per se. Rather, it’s because
sick patients with multiple medical problems and vulnerabilities are being
taken to the radiology suite and staying there,
sometimes for prolonged periods. The events include things like falls,
medication errors, patient mixups, IV connection
errors, running out of oxygen, conscious sedation incidents, suicides, and
others.
But one risk that we’ve
only occasionally mentioned in connection with radiology is the risk of
transmitting infections. Rob Fabrizio recently penned an article on how
radiology facilities can help reduce health-care associated infections (Fabrizio
2023). He notes that, in hospitals,
radiology departments can be a major reservoir for HAI’s “because they’re
frequently utilized, shared locations for diverse patient populations—from
children to the elderly to people with complex conditions and unknown diseases”.
He also notes that radiology departments have evolved into multi-room
facilities with an array of equipment and image-guided interventional
treatments, increasing the chances for bacterial spread. Given the large numbers of patients that pass through daily or have X-ray
exams performed portably, contamination of radiographic equipment and
accessories is unavoidable. That shared space and shared equipment can turn
radiology departments into breeding grounds and both colonized and infected
patients waiting for different radiological tests can increase the risk of HAI
spread. Hospitals seldom have dedicated equipment just for use on infectious
patients.
Fabrizio notes many
studies have demonstrated the presence of microorganisms on medical equipment
and radiology workstations. Furthermore, most disinfectants require that
treated surfaces remain visibly wet with the disinfectant for several minutes
to achieve maximum effectiveness but, because of high patient volumes, busy
imaging facilities can’t wait that long. And contaminated hands of healthcare
workers and patients can lead to transfer of infectious pathogens from one
person to another and to adjacent surfaces and devices.
Portable imaging
raises yet further issues. Portable imaging units come in close
proximity to pathogen-laden surfaces in the intensive care unit (ICU)
and the emergency department (ED). And, if a tech’s hands become contaminated
when using a portable unit, it could result in the rapid spread of HAI’s.
That’s because portable X-rays are often utilized for multiple patients in a
short amount of time, all while using just one detector across all patients and
multiple departments.
He also notes that,
in the case of MRI, the most common place for infection is the surface of the
machine’s bore, which is a difficult place to access so it’s often overlooked
during routine cleaning and disinfection. Our October 2008 What's New in the Patient Safety World
column “Preventing
Infection in MRI” highlighted an excellent 3-part series by Peter
Rothschild “Preventing infection in MRI: Best practices for infection control
in and around MRI suites” (Rothschild
2008a, 2008b,
2008c).
Fabrizio recommends hospitals and radiology facilities do
the following to help reduce HAI’s:
·
Build a culture of safety.
·
Reduce waiting time
·
Sterilize hospital equipment
·
Demand hand hygiene
·
Clean and disinfect radiology equipment
·
Lead by example
·
Use antibacterial imaging equipment
·
Utilize portable devices for compromised patients
He stresses that cultivating a culture of safety in
the organization and the department should be priority number one. Staff should
have an up-to-date knowledge and standardized operating procedures to minimize
HAI spread via strict protocols, training, personnel, and radiology equipment. Radiology managers must lead by example and
require best practice protocols.
Reducing waiting time is a laudable goal for both
efficiency and patient satisfaction. But it should also be a goal to help
prevent HAI’s. Prolonged exposure of
patients to other patients and family members in waiting areas increases the
possibility of spreading HAI’s from person to person. Imaging
waiting rooms also have lots of “high touch” surfaces such as arms on chairs,
tabletops, kiosk screens, and more that can become contaminated. Staggering
appointments may help, though he notes this is often difficult in the hospital
setting.
Sterilizing hospital equipment applies not only to the surfaces of imaging equipment but also other
equipment like touch screens, keyboards, electrocardiogram leads, computer
mice, patient transfer devices, and immobilization straps. Every facility must
develop and use an appropriate disinfection procedure before and after every
patient visit to the radiology department.
Demanding hand hygiene is traditionally the most important strategy used around the world to
prevent HAI’s. He notes that, in facilities where C. diff colonization or
infection is likely (which includes most imaging facilities), proper hand
washing with soap and water rather than alcohol-based sanitizers is required. (Note
that our April 2023 What's New in the Patient Safety World column “New
Handwashing Guidelines” discussed the recently revised hand hygiene
guidelines from the leading infection prevention organizations (Glowicz
2023). Those guidelines
emphasize that alcohol-based hand sanitizer dispensers should always be widely
available and never prohibited, even in situations when washing with soap and
water are indicated. When healthcare personnel suspect organisms that are
difficult to remove, such as C. difficile and noroviruses, healthcare personnel
should wear gloves and follow structured techniques for hand washing and hand
sanitizing.
Fabrizio recommends use of antibacterial
imaging equipment. We’ll decline comment on that one since his
recommendations involve equipment and supplies that his company manufactures
and sells.
Fabrizio also emphasizes utilization of portable devices
for compromised patients. Makes sense, but you need to make sure that the
equipment is wiped down or otherwise sanitized between patients and that the imaging
technician practices good hand hygiene or wears gloves where appropriate. Again,
Fabrizio recommends use of radiography equipment that features
built-in antibacterial protection (but his company makes and sells these).
The one thing
missing from the latter discussion is reducing unnecessary portable imaging. We are still amazed at how often we see ICU patients getting “routine”
daily X-rays! In our November 10, 2009 Patient Safety Tip of the Week “Conserving
Resources…But Maintaining Patient Safety” we noted a French study (Hejblum
et al 2009) that compared
the routine daily chest x-ray strategy against an on-demand strategy (where
chest x-rays are ordered based on clinical questions). They found that the
on-demand strategy resulted in 32% fewer x-rays being done with no obvious
adverse clinical consequences. Fewer x-rays should translate to lower costs,
fewer x-rays of limited clinical utility, lower radiation exposure, and
theoretically even less exposure to microbial pathogens on the portable x-ray
equipment.
Potential conflicts
of interest aside, Fabrizio’s article is an excellent reminder that the
radiology department is a hub for hospital activity and, therefore, a potential
hub for spread of microbial pathogens. Take a hard
look and see if your radiology department is doing its
role in prevention of HAI’s.
Some of our prior
columns on patient safety issues in the radiology suite:
·
October 16, 2007 “Radiology
as a Site at High-Risk for Medication Errors”
· February
19, 2008 “MRI
Safety”
·
September 16, 2008 “More
on Radiology as a High Risk Area”
· October
7, 2008 “Lessons
from Falls....from Rehab Medicine”
· October
2008 “Preventing
Infection in MRI”
·
March 17, 2009 “More
on MRI Safety”
·
March 2009 “Risk
of Burns during MRI Scans from Transdermal Drug Patches”
·
August 11, 2009
“The
Radiology Suite…Again!”
· January 2010 “Falls in the Radiology Suite”
· August
2010 “Sedation
Costs for Pediatric MRI”
· January 25, 2011 “Procedural Sedation in Children”
·
February
1, 2011 “MRI Safety Audit”
·
October
25, 2011 “Renewed Focus on MRI Safety”
·
March 13, 2012 “Medical
Emergency Team Calls to Radiology”
· August 2012 “Newest MRI Hazard: Ingested Magnets”
· October 22, 2013 “How Safe Is Your Radiology Suite?”
· February 25, 2014 “Joint Commission Revised Diagnostic Imaging
Requirements”
· July 2014 “New MRI Risks: for Staff!”
· July 1, 2014 “Interruptions and Radiologists”
· November 2014 “More Radiologist Interruptions”
· October 21, 2014 “The Fire Department and Your Hospital”
· June 23, 2015 “Again! Mistaking Antiseptic Solution for
Radiographic Contrast”
· August 25, 2015 “Checklist for Intrahospital Transport”
· March 22, 2016 “Radiology
Communication Errors May Surprise You”
· August 2016 “Guideline
Update for Pediatric Sedation”
·
October
2016 “MRI
Safety: There’s an App for That!”
· January 17, ,2017 “Pediatric
MRI Safety”
· August 8, 2017 “Sedation
for Pediatric MRI Rising”
· November 14, 2017 “Tracking
C. diff to a CT Scanner”
· March 2018 “MRI
Death a Reminder of Dangers”
· March 2018 “Cardiac
Devices Safe During MRI But Spinners!?”
· April 2018 “Radiologists
Get Fatigued, Too”
·
May 2018
“Cost
of Interrupting a Radiologist”
· November 2018 “OMG!
Not My iPhone!”
· December 11, 2018 “Another NMBA Accident”
· April 2, 2019 “Unexpected Events During MRI”
· September 2019 “New MRI Hazard: Magnetic
Eyelashes”
· October 15, 2019 “Lots More on MRI Safety”
· November 5, 2019 “A Near-Fatal MRI Incident”
· November 12, 2019 “Patient Photographs Again
Help Radiologists”
· November 26, 2019 “Pennsylvania Law on
Notifying Patients of Test Results”
· January 7, 2020 “Even More Concerns About MRI
Safety”
· July 14, 2020 “A Thesis on Intrahospital
Transports”
· August 25, 2020 “The Off-Hours Effect in
Radiology”
·
October 2020 “New
Warnings on Implants and MRI”
·
January 2021 “New
MRI Risk: Face Masks”
·
May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
· June 1, 2021 “Stronger Magnets, More MRI
Safety Concerns”
· November 2021 “Yet Another Risk During MRI”
· January 2022 “MRI
Safety Issues”
· February 2022 “Managing Incidental Findings”
· June 2022 “Where Are You Barcoding?”
· July 12, 2022 “Radiologists Racked by
Interruptions”
· July 26, 2022 “More Risks in the Radiology
Suite”
· May 2023 “Factors
Associated with Radiology Diagnostic Errors”
References:
Fabrizio R. How
Radiology Facilities Can Help Reduce Health-Care
Associated Infections. Diagnostic Imaging 2023; Jul 13, 2023
https://www.diagnosticimaging.com/view/radiology-facilities-reduce-health-care-associated-infections
Rothschild PA. Preventing infection in MRI: Best practices
for infection control in and around MRI suites, part I. AuntMinnie.com 2008; June
20, 2008
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&itemid=81530
(Rothschild
2008a),(2008b),
(2008c)
Rothschild PA. Preventing infection in MRI: Best practices
for infection control in and around MRI suites, part II. AuntMinnie.com 2008; June
27, 2008
https://www.auntminnie.com/index.aspx?Sec=sup&Sub=mri&Pag=dis&ItemId=81616
Rothschild PA. Preventing infection in MRI: Best practices
for infection control in and around MRI suites, part III. AuntMinnie.com 2008;
July 3, 2008
https://www.auntminnie.com/index.aspx?sec=ref&sub=wht&pag=dis&ItemID=81666
Glowicz J, Landon E, Sickbert-Bennett E, et al. SHEA/IDSA/APIC Practice
Recommendation: Strategies to prevent healthcare-associated infections through
hand hygiene: 2022 Update. Infection Control & Hospital Epidemiology 2023;
1-22 Published online February 8, 2023
Hejblum G, Chalumeau-Lemoine L, Ioos
V, et al. Comparison of routine and on-demand prescription of chest radiographs
in mechanically ventilated adults: a multicentre,
cluster-randomised, two-period crossover study. The
Lancet 2009; 374(9702): 1687-1693 Early Online Publication, 5 November 2009
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61459-8/fulltext
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