Reducing the potential for phlebotomy tourniquets to act as a reservoir for meticillin-resistant Staphylococcus aureus

Reusable tourniquets for blood sampling as a source of multi-resistant organisms- a systematic review

Introduction

The use of reusable tourniquets is widespread around the world, and reports suggest they may be overused. Several studies have shown that reusable tourniquets can affect the spread of pathogens between patients. Based on available studies, this review aims to analyse the indirect transmission of antimicrobial-resistant pathogens present on blood collection tourniquets, which may spread infectious diseases between patients in daily clinical practice.

Methods

A systematic review of the literature was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol guidelines. The contents of PubMed, EBSCO (electronic databases), and Scopus were screened. Keywords used in the search included: "tourniquet," "cross infection," "nosocomial infection," "staphylococcus aureus," "MRO," "pathogen," "infectious disease," "anti-microbial," or a combination of these using AND or OR operators. Finally, 13 publications were included. Data were analysed both descriptively and quantitatively by calculating a balanced average for specific synthesized data.

Results

The proportional observation based on the number sampled median was 77. The genus MRSA was the type of bacteria most commonly found: on 12% of all tested tourniquets. The amount of MRSA found on tourniquets was mean ± SD 14.6 ± 45.89. A review of studies also revealed the presence of coagulase-negative staphylococci, grew Bacillus, and Staphylococcus aureus.

Conclusion

Patient safety may be at risk due to elevated contamination rates of reusable tourniquets. The microorganisms responsible for this contamination include a variety of species, the most common being the genus Staphylococcus. For this reason, we recommend the use of disposable tourniquets.

Reduced bacterial contamination rates detected on silicone tourniquets compared to conventional tourniquets in clinical routine

Background

Tourniquets used for peripheral venous vascular access such as blood sampling are regularly contaminated in clinical routine. Although most contaminations are harmless, some pose a possible risk for infection. To improve peripheral venous access infection control standards, tourniquets with no or as few as possible bacterial burden should be used. Conventional tourniquets can be reprocessed by autoclaving or by incubating in disinfectants. However, both methods are time-consuming and not suitable for immediate use between patients. In contrast, silicone tourniquets can be quickly and simply reprocessed with wipe disinfection. In vitro studies from the manufacturer have demonstrated reduced bacterial contamination on silicone tourniquets after usage compared to conventional tourniquets. This study aims to independently investigate the bacterial load on both types of tourniquets in clinical routine.

Methods

In a first trial, new conventional and silicon tourniquets were used for blood sampling in one facility with strict guidelines for reprocessing (after each patient or not at all) for 1 day and tested for bacterial contamination. In a second trial, new tourniquets were used in four facilities while the mode and frequency of tourniquets’ reprocessing was defined individually by each facility. The number of treated patients, mode and frequency of reprocessing and other relevant handling measures were documented.

Results

Under controlled conditions, with strictly specified reprocessing, slightly fewer bacteria were found on silicone than on conventional tourniquets. In routine clinical practice the reprocessing frequency was not higher for silicone tourniquets in practice. Yet, in all four facilities, there were significantly fewer bacteria found on silicone than on conventional tourniquets.

Conclusion

Although tourniquets are classified as non-critical medical devices, results show – together with benefits of faster and easier reprocessing – that silicone tourniquets can improve infection control of venous vascular access.

Vein Pattern Locating Technology for Cannulation: A Review of the Low-Cost Vein Finder Prototypes Utilizing near Infrared (NIR) Light to Improve Peripheral Subcutaneous Vein Selection for Phlebotomy

One of the most common means for diagnosis is through medical laboratory testing, which primarily uses venous blood as a sample. This requires an invasive method by cannulation that needs proper vein selection. The use of a vein finder would help the phlebotomist to easily locate the vein, preventing possible pre-analytical error in the specimen collection and even more discomfort and pain to the patient. This paper is a review of the scientific publications on the different developed low-cost vein finder prototypes utilizing camera assisted near infrared (NIR) light technology. Methods: Electronic databases were searched online, these included PubMed (PMC), MEDLINE, Science Direct, ResearchGate, and Institute of Electrical and Electronics Engineers (IEEE) Xplore digital library. Specifically, publications with the terms vein finder prototype, NIR technology, vein detection, and infrared imaging were screened. In addition, reference lists were used to further review related publications. Results: Cannulation challenges medical practitioners because of the different factors that can be reduced by the utilization of a vein finder. A limited number of publications regarding the assessment of personnel performing cannulation were observed. Moreover, variations in methodology, number of patients, type of patients according to their demographics and materials used in the assessment of the developed prototypes were noted. Some studies were limited with regard to the actual human testing of the prototype. Conclusions: The development of a low-cost effective near infrared (NIR) vein finder remains in the phase of improvement. Since, it is being challenged by different human factors, increasing the number of parameters and participants/human for actual testing of the prototypes must also be taken into consideration for possible commercialization. Finally, it was noted that publications regarding the assessment of the performance of phlebotomists using vein finders were limited.

Health professionals' practices related with tourniquet use during peripheral venipuncture: a scoping review

OBJECTIVES

during peripheral venipuncture, health professionals are recommended to use a tourniquet above the puncture site in order to potentiate venous distension. Given its characteristics and use in clinical settings, tourniquets may represent a source of microorganism dissemination. However, the results of scientific studies in this area are scattered in the literature. This scoping review aims to map the available evidence on health professionals' practices related with tourniquet use during peripheral venipuncture and associated microbiological contamination.

METHODS

scoping review following the Joanna Briggs Institute methodology. Two independent reviewers analyzed the relevance of the studies, extracted and synthesized data.

RESULTS

fifteen studies were included in the review. Overall, tourniquets were reused without being subject to recurring decontamination processes. It has been found that practitioners share these devices among themselves and use them successively for periods between two weeks and seven and half years.

CONCLUSION

nursing practices related to tourniquet use during peripheral venipuncture are not standard. Reuse of tourniquets may jeopardize the patient's safety if reprocessing (cleaning and disinfection/sterilization) is not adequate, given the type of tourniquet material and microbiota found. New studies are needed to assess the impact of various types of reprocessing practices on tourniquet decontamination and patient safety.

Hygiene of venepuncture tourniquets in Denmark

Tourniquets are widely used to make the vein more visible prior to blood collection. Venepuncture tourniquets are however a non-sterile and potentially reusable equipment. Several studies have shown that they are colonised by a variety of pathogenic bacteria and consecutively use of the same tourniquet on multiple patients will increase the risk of a nosocomial infection. This matter is however only scarcely studied. The objective of this study was to investigate the nationwide use of disposable and non-disposable venepuncture tourniquets and the standardised procedures for cleaning the tourniquets. A questionnaire concerning use and cleaning of tourniquets was therefore sent to all major Danish clinical biochemistry laboratories (n = 12). All but one laboratory had a local procedure for usage and handling of tourniquets, including structured procedures for cleaning. Despite this, only 75% of laboratories had a guideline for cleaning the tourniquets and only 50% had a specified cleaning program. At the hospitals using non-disposable tourniquets the handling differed considerably and at two hospitals the tourniquets were only cleaned once a week, while one laboratory did not clean the tourniquet before it was visibly stained. Of note, five of the eight hospitals using disposable tourniquets only disposed the tourniquets on a daily basis. In conclusion, there is a lack of guidelines for handling tourniquets in 25-33% of the hospitals and a number of hospitals used both types (disposable and non-disposable), which could confuse the handling of the tourniquets. A national guideline for usage and cleaning of venepuncture tourniquets is therefore strongly recommended.

Evaluation of Blood Collection From the Proximal Side of a Fluid Infusion Site

Background

We aimed to determine if blood data are unaffected by transfusion method when the blood is sampled from the proximal side of the infusion site under temporary suspension of transfusion.

Methods

In five 30-week-old Japanese white male rabbits, fluid infusion routes were secured via left auricular veins with a disposable plastic indwelling cannula (24-G needle). Solita T3 (22 mL/h) was administered to each animal using a syringe pump. Ten minutes after starting infusion, 2 mL blood was sampled from a distance of 2 cm on the central side of the infusion site with ongoing fluid infusion, from the opposite side (the right auricular vein), and from the central side of the infusion site with suspended fluid infusion. We cross-verified and compared results of 41 biochemical and blood cell examination items for samples collected from the central side with ongoing fluid infusion, from the central side with suspended fluid infusion, and from the opposite sides by comparison with Tukey’s test.

Results

A significant difference was noted in tested items between blood samples collected from the proximal side with ongoing fluid infusion and those collected from the proximal side and from the contralateral side with suspended fluid infusion. Conversely, for all test items, no significant difference was noted in the test item data between blood samples collected from the proximal side with suspended fluid infusion and those collected from the contralateral side.

Conclusions

We successfully verified and demonstrated that blood samples collected from the proximal side of the infusion site remain unaffected by fluid infusion when drawn under the conditions of suspended fluid infusion.

Preanalytical external quality assessment of the Croatian Society of Medical Biochemistry and Laboratory Medicine and CROQALM: finding undetected weak spots

INTRODUCTION

The aim of this paper is to present results of first two years of preanalytical external quality assessment (EQA) in Croatia.

MATERIALS AND METHODS

This paper summarizes results from 6 rounds of preanalytical EQA during 2014-2016 in 161-175 Croatian laboratories (number ranged between cycles). EQA was designed as an online survey of the compliance with National recommendations for phlebotomy (NRP). Forty-seven questions in 5 categories are analyzed (materials and equipment, patient identification, patient preparation, sampling and storage). Additionally, preanalytical cases are presented. Overall performance scores (Question score (Qscore) for compliance with NRP and Case score (Cscore) for preanalytical cases) are calculated for each question/case as a proportion of laboratories with satisfactory procedure (x 100). Qscores and Cscores ≥ 70 were classified as acceptable (maximal score = 100).

RESULTS

In investigation of compliance with NRP, acceptable Qscores were obtained for 34/47 questions. The lowest scores were observed for the availability of sterile disposable tourniquets (Qscore = 15) and safe-sharp needles (Qscore = 34), obtaining patients address as an identifier (Qscore = 21), using glycolysis inhibitor tubes for glucose concentration measurement (Qscore = 21) and verification of manufacturers declarations on temperature and time of storage (Qscore = 31). There was no statistically significant difference in overall Qscore according to different categories of phlebotomy procedures (P = 0.284). The results of preanalytical cases showed acceptable Cscore values for all cases (89-96).

CONCLUSION

First two years of preanalytical EQA showed good compliance with the NRP and excellent expertise in resolving complex preanalytical issues. Major critical spots are lack of availability of safe-sharp needles, disposable tourniquets and glucose inhibitor tubes.

Phlebotomy, a bridge between laboratory and patient

The evidence-based paradigm has changed and evolved medical practice. Phlebotomy, which dates back to the age of ancient Greece, has gained experience through the evolution of medicine becoming a fundamental diagnostic tool. Nowadays it connects the patient with the clinical laboratory dimension building up a bridge. However, more often there is a gap between laboratory and phlebotomist that causes misunderstandings and burdens on patient safety. Therefore, the scope of this review is delivering a view of modern phlebotomy to "bridge" patient and laboratory. In this regard the paper describes devices, tools and procedures in the light of the most recent scientific findings, also discussing their impact on both quality of blood testing and patient safety. It also addresses the issues concerning medical aspect of venipuncture, like the practical approach to the superficial veins anatomy, as well as the management of the patient's compliance with the blood draw. Thereby, the clinical, technical and practical issues are treated with the same relevance throughout the entire paper.

Quantifying patient bacterial exposure risk from reusable phlebotomy tourniquets in a New Zealand secondary level hospital

AIM

This study aimed to assess for the presence of multi-drug resistant organisms (MDROs) on tourniquets and quantify the number of bacteria to which patients might be exposed with each blood collection episode.

METHODS

Tourniquets were randomly sampled in a 246-bed, secondary level, New Zealand hospital, which is currently non-endemic for MDROs. A 6-cm length of each tourniquet sampled was applied to the surface of an agar plate and the colony forming units (CFUs) were enumerated. All colonies were then screened for MDROs using standard methods. CFU counts per linear centimetre were multiplied by a range of patient arm circumference measurements. Comparison was also made between non-disinfected tourniquets left on the wards and phlebotomy service tourniquets after daily decontamination with a proprietary disinfectant.

RESULTS

The median exposure risk from non-disinfected tourniquets was 173 CFUs per collect (95% CI, 104-861). None of the general ward tourniquets grew any MDROs but four out of five dedicated, single-patient reusable isolation room tourniquets grew MRSA. Disinfected tourniquets had few if any CFUs and CFU counts were significantly lower than non-disinfected tourniquets (P = 0.0001).

CONCLUSION

The quantitative risk from reusable tourniquets appears low in the setting of MDRO non-endemicity, with the application of standard infection control practices.

The identification and epidemiology of meticillin-resistant Staphylococcus aureus and Clostridium difficile in patient rooms and the ward environment

BACKGROUND

Research has indicated that the environment may play an important role in the transmission of meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile in healthcare facilities. Despite the significance of this finding, few data exist from longitudinal studies investigating MRSA and C. difficile contamination, concurrently, in both patient rooms and the general ward environment. The objectives of this study were to determine the prevalence of MRSA and C. difficile contamination in patient rooms and the ward environment and identify risk factors associated with a surface being contaminated with these pathogens.

METHODS

Environmental surfaces in patient rooms and the general environment in the medical and surgical wards of a community hospital were sampled six times over a 15 week period. Sterile electrostatic cloths were used for sampling and information pertaining to the surface sampled was recorded. MRSA isolates and C. difficile specimens were obtained from hospitalized patients.Enrichment culture was performed and spa typing or ribotyping was conducted for MRSA or C. difficile, respectively. Exact logistic regression models were constructed to examine risk factors associated with MRSA and C. difficile contamination.

RESULTS

Sixteen (41%) patient rooms had ≥ 1 surfaces contaminated with MRSA and/or C. difficile. For 218 surfaces investigated, 3.2% and 6.4% were contaminated with MRSA or C. difficile, respectively. Regression models indicated that surfaces in rooms exposed to a C. difficile patient had significantly increased odds of being contaminated with C. difficile, compared to surfaces in unexposed patient rooms. Additionally, compared to plastic surfaces, cork surfaces had significantly increased odds of being contaminated with C. difficile. For 236 samples collected from the ward environment, MRSA and C. difficile were recovered from 2.5% and 5.9% of samples, respectively. Overall, the majority of MRSA and C. difficile strains were molecularly identified as spa type 2/t002 (84.6%, n = 11) and ribotype 078 (50%, n = 14), respectively.

CONCLUSIONS

In patient rooms and the ward environment, specific materials and locations were identified as being contaminated with MRSA or C. difficile. These sites should be cleaned and disinfected with increased vigilance to help limit the transmission and dissemination of MRSA and C. difficile within the hospital.

Hand sanitizer dispensers and associated hospital-acquired infections: friend or fomite?

BACKGROUND

Waterless alcohol-based hand sanitizers are an increasingly popular method of hand hygiene and help prevent hospital-acquired infection (HAI). Whether hand sanitizer dispensers (HSDs) may themselves harbor pathogens or act as fomites has not been reported.

METHODS

All HSDs in the surgical intensive care unit of an urban teaching hospital were cultured at three sites: The dispenser lever, the rear underside, and the area surrounding the dispensing nozzle.

RESULTS

All HSDs yielded one or more bacterial species, including commensal skin flora and enteric gram-negative bacilli. Colonization was greatest on the lever, where there is direct hand contact.

CONCLUSION

Hand sanitizer dispensers can become contaminated with pathogens that cause HAI and thus are potential fomites.

Reusable venesection tourniquets: a potential source of hospital transmission of multiresistant organisms

OBJECTIVE

To determine the prevalence of multiresistant organism (MRO) colonisation of reusable venesection tourniquets.

DESIGN AND SETTING

A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs - methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β-lactamase-producing Enterobacteriaceae - using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010.

MAIN OUTCOME MEASURE

Prevalence of MRO colonisation of tourniquets.

RESULTS

The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19; both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets.

CONCLUSION

Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.