The Centers for Disease Control and Prevention (CDC) estimates that nearly two million healthcare-associated infections (HAIs) occur annually in the U.S., cumulatively costing U.S. hospitals nearly $45 billion annually. In 2009, the Centers for Medicare & Medicaid Services stopped reimbursing hospitals for HAIs for Medicare patients, leaving hospitals to foot the bill.

Infection prevention has become a top priority, and portable imaging is a prime target. “If portable systems, which are transferred across entire hospital campuses, are not properly controlled for infection, it can be a big problem,” says Edwin Zhang, MD, from the department of radiology and diagnostic imaging at University of Alberta in Edmonton, Canada, who authored a review article about methicillin-resistant staphylococcus aureus (MRSA) in the American Journal of Roentgenology in November 2011.

Unfortunately, bacteria are pervasive. Cultures of portable x-ray systems at Hadassah Hebrew University Hospital in Jerusalem, revealed the presence of Gram-negative bacteria 50 percent of time after an intervention aimed at infection control and reducing system contamination, up from 39 percent during the observation period, according to a study published August 2009 in CHEST.

What’s a department to do?

Zhang refers to a culture of infection control awareness. This collaborative, enterprise-wide program extends beyond radiology. “Everyone—housekeeping staff, nurse, technologists—has to be on board. The infectious disease department should actively collaborate with departments at high risk for spreading infection and lend expertise regarding transmission.”

There is near-universal agreement regarding the top prevention strategy.  

“Hand hygiene is No. 1 on the list,” says Stephanie Ellingson, MS, RT, education program director at University of Iowa Hospitals and Clinics in Iowa City.

When the infectious disease director at Centra Health in Lynchburg, Va., launched an enterprise-wide hand hygiene campaign and appointed a champion in each department, radiology seized the opportunity and boosted its hand hygiene compliance from a low of 85 percent in June 2010 to 99 percent in March 2011.

“We kept it fun,” says Melissa Massie,  RT, an x-ray technologist at Centra. The team kicked off the project with a cookout, where Massie shared tips and pointers. She used a potion that illuminates bacteria under UV light to show how artificial nails trap infection and also surveyed staff for compliance tips. “Their requests were simple, such as more and better placement of alcohol-based hand sanitizers and the use of different sanitizing products that are easier on the hands.”

The fun component is paired with a twice-monthly surveillance of hand-washing compliance. Staff members who comply are sent a congratulatory email, while those who do not receive a reminder about hand-washing techniques. This type of reward/sanction system might be an optimal method to ensure protocols are followed, says Zhang.

Beyond the basics

Although hand hygiene may be the staple of every infection prevention regimen, it is far from the only strategy. Portable x-ray systems are a primary mechanism for transporting bacteria, says Zhang, because they are ubiquitous throughout the hospital. The basics are simple: technologists should don gowns, gloves and masks prior to imaging any patient infected with MRSA or Clostridium-difficile (C-diff.). Any system parts that might contact the patient or patient bedding should be covered with a disposable plastic cover. Most hospital employees are cognizant of standard precautions and policies, but there may be varying levels of compliance. Precautions can be a convenience issue, and staff can slip.

Another challenge is to make sure that staff and equipment are thoroughly cleaned after exiting the room of an infected patient, says Darnell Ramiscal, RT, an x-ray technologist at Hines VA Hospital in Chicago.

A combination of staff training, monitoring and intelligent engineering can go a long way toward curbing the risk. Most hospitals cover infection prevention during annual in-services with some delivering additional online reminder courses every few months. Monitoring hand-washing and offering awards for individual or departmental compliance also are smart strategies that help build a culture of infection prevention. Finally, newer portable x-ray systems are designed with fewer nooks and crannies to streamline cleaning and feature holders for the containers of disposable wipes used to clean systems between patients.

Portable ultrasound is a bit more complex than portable x-ray. At the University of Iowa, sonographers carry a kit outfitted with packets of gel, T-spray to clean transducers and sanitizing wipes. In addition to standard precautions—hand hygiene, gloves, gowns, masks—Ellingson recommends extra precautions for some cases. “We might take two sonographers to perform a study on a patient with MRSA or C-diff. One can conduct the exam and the other can run the keyboard. That way, the machine is not contaminated to the same degree that it would be with a single sonographer completing the exam.” In both models, the system and transducer are thoroughly cleaned before the team travels to the next patient.

The decision to double sonographers is based on a patient’s isolation status. “It’s a way of expediting infection prevention measures and maintaining workflow,” says Ellingson.

Other patients also require additional precautions. When sonographers image infants in the neonatal intensive care unit (NICU) or patients in isolation, they use individual packets of transducer gel rather than a bottle of gel, to eliminate the risk of using a bottle that might be contaminated.

At the University of Iowa, sonographers also cover the transducer with a sterile drape and use individually packaged gel when imaging a patient with an open wound. In a few cases, improperly trained staff have attempted to bypass the sterile drape and opted to sterilize the transducer with betadine and alcohol, says Ellingson. There are two problems with the approach: it may not effectively sterilize the transducer and it may invalidate the warranty, as it ignores manufacturer’s guidelines.

Many infection prevention practices are standard and easily recognizable. The correlation between other factors and infection prevention may be less visible. “Our retention rates in the imaging department are phenomenal. We have less than 1 percent staff turnover. Our technologists have been trained properly and continue applying the same practices,” says Carol Pugh, RN, infection control nurse at Windber Medical Center in Windber, Pa. The center’s HAI rate was a very modest 0.39 percent for the first 10 months of 2011.

At Hines VA Hospital, Ramiscal notes that patients are aware of infection prevention, with many observing staff to make sure they wash their hands before and after procedures.

Standard infection prevention precautions are well-publicized and relatively easy to implement. Creating a culture of awareness and prevention is a fairly straightforward enterprise project. Portable imaging has a key role to play.