Excreta Management

1. Clinical   
2. Good practices   
3. Material choice

Excreta Management - CLINICAL

 

Enterococcus

Clostridium

Incidence of ESBL
in E. coli, pneumoniae, E. cloacae

Excreta

 

- Vomit, Urine, Feces

 

- A reservoir of microorganisms that can cause infections with very high dissemination potential:

  • Excretion of 107 to 109 bacteria/g of feces

  • Excretion in urine of 108 to 109 ESBL-producing E. coli / day in urinary infections

  • Excretion of 107 norovirus per 20-30 ml of vomit (gastroenteritis)1

Feces-associated bacterial risk

 

The digestive tract is a reservoir of many
bacterial families such as:

  • Escherichia coli,

  • Klebsiella pneumoniae,

  • glycopeptide-resistant enterococci,

  • Clostridium difficile, etc.

Enterobacteria

- Responsible for 38% to 50% of Healthcare
Associated Infections (HAI) and Nosocomial
Infections (NI)
- Antibiotic-resistant
- Emergence of “Highly Resistant Bacteria” (HRB)

and “Super Bacteria”
- Stable in the environment for up to

Enterococcus faecalis: 5 days,
Rotavirus: 10 days,
Norovirus: 1 week,
Escherichia coli: 1 week,
Spores of Clostridium difficile, VRE, MRSA,
Acinetobacter: 4 to 5 months
1

D.Trystram - V.jarlier - 18 septembre 2012 - BMR-AP-HP Collégiale de BVH

Resistant E. Coli around the world

Extent of Nosocomial Infections2

 

- In developed countries, 5% to 10% of patients
(up to 30% / intensive care unit)


- In developing countries, 2 to 3-fold greater
prevalence


- 7th highest cause of death in the world:
2 million deaths per year


Examples (No. of NI, No. of deaths / year)
- USA: 2 million NI; 80,000 deaths
- France: 750,000 NI; 4,200 to 9,000 deaths
- Mexico: 450,000 NI; 41,000 deaths

Clostridium difficile in USA

Dependent patients hygiene
and excreta management

 

Apply best practice rules
and choose the right equipment to:


- Prevent risk of infection: Cross-transmission
(interhuman, equipment, patient environment)


- Improve working conditions and the safety
of health workers and caregivers

 

- Promote patient mobility (prevent de novo
incontinence), modesty and dignity

 

- Reduce direct costs (equipment, disposables,
work time) and indirect costs (consequence of NI)

Collection equipment

(bedpans, commodes, urinals):
the weak links in excreta management

Continent dependent patients

High-risk movements, poor hygiene

Bedpans, commodes, urinals, etc. are reservoirs
of pathogenic microorganisms.
Their handling exposes the caregiver, patient
and environment to microbial contamination.

Traditional hygiene methods:

- Manual cleaning, a thankless, tedious task,
the most expensive and risky method: to be banned.
- Bedpan washer or macerator: heavy, expensive
equipment, with frequent malfunctions
(2/3 of bedpan washers malfunction more than
once a year3), do not resolve the problem of
carrying full bedpans to the washing equipment
(risk of transmission throughout the facility).
Example: AP-HP hospital survey in 20123
High-risk handling of bedpans: 79% of departments.

Incontinent dependent patients

- Traditionnal bed bath4:

Potentially contaminating
Bedpan = reservoir of pathogens
Risk of being interrupted during the bath

Example of a “clean” bedpan put away
in a resuscitation room
3

Sources (extracts and adaptations):
1- The Role Played by Contaminated Surfaces in the Transmission of Nosocomial Pathogens • Author(s): Jonathan A. Otter, Saber Yezli, Gary L. French Source: Infection Control and Hospital Epidemiology, Vol. 32, No. 7 (July 2011), pp. 687-699 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America 2-WHO, Health care-associated infections FACT SHEET 3- Bulletin du CClin Paris-Nord n°41, décembre 2012, Enquête sur la gestion des excreta dans les hôpitaux de l’AP-HP, Margaux Lepainteur, Simone Nérome, Gisèle Bendjelloul, Brigitte Cottard-Boulle, Catherine Monteil, Michèle Huang, Vincent Jarlier, Sandra Fournier et le réseau des équipes d’hygiène de l’AP-HP 4-Photo toilette au lit 2010 Resclin-Champagne-Ardenne 5- Analyse comparative des équipements de traitement de Clostridium difficile s bassins Agence d’Evaluation des Technologies et des Modes d’Intervention en Santé (AETMIS 2009): Vol 5: N4

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Excreta Management - GOOD PRACTICES

In healthcare facilities: Recommended use

Used by thousands of hospitals worldwide
Recommended by hospital hygiene authorities

APIC

“If the CDI resident must use a
bedside commode, line the commode
with a plastic bag and absorbent
material to reduce healthcare worker
exposure to fecal material.
1

Average infection rate:
Proven decrease

AETMIS

“Hygienic bags would be a safer procedure
because the supplies do not leave the
isolation area. This alternative requires little
or no infrastructure… they save many nursing
care hours because the procedure is fast.
2

Caregiving:
Proven efficiency

CCLIN APHP

“Use disposable excreta
collection bags containing
absorbent materials for
all patients who use
bedpans.
3

Maitrise budgétaire :
Economies prouvées

Reduction in potential costs: The use of Personal Protection Equipment
(PPE) fell, leading to savings of $3.15 to $4.15 for each bedpan use.
4

For home health care: Recommended use

In home health care, as in nursing homes, the caregiver’s (CNA, home caregiver or family member)
mission is to care for the fundamental needs
6 of dependent patients.

Mobility is a fundamental need6. 

The partial or total loss of mobility poses significant problems at home - including
elimination complications - and can lead to risks related to decubitus.
7

De novo incontinence:
Mobility encouraged

Patient well-being:
Fundamental needs respected

Caregivers’ work:
Conditions optimized

Encouraging mobility is recommended
to prevent the causes of functional incontinence
due to restricted mobility:


Choose plastic collection devices (bedpan,
commode chair with pail, urinal) to delay
the use of diapers as long as possible.


This also helps to preserve the modesty and
dignity of the dependent person.
8

Sources (extracts and adaptations):
1- from APIC Implementation Guide. Guide to Preventing Clostridium Difficile infections. February 2013 2- Analyse comparative des équipements de traitement des bassines de lit (VOL. 5 : No 4) - 2009 Québec, Canada - AETMIS (Agence d’Evaluation des Technologies et des Modes d’Intervention en Santé) 3- Gestion des excrétas Recommandations officielles du 27/09/2012 France - CLIN Central de l’APHP (Assistance publique Hôpitaux de Paris) 4- Vitale, E. (2011, May). Safer Panhandling to Reduce the Rate of Vancomycin Resistant Enterococci - Giving staff the right tools to safely and efficiently do their job. Poster session presented at the CHICA-Canada National Education Conference, Toronto, ON 5- Outil est mis gracieusement à disposition des établissements de santé par l’ARLIN Haute Normandie. Les établissements sont tenus de valider et vérifier leurs données. Pour tout renseignements complémentaires contacter denis.thillard@chu-rouen.fr , date de réalisation 10/04/2014 6- Henderson, V., La nature des soins infirmiers (traduction de l’édition américaine The Principles and Practice of Nursing de 1994), Inter Editions, Paris, France, 1994 7- Syndrome d’immobilisation Corpus de Gériatrie - Janvier 2000 8- Prévenir la dépendance iatrogène liée à l’hospitalisation chez les personnes âgées - HAS : Haute Autorité de santé, France 2 CNPG : Collège national professionnel de gériatrie, France 9- Actualisation des précautions standard - Hygiènes - Volume XXV - n° hors série - juin 2017 10– Davanzo E, Frasson C, Morandin M, Trevisan A. Occupational blood and body fluid exposure of university health care  workers. Am J Infect Control 2008; 10: 753-756.
 

Due to consequences that are sometimes underestimated, excreta management
demands increased vigilance from health professionals.
9


A study has shown that 23% to 65% of health professionals have been exposed
to splashes.
10

 

Excreta Management - MATERIAL CHOICE

Selection criteria for super-absorbent hygienic bags

“General features of the ideal product for preventing and caring for Incontinence Associated Dermatitis (IAD): ... hypoallergenic.” 1


The patient is in prolonged contact with the bag (bedpan liner, toilet bowl or commode liners, male urinal).

The caregiver is in repeated contact. It is recommended that dermatologically tested, hypoallergenic bags and
pads be used
, to avoid problems of skin irritation and skin or respiratory allergy, in particular for frail patients or those with sensitive skin.2

Hypoallergenic

Regular absorbent pads:
unwrapped and allergenic

All absorbent pads on the market contain allergens: fragments of absorbent cellulose (fluff) and Super-Absorbent Polymers (acrylates).

To prevent these allergens from being discharged under dry conditions and dispersed in the hygienic bag, or on the patient’s skin or in their surroundings, it is recommended that absorbent pads be used, wrapped in an envelope permeable to body fluids.

“Acrylates have been used in super-absorbent polymers (e.g. in diapers). Acrylate contact allergy is frequently observed in the occupational as well as the non-occupational setting.
Skin allergies to acrylates are confirmed by patch testing
2 (dermatological tests).”


“Skin problems due to the use of absorbent hygiene products... Improved product design features are believed to explain the decline in observed diaper dermatitis among infants. With regard to skin problems linked to incontinence in adults and the use of absorbent hygiene products…
individuals with frail, sensitive skin or with skin diseases should preferably use high-quality products that feature superabsorbent polymers and water vapor–permeable wrapping, to minimize the risk of skin complications.
3

Wrapped pads

- The maximum normal physiological capacity of the adult bladder is 300 to 600 ml. Any amount above that is pathological and the bladder may become spherical, hence the term “vesical globe” (the bladder can hold up to a liter of urine before rupturing).4


- Intestinal infections, secretory or ulcerative colitis: volume of liquid stool > 500 ml/day.5


- A study has shown that in a 3-month period, 37% of nurses reported exposure to splashes.6


- Recommended technique: Wait for the liquid to gel.7

Absorption of 600 ml of body fluids is recommended to handle most situations and minimize the risks of soiling, splashes or high-risk manipulations.

Absorption 600ml

Bladder: 300 to 600 ml

Sources (extracts and adaptations):  
1- Beeckman D et al. Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds International 2015. 2- Contact Allergy to Acrylates, Anthony Goon National Skin Centre, Singapore. Forum for Nord Derm Ven 2011, Vol. 16, No. 126 3- Clinics in Dermatology, Volume 26, Issue 1, January–February 2008, Pages 45-51 , Skin interaction with absorbent hygiene products ,Author links open overlay panel BoRunemanPhD -4 Wikipedia - Vessie – Bladder 5- LES FONDAMENTAUX DE LA PATHOLOGIE DIGESTIVE © CDU-HGE/Editions Elesevier-Masson - Octobre 2014 6- Doebbeling B, Vaughn TE, Mccoy KD, Beekmann SE, Woolson RF, Ferguson KJ. Percutaneous injury, blood exposure, and adherence to standard precautions: Are hospital-based health care providers still at risk? Clin Infect Dis 2003; 8: 1006-1013. 7- La gestion des excreta au quotidien, 14ème journée du Réseau Régional d’Hygiène - ARLIN de Basse-Normandie 25/09/2014 Francine Delaisements – Murielle Siharath CH L’Aigle CH Flers.

The new super-absorbent hygienic bags

protection through containment

Bedpan liner - Commode liner - Toilet bowl liner - Male urinal - Vomit bag

5 models to optimize excreta management

- The bag contains the hermetically sealed excreta, the pad gels the excreta for greater safety
- Dual action containment of odors: mechanically (closing the bag) and chemically (the pad’s polymers reduce the transformation of urea into ammonia).
- Better hygiene, a single-use product, time saved and simple, risk-free elimination.

Super-absorbent hygienic bags
100% effective, simple to use, cost-effective

- No more splashes, thankless tasks or persistent odors
- Controlling the risk of infection, combating nosocomial infections
- More comfortable working conditions and safety for health workers and caregivers
- Patient environment, modesty, dignity and comfort preserved.

2 options for more efficient super-absorbent hygienic bags

AM51

• Effective antibacterial and antifungal action
Active against 50 strains and spores of Clostridium difficile

• Long shelf life: 5 years before use

  Rapid degradation after use and elimination

OB+

• Excreta management
> Risk of contamination:
- Contamination of patient environment
- Interruption of the task (bag not immediately thrown out)

AM51

• AM51 Antimicrobial Bags
> Additive incorporated in the bag’s material:
- Effective against bacteria, fungi and spores
- Active against 50 strains and spores of Clostridium difficile

• A protective antimicrobial barrier >  Tests conducted by independent laboratories

Test performed according to standard JIS Z 2801:2010

Test performed according to a method adapted from ISO 22196:2011

A test on Escherichia coli and Staphylococcus aureus
significantly reduced (≈ 4 Log) the number of bacteria.

A test on Clostridium difficile spores
significantly reduced their number by more than 5 Log (99.999%).

1 month

Aerobic degradation

Reduce the environmental impact of waste generated

• AM51 Antimicrobial Bags
> Additive incorporated in the bag’s material
- Long shelf life (5 years)
- Quick degradation following elimination under aerobic conditions

OB+

• Waste management
> Under aerobic conditions
- Standard degradation of polyethylen: > 50 years
- Degradation of OB+ polyethylen: rapid

18 month

24 month

Bioassimilation

Additive AM51 :
• Registered with the European Union BPR, US-EPA • Compliant with 94/62/EC Directive on packaging and waste (no heavy metals) • Non-toxic, FDA and EPA approved.
• Tested on spores of Clostridium difficile (according to ISO 22196 : 2011 standard), and 50 strains especially: Aspergillus amstelodami, Aspergillus nidulans, Aspergillus niger, Candida albicans, Corynebacterium minutissimum, Corynebacterium spp, Enterobacter gergoviae, Escherichia coli , Escherichia coli 0157 H7, Klebsiella pneumoniae, Listeria monocytogenes Mesophilic aerobes, Mucor racemosus, Myceliophthora thermophila, Penicillium chrysogenum, Proteus mirabilis, Proteus vulgaris, Pseudomonas aeruginosa, Pseudomonas cepacia, Pseudomonas putida, Saccharomyces cerevisiae, Salmonella enteritidis, Staphylococcus aureus, Methicillin Resistant Staphylococcus aureus (MRSA), Trichophyton mentagrophytes).
* Additive OB+ :
OB+ long-term storage liners (with a use-by date of 5 years) are biodegradable under aerobic conditions, heat, and/or sunlight The exact rate and extent of that degradation is unpredictable and depends on the amount of light and heat the product receives. OB5 plastic will not degrade and will not emit greenhouse gases under anaerobic conditions in landfills.

Warning: users are required to check if OB + is allowed in their country.