Evidence matters

The latest potential safeguard to prevent the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, can be found in almost every kitchen pantry – salt! Canadian and international researchers are examining whether coating masks, air filters, and high-touch surfaces with sodium chloride (salt) might help prevent the spread of SARSCoV-2 and other viruses and bacteria.

In a recent issue of Health Technology Update, CADTH looked at the latest research on compressed salt surfaces for reducing the transmission of viruses and bacteria. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures. The CADTH Health Technology Update newsletter describes new and emerging health technologies that are By Martin Qiu A s the Canadian healthcare system prepares for a potential second wave of COVID-19, there are lessons to be learned from a recent study published in the Journal of Medical Internet Research about a telemedicine practice in Wuhan, China that employed a social media app to monitor patients in the early days of the pandemic.

In January 2020, Wuhan’s local medical capacity was quickly overwhelmed by the large number of

likely to have a significant impact on health care in Canada.

Salt is a natural substance that inhibits the growth of bacteria and has long been used in food preservation, flavouring, pharmaceuticals, agriculture, and at-home remedies. The theory behind salt’s potential ability to inhibit SARSCoV-2 is that when droplets containing virus particles encounter a salt-coated surface, the water in the droplets dissolves some of the salt. When the water evaporates, the salt recrystallizes and the jagged salt crystals pierce the virus membrane, ultimately killing it. This method has been tested against influenza viruses and bacteria and has been proven to be effective. Compressed salt is therefore being investigated as an antimicrobial for use on high-touch surfaces – such as door push plates, bed rails, and taps – by an Alberta company, Outbreaker Solutions Technolo

gies. Pilot evaluations of Outbreaker patients who swarmed to hospitals for help. Many health-care workers were infected with COVID-19 and medical care supplies were depleted. To prevent the health-care system from collapse, China advocated for infected patients with mild symptoms to stay home and self-quarantine. A small percentage of home-quarantined patients – approximately one to four per cent – eventually developed severe or critical conditions, yet those patients did not exhibit different onset symptoms. products (compressed salt-coated surfaces) have been carried out at several Alberta facilities. A 2016 pilot study found that a compressed sodium chloride surface reduced contamination with the methicillin-resistant Staphylococcus aureus (MRSA) bacteria by 94 per cent within the first 60 seconds compared with 71 per cent to 73 per cent for copper surfaces. Outbreaker is currently investigating whether these salt-coated surfaces will have a similar impact against SARS-CoV-2.

Other salt-related developments are also underway, including salt-coated facial masks and air filter materials, as well as a saltwater soaking solution for household materials and cloth masks. A team from the University of Alberta found that salt-coated facial masks effectively deactivated influenza virus aerosols and bacteria bio-aerosols and is currently investigating whether it will also protect against SARS-CoV-2, which has a similar morphology to other tested viruses. Elsewhere, a research team in Boston investigated whether saltwater-soaked materials – such as paper towels and surgical masks – were able to filter out particles the size of viruses in droplet testing. The investigators found that there was a decrease in bacterial growth on masks they had contaminated with E. coli, especially in portions with higher salt saturation. These findings suggest that salt-water treated kitchen paper towels could be an inexpensive and accessible way to add an additional layer of protection for people wearing homemade cloth masks or for health care workers who need to extend the life of their personal protective equipment, or PPE.

While these technologies show promise, they have not been tested

against SARS-CoV-2 nor have they been vetted or recommended by any federal or public health authorities for use on surfaces or facial masks.

While salt may have antimicrobial properties when applied to surfaces and materials, this doesn’t mean that injecting it or spraying it up the nose can prevent or cure COVID-19. Much like bleach, which has antimicrobial properties and is used on everyday surfaces in your home, it does not mean it will have the same effect in the body; in fact, ingesting bleach can be harmful! Salt, on the other hand, is generally safe for consumption and is often found in your favourite dishes, however, at high temperatures it can produce a vapor that is an eye irritant, and ingesting high doses can be toxic to humans and animals.

While there is currently no evidence that certain surfaces or surface coatings can halt or inhibit the growth of SARSCoV-2, Health Canada has compiled a list of hard-surface disinfectants with evidence against the virus. Investigation of new technologies continues as we learn more about the virus. As schools and public spaces re-open, increasing the effectiveness of masks and antimicrobial surfaces could be a positive preventive public health intervention.

For more information, read the Health Technology Update newsletter at cadth.ca/health-technology-update-issue-27-0. If you’d like to learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region: cadth.ca/Liaison-Officers. To suggest a new or emerging health technology for CADTH to review, email us at HorizonScanning@cadth.ca. ■ H

Hospital-acquired infections, sometimes referred to as healthcare-associated infections (in both cases, HAIs) are the most frequent adverse events affecting patients in hospitals around the world. 1 In Canada, more than 200,000 patients contract HAIs per year. 2 Common types of HAIs can include urinary tract infections (UTI), blood stream infections (BSI) including central line-associated bloodstream infections (CLABSI), and can be caused by organisms such as Clostridioides difficile (C. diff) and methicillin-resistant Staphylococcus aureus (MRSA). 2 In a time when our hospitals are already battling the COVID-19 pandemic, measures to limit the risk of these infections, along with preserving the associated resources to manage them, is especially vital.

While any HAI may be detrimental for a patient, infections by antimicrobial-resistant organisms, like MRSA, can be particularly concerning, especially as patients face existing infections, injuries or chronic conditions. 3 While the rate of HAIs in Canadian hospitals is fortunately declining, the number of infections caused by organisms with antimicrobial resistance (AMR) is increasing and over 50 per cent of HAIs are resistant to at least one antibiotic. 4,3

In the most dire cases, HAIs can be fatal. 3 In other cases, they can result in prolonged hospital stays, long-term disability and additional costs for families and patients. 1 Healthcare workers are also impacted by HAIs, as special WHILE THE RATE OF HAIS IN CANADIAN HOSPITALS IS FORTUNATELY DECLINING, THE NUMBER OF INFECTIONS CAUSED BY ORGANISMS WITH ANTIMICROBIAL RESISTANCE (AMR) IS INCREASING

control measures must be taken when treating an individual with a resistant infection, requiring time and resources. On a broader scale, HAIs also take a financial toll on our public health system: in 2012, costs to manage the estimated 37,900 C. diff episodes in Canada amounted to approximately $281 million. 2

With the use of sophisticated surveillance tools, hospital teams can identify, track and report resistant infections when and where they occur. Policies such as mandatory reporting can support more frequent data collection and insight generation. Consistent and comprehensive reporting through normalization of data can also support extensive benchmarking, allowing hospital administrators and governments to observe the impacts of strategies to combat HAIs.

Canadian institutions may also find they spend considerable time manually engaging in these requisite reporting obligations. Adoption of automated surveillance tools has been helpful across numerous health systems, including Hackensack Meridian Health–JFK Medical Center, an example of a hospital that has seen great success in their efforts to combat HAIs. After identifying an increase in the number of C. diff infections in December 2016, a steering committee of key stakeholders was tasked with developing a strategy to reduce the rates of this resistant infection. Their plan involved utilizing the BD HealthSight™ Clinical Advisor and Infection Advisor with MedMined™ Insights (formerly MedMined™ Surveillance Advisor) technology, as well as a review of current protocols and practices for infection prevention. The BD software aggregates and standardizes patient data to empower clinicians to intervene with at-risk patients, determine trends on infection types and facilitates benchmarking within a hospital or region. With use of the surveillance tool and guidance from the BD team, Hackensack Meridian Health–JFK Medical Center implemented daily huddles using mobile tablets to increase collaboration and information sharing, trained all front-line staff on new infection-prevention protocols and ensured appropriate testing allocation based on where symptoms suggested such tests were most needed. Within a year, Hackensack Meridian Health–JFK Medical Center saw a reduction of C. diff cases by 48%. 5

By re-evaluating current practices and finding opportunities to improve current protocols, hospital teams can drastically reduce the rate of HAIs, benefitting patients, healthcare workers and entire hospital systems. With adequate infection prevention and control programs and strategies, hospital teams can better protect patients by reducing infections and supporting better outcomes.

To collaborate with us and learn more about AMR, visit: go.bd.com/ learnmoreAMR Q H

1. World Health Organization. “The burden of health care-associated infection worldwide.” 2020. https://www.who.int/infection-prevention/publications/burden_hcai/en/. Accessed July 2020. 2. Government of Canada. “Evaluation of Healthcare-Associated Infection Activities at the Public Health Agency of Canada 2012-13 to 2016-17.” 2018. https://www.canada.ca/en/public-health/ corporate/transparency/corporate-management-reporting/evaluation/healthcare-associated-infection-activities-2012-2017.html#es. Accessed July 2020. *RYHUQPHQWRI&DQDGD´7KH&KLHI3XEOLF+HDOWK2IÀFHU·V5HSRUWRQWKH6WDWHRI3XEOLF+HDOWKLQ&DQDGD²+HDOWKFDUHDVVRFLDWHGLQIHFWLRQV²'XHGLOLJHQFHµKWWSVZZZFDQDGD

FDHQSXEOLFKHDOWKFRUSRUDWHSXEOLFDWLRQVFKLHISXEOLFKHDOWKRIÀFHUUHSRUWVVWDWHSXEOLFKHDOWKFDQDGDFKLHISXEOLFKHDOWKRIÀFHUUHSRUWRQVWDWHSXEOLFKHDOWKFDQDGDLQIHFWLRXVGLVHDVH never-ending-threat/healthcare-associated-infections-due-diligence.html. Accessed July 2020. 4. Jennie Johnstone, Gary Garber and Matthew Muller. “Health care-associated infections in Canadian hospitals: still a major problem.” 2019. https://www.cmaj.ca/content/191/36/E977. Accessed

July 2020. %'´%'0HG0LQHGŒ6XUYHLOODQFH$GYLVRUFDVHVWXG\µ

To address this dilemma, seven medical workers at Tongji Medical School Hospital, including two doctors and three nurses, set up a group chat on WeChat, a popular social media app in China. They invited patients at their clinic who were experiencing mild symptoms of COVID-19 but could not be diagnosed or treated to join the group.

Upon sign-up, individuals were required to fill in a quarantine assessment questionnaire, and then to fill in a monitoring form on WeChat every day to self-assess their conditions. The form updated the medical team on a number of symptoms including fever, dyspnea, lack of strength and muscle soreness. Based on the update, the medical workers analyzed the symptom changes and used the individual chat function to provide instructions and suggestions to patients. A telemedicine system was thus established.

In total, 188 home-quarantined individuals joined the telemedicine system, including 74 patients who were eventually diagnosed with COVID-19. For the 114 individuals who may have just been experiencing cold or flu symptoms, the telemedicine system prevented possible cross-infection by reducing their unnecessary clinic visits.

Out of the 74 positive COVID-19 patients, six progressed to severe or critical conditions during home quarantine. Thanks to the telemedicine system, which enabled the medical team to take note of their deteriorating conditions, all six patients were admitted to the hospital in a timely fashion. One patient was on ECMO support for 17 days, but all 74 patients eventually recovered.

The telemedicine system has done much more than save six patients’ lives or prevent 114 people from infection. According to the study, several patterns of symptom changes were identified through vigorous statistical analysis as predictors for disease progression, which shed light on further understanding of the virus.

In addition, the WeChat group worked as a support group that facilitated social interactions among those isolated and infected individuals. Patients shared songs, photos and recovery news to cheer each other on, largely alleviating their psychological stress. The medical team included a rehabilitation physician and a psychologist who provided formal consultation on recovery exercises and mental health issues.

The telemedicine system also benefited the Chinese health-care system at large, as this model can enlist the help of infected but recovered medical staff who are self-quarantining at home. Indeed, one nurse on the original medical team in the study was infected with COVID-19, and she worked from home to support the telemedicine system. Thus, in the case that COVID-19 surges again in Canada, this model could be used to ease shortages in the medical workforce and free up workers to fight on the frontline.

With the wide availability of social media apps, this model can be easily adopted around the world. It does not matter which app is used. As long as home-quarantined patients can use the same platform to form a virtual support group and have timely access to medical professionals, the detrimental impacts of COVID-19 on physical and mental health can be greatly contained. ■ H

Martin Qiu, associate professor of Business at Wilfrid Laurier University’s Lazaridis School of Business and Economics, helped develop the telemedicine system and analyze the data.

In today’s hospital environment, the patient experience, their health outcomes and the support of their professional care-givers has never been more important. One of the key areas within the hospital and health care setting that has, and remains a challenge, is the safe and efficient method of dealing with human waste. With mounting pressure on cost reduction, demands for increased efficiency and the need for improved infection control, the process of effectively dealing with human waste can put additional stress on nursing and care staff.

Within the last century, a simple, yet effective way to combat these pressures, while delivering optimum care results has been achieved through the development of environmentally friendly, moulded pulp products and maceration disposal units. The pioneer and current leader in this field is Vernacare, who first introduced moulded pulp products and maceration units to the healthcare system.

Vernacare brought the new biodegradable pulp product line made from 100% recycled post-consumer newsprint to the market in 1959 to replace the traditional method of human waste disposal via plastic or metal reusable bedpans, urinals, bowls and basins.

This new product line revolutionized human waste methods by introducing single use, maceratable waste containers to the bedside.

Single use pulp products dramatically reduce the spread of infection and save precious nursing time previously spent on unproductive and often unsafe manual washing and disinfecting of reusable bedpans, urinals and basins.

To complement the advent of moulded pulp products and further enhance the human waste disposal system, environmentally friendly, compact and hands-free maceration units were added to complete the system. The maceration unit allows for the ultra-hygienic and efficient disposal of single use pulp products through the existing sewer system with minimal and in some cases no disruption to the existing plumbing configuration within the health care facility or hospital. Not all maceration units can provide the assurance of minimization of particle size to ensure no dry or bulky material can pass into the pipework and causing disruptive clogs. Only Vernacare’s SmartFlow Technology can deliver this type of efficiency. Single-use containers and maceration units are now common place in hospitals around the world, thanks to the dedicated product development innovation focus of Vernacare.

Other critical factors to consider and ensure successful implementation of this type of human waste disposal system are the ongoing training, support and supply chain effectiveness of your supplier. Selecting a supplier who has singular control from product manufacturing through to distribution and servicing of the products and system ensures the highest quality and reliability of this critical function. Again, Vernacare has the only moulded pulp factory in the world that is exclusively dedicated to the manufacture of medical grade products and their comprehensive training and service support is unparalleled. Downtime in human waste management is simply unacceptable.

By working with the only end to end supplier in human waste systems, health care facilities can enjoy the benefits of improved infection control, assured excellence in material quality, better use of nursing resources, and improved efficiencies all resulting in enhanced patient experiences and cost control. The industry has been well served by Vernacare in their dedication to this vision, as the originator and leader in the field of human waste systems.

The healthcare and patient care sectors are experiencing rapid evolution and change. Vernacare is an organization that is a trust partner known for delivering uncompromised quality and service support. Excellence in patient outcomes and staff morale depend on the quality of care often contingent on products that facilitate wellbeing and positive, reliable results. This objective is well served and understood by Vernacare, the global leader and innovator in human waste management systems. Q H