APIC 2012 Onsite Program

Transcription

3 9 T H A N N UA L E D U C AT I O N A L C O N F E R E N C E & I N T E R N AT I O N A L M E E T I N G
INFECTION PREVENTION:
Improving Outcomes, Saving Lives
Onsite Program
and Abstracts Book
www.apic.org/ac2012
APIC gratefully acknowledges
the following companies for their generous support of the
Annual Conference.
Platinum Sponsors
Gold Sponsors
Silver Sponsors
Bronze Sponsors
Contributors
Best Practices Professionals, Inc.
Oxford Immunotec Inc.
Centurion Medical Products
Sanosil International
Diversey
The Society for Healthcare Epidemiology
Draeger
Smiths Medical
Jani-King International
Welcome from the Chair
If you are reading this letter then you are already a member of the
choir or the cheering squad. You traveled either near or far to come
to San Antonio to join your peers in what will be an interesting,
engaging, and highly motivating three days. You figured out a way
to convince your facility that they could live without you for three
days because when you return, you will bring numerous new ideas
for improvement that will result in the prevention of infections and
many, many lives saved.
I had the honor of chairing this year’s APIC Annual Conference. I would like to salute my
co-chair, Karen Hoffmann, and the rest of the committee who have worked tirelessly and
endlessly over the past year to bring you a meaningful, practical, and memorable conference.
The theme of this year’s conference is “Infection Prevention: Improving Outcomes,
Saving Lives.” Have you ever paused to think about how many people are walking around
this earth, celebrating birthdays, attending graduations, and embracing life because of
what YOU do?
We often speak about the power of peer-to-peer learning and why it is the in-person
connection that energizes us and gives us the tools to try something new and implement
creative and innovative changes. We all know that while change does not necessarily
result in improvement, improvement can’t happen unless we change. We have science
that drives our practice but the key to success is understanding how to apply the science.
It is the “How-to’s” that we come to conference to learn. I guarantee that each of you will
leave APIC 2012 with multiple examples of how to apply the science that will impact the
patients you serve. Infection Prevention is all about Improving Outcomes and Saving
Lives. Sure feels good, doesn’t it?
Have a great conference, enjoy the beautiful city of San Antonio and all it has to offer,
and if you see me in the hallways, please stop and say hello.
Best regards,
Barb DeBaun, RN, MSN, CIC
Chair, 2012 Annual Conference Committee
2012 ANNUAL CONFERENCE COMMITTEE
Chair
Barb DeBaun, RN, MSN, CIC
Vice-Chair
Karen Hoffmann, RN, MS, CIC,
Members
Judie Bringhurst, RN, MSN, CIC
Vickie Brown, RN, MPH, CIC
Titus Daniels, MD, MPH
Kate Ellingson, PhD
Michelle Farber, RN, CIC
Sally Hess, MPH, CIC
Debra Johnson, BSN, RN, CIC
Lela Luper, RN, BS, CIC
Amy Richmond, RN, BSN, MHS, CIC
Diane Surdi, RN, BSN
Nancy Zanotti, RN, BSN, MPH, CIC
Mary Post, RN, MS, CNS, CIC
Table of Contents
What’s New ............................................5
Meetings-at-a-Glance ..............................7
Schedule-at-a-Glance ..............................9
2012 APIC Awards ................................13
General Conference Information..............14
Education Program Information ..............17
Exhibitor-Sponsored Symposia/Events ....53
Speaker Disclosures ..............................57
Acknowledgments..................................59
Session Tracking Form ..........................60
Continuing Education Credit
The Association for Professionals in Infection Control
and Epidemiology, Inc. (APIC) is accredited as a
provider of continuing nursing education by
the American Nurses Credentialing Center’s
Commission on Accreditation (ANCC).
Contact Hours
One contact hour = 60 minutes.
APIC is approved for providing continuing nursing
education by the California Board of Nursing, provider
number CEP 7146.
Continuing Medical Laboratory Education (CMLE)
This educational activity is recognized by the American
Society for Clinical Pathology as meeting the criteria for
CMLE credit. ASCP CMLE credit hours are acceptable
to meet the continuing education requirement for the
ASCP Board of Registry Certification Maintenance
Program.
ACCENT® Continuing Education Credit
The American Association for Clinical Chemistry, Inc.
(AACC) designates this activity for ACCENT® credit
hours. AACC is an approved provider of continuing
education for clinical laboratory scientists licensed in,
but not limited to, the states of California, Florida,
Louisiana, Montana, Nevada, Noth Dakota, Rhode
Island, and West Virginia.
ACCENT® Activity No. will be provided; ACCENT®
Activity California No. will be provided and Florida
category ACCENT® Continuing Education Credit in
Clinical Chemistry/Toxicology; Supervisory/
QA/Administration/ QA/QC/Safety; Medical Errors;
Microbiology/Mycology/ Parasitology;
Serology/Immunology.
Requirements to Receive CE Contact Hours:
1. Go to www.apic.org/ac2012 to log in.
2. Complete the Overall Conference Evaluation and
individual Session Evaluations for each of the
sessions that you attended.
3. Download your certificate and VOA transcript
once complete.
3
W H AT ’ S N E W
Science to Practice
Reception and Awards
Ceremony
Please join us Tuesday, June 5 from 6:30-8:30
p.m. in Salons H-L of the Grand Ballroom at the
Marriott Rivercenter Hotel to celebrate our
research program and honor our 2012 scientific
award winners. Space is limited so arrive early.
More Science
New this year—One full hour on Monday, June 4
dedicated to oral abstract presentations. Engage
in sharing the latest strategies for managing the
various issues faced by infection preventionists
and epidemiologists.
Education to Go
All conference attendees receive a
complimentary copy of the standard conference
proceedings which includes all applicable
educational sessions in webinar format. Share
this information with your co-workers so that they
too can benefit from the education at APIC
2012. This is made possible thanks to an
educational grant from Covidien. Be sure to stop
by the Covidien booth #703 in the Exhibit Hall
to pick up your copy. Sponsored by
Certification Matters
Every Day
APIC is launching its new campaign “Certification
Matters Every Day” to celebrate all those who have
achieved or are seeking their CIC certification.
Look for daily events including a special CIC
Lounge at the Welcome Reception Sunday evening
featuring decadent desserts; on Wednesday
during exhibit hall hours there will be moderated
round table discussions about certification.
Sponsored by
APIC Village
An exciting area of the exhibit hall devoted
exclusively to APIC-related activities. Browse new
APIC resources, view Film Festival entries, and
try a hands-on demo of the APIC ANYWHERE®
Online Education Center. Other great
opportunities include:
䡲 Knowledge Bar – Have burning questions that
need real answers? Use the Knowledge Bar to
meet one-on-one with clinical experts and get
those answers you’ve been waiting for.
䡲 Technology Lounge – Visit this area to find a
willing and experience infection preventionist
to serve as your mentor. You will also have the
chance to find out more about everything that
MyAPIC has to offer, as well as any new
technology-related initiatives.
䡲 Building Bridges Projects – Gain information
about the free tools and resources launching
as part of the IP Col-lab-oration Project and
the Clean Spaces, Healthy Patients projects.
䡲 Photo Booth – “Ham it up” for the camera and
take home your conference souvenir photo.
Sponsored by
Exhibit Hall Raffle
Stations
Win prizes just by scanning your badge at the
official APIC 2012 Exhibit Hall raffle stations.
APIC has placed two raffle stations at different
locations within the exhibit hall. Find them, scan
your badge, and you could win educational
publications and fun prizes! Sponsored by
Charging Station
Need to charge your phone, ipad, tablet or other
mobile devices while onsite at the convention
center? Don’t go back to your hotel room, just
stop by the APIC 2012 Charging Station. You can
rest a few minutes while your device is charged.
Sponsored by
5
*As of 5/5/12 subject to change
M E E T I N G S - AT- A - G L A N C E
MEETING
Sunday, June 3
APIC Research Council
Nominating & Awards Committee
Emergency Preparedness Committee
Section Meeting - Ambulatory Care
AJIC Editorial Meetings
Public Policy Committee
Practice Guidelines Committee
Communications Committee
Chapter Treasurers
Professional Development Council
Conference Orientation Session
Monitor Training
New Member Reception
International Attendees’ Reception
NHSN Hospital System
Welcome Reception
Carole DeMille Award Winner Reception (invitation only)
TIME
LOCATION
ROOM (TENTATIVE)*
9 a.m.-12 p.m.
10 a.m.-3 p.m.
11 a.m.-1 p.m.
1-3 p.m.
1-5 p.m.
1-5 p.m.
2-4 p.m.
3-5 p.m.
3-4 p.m.
3-5 p.m.
3:30-4:30 p.m.
4-4:30 p.m.
4:30-5:30 p.m.
4:30-5:30 p.m.
4:40-5:30 p.m.
5:30-7 p.m.
8-9:30 p.m.
Marriott Rivercenter
Convention Center
Convention Center
Room 2
Room 6
Room 5
Grand Ballroom - Salon A
Room 13-14
Room 10
Room 5
Room 4
Room 16
Room 8
Room 214 AB
Room 6
Room 17-18
Room 1-2
Room 205
Grand Ballroom
Room 17-18
Monday, June 4
Partners in Leadership Reception (invitation only)
Section Meeting - Behavioral Health
Section Meeting - Pediatrics
Section Meeting - Long-Term Care
6-7 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
Room 1-2-3-4
Room 13-14
Grand Ballroom - Salon D
Salon AB
Tuesday, June 5
Exhibitor Meeting
Chapter Legislative Representatives
Past Presidents’ Luncheon (invitation only)
Member Services Committee
APIC Business Meeting
Focus Group - Consultants
Focus Group - Navy
Focus Group - State Health Departments
Focus Group - UHC Acute Care
Capella Healthcare Group
Section Meeting - Long-Term Acute Care
Section Meeting - Minority Health & Safety
Section Meeting - International
Section Meeting - EMS & Public Safety
Section Meeting - Home Care
Section Meeting - VA
Science to Practice - Reception & Awards Ceremony
9-10 a.m.
11 a.m.-1:15 p.m.
12-1:15 p.m.
1:45-3:15 p.m.
4:30-6 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6-7:30 p.m.
6:30-8:30 p.m.
Convention Center
Convention Center
Convention Center
Room 209
Room 1-2-3-4
Room 13-14
Room 209
Room 205
Room 3-4
Room 1
Room 5
Room 6
Room 15
Room 16
Room 17-18
Room 12
Room 9
Room 10
Grand Ballroom - Salon A-B
Grand Ballroom - Salon HIJKL
Wednesday, June 6
Heroes of Infection Prevention & VIP Breakfast (invitation only) 6:30-7:30 a.m.
Education Committee
11:45 a.m.-1:15 p.m. Marriott Rivercenter
Grand Ballroom - Salon I-J
Room 6
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2012AC_Onsite Pgm_BLK_PMS_PRESS_Layout 1 5/15/12 10:48 AM Page 9
S C H E D U L E - AT- A - G L A N C E
All events are located at the San Antonio Convention Center unless otherwise noted.
Sunday, June 3
3:30-4:30 p.m.
4:30-5:30 p.m.
4:30-5:30 p.m.
5:30-7 p.m.
Orientation Programs
International & New Attendees Orientation
New Member Reception
International Attendee Reception
Welcome Reception
Room 214
Marriott Rivercenter: Room 17-18
Marriott Rivercenter: Room 1-2
Marriott Rivercenter: Grand Ballroom
Monday, June 4
8 a.m.-5:30 p.m.
8-10:30 a.m.
Posters on Display
Hall D
Opening Plenary
Ballroom C
Opening Ceremony/President’s Address/Carole DeMille Award Presentation/Elaine Larson Lectureship
10:30 a.m.-1:30 p.m. Exhibit Hall Open (Coffee break 10:30 a.m.; Lunch served at 11:30 a.m.)
Halls C-D
12:30-1:30 p.m.
Poster Presentations
Halls C-D
1:30-2:30 p.m.
Oral Abstracts
Antimicrobial Resistance/Pathogens
Room 214 CD
Blood Stream
Room 217 A
Hand Hygiene
Room 217 B
Infection Prevention Program
Room 214 AB
Isolation & MDRO’s
Room 217 C
Public Reporting/Public Policy
Room 217 D
Special Populations
Room 210
Surgical Site Infection
Room 212
3-4 p.m.
Concurrent Sessions
Brick by Brick: Building Ontario’s First Regional Hospital Infection
Surveillance System: Technology Enhances Patient Safety
Room 214 CD
One Stick at a Time: A Toolkit for an Effective Healthcare Personnel
Immunization Program
Room 217 A
How Do We Find Them and How Do We Keep Them: Recruitment and
Training of The New Infection Preventionist
Room 217 B
CDC Outbreak Session 2012
Room 214 AB
Disinfection and Sterilization in Physician Practices and Specialty Clinics
Room 217 C
Really, Are You Serious?
Room 217 D
3-5:30 p.m.
Workshops
Home is Where the Germs Are: Infection Prevention Surveillance in Home Care
Room 008
Using the Joint Commission Infection Control Standards and NPSG 7 to Drive
Practice Change and Attain Adequate Resources: a Leadership Workshop
Room 007
How to Report and Apply the NHSN SSI Definitions
Ballroom C-3
Managing is More than Leading
Room 006 AB
Utility Systems and Infection Prevention Implications for the Environment of Care
Room 006 CD
4-4:30 p.m.
COFFEE BREAK
Tower View Lobby
4:30-5:30 p.m.
Concurrent Sessions
Mandatory Reporting Of Healthcare Personnel (HCP) Influenza Vaccination Using
the National Healthcare Safety Network (NHSN) System
Room 214 CD
The Infection Preventionist’s Role in Implementation Science: Examples From the Field Room 217 A
Elevating Your Teaching to a New Level: Becoming a Master Educator
Room 217 B
Updated SHEA Guidelines for HIV or Hepatitis B Infected Workers
Room 214 AB
The C-Suite Infection Preventionist Journey: Impacting Patient Safety, Community
Health, and Public Trust
Room 217 C
Infection Prevention Community Response - Germs on Coats, Privacy Curtains
Room 217 D
Tuesday, June 5
8-9 a.m.
Concurrent Sessions
A Bundle Approach to Prevent CAUTIs
It’s a Gas! Infection Prevention in Anesthesia
Peer Reviewed Publication: Why Not Me?
Talking to Patients: The Expanding Role of Infection Preventionists in Communicating
HAI Prevention
SSI Prevention in Ambulatory Surgery Centers - A Collaborative Project AORN/APIC
Room 214 CD
Room 217 A
Room 217 B
Room 214 AB
Room 217 C
9
S C H E D U L E - AT- A - G L A N C E
Tuesday, June 5 (continued)
8-9 a.m.
10
Concurrent Sessions (continued)
Infection Preventionists Leading Change: Effects of Healthcare Reform on
Infection Prevention
8-10:30 a.m.
Workshops
Infection Prevention Risk Assessment; the Starting Place for Your IP Program
NHSN - CAUTI Workshop: Preparing for CMS Reporting
Human Factors and Ergonomics in Infection Prevention
How to Develop an Infection Surveillance Program in Long-Term Care
9:30-10:30 a.m. Concurrent Sessions
Immediate Use Steam Sterilization: The New Frontier
A View Across The Pond: Europe’s Challenges and Successes in Addressing
Multi-Resistant Healthcare Infections
The Infection Prevention Liaison: Your Connection to Improve Infection
Prevention at the Bedside
Facility Guidelines Institute Construction Guidelines for ASHE
All in the Family: Partnering With Families to Improve Outcomes
Preventing CAUTI: Disrupting the Life Cycle of the Urinary Catheter
Heroes of Infection Prevention
9:30-10:30 a.m. Ask-the-Expert
T's: Talk With Titus, Tom, and Tracy
Occupational Health Issues That ‘Should’ Keep You Up at Night
Bugs Behind Bars: Infection Prevention and Control in Jails, Prisons, and
Mental Health Facilities
Ambulatory Care Challenges of the Now and the Future. Ask the Expert. Let’s Talk.
10 a.m.-5:30 p.m. Posters on Display
10:30 a.m.-1:30 p.m. Exhibit Hall Open (Coffee break 10:30 a.m.; Lunch served at 11:30 a.m.)
12:30-1:30 p.m. Poster Presentations
1:30-2:30 p.m.
Concurrent Sessions
MDR Gram-Negative Infections: Across the Continuum of Care
Infection Prevention Programs Measured Against Evidenced-Based Practice
Molecular Tools for Outbreak Investigations
Perspectives on Use of Standardized Infection Ratios (SIRs) for Assessing
Performance: A Surgeon and an Infection Preventionist
Living Longer But are They Better? Targeted Methods to Improve Outcomes in
Nursing Home Residents: Modifiable Risk Factors for Respiratory Infections
Making “Contagion” Contagious: Views from the Lab and the Set
1:30-4 p.m.
Workshops
How and Why to Write an Abstract
Clean Spaces, Healthy Patients
Gaining Analytic Insights from NHSN for Prevention: Focus on CLABSI and CAUTI
Bored to Death? How to Sustain Quality and Safety Improvements in the ICU
Beyond CMS: Assessing Your Ambulatory Facility
3-4 p.m.
Concurrent Sessions
The Emperor’s New Clothes - CLABSI Definition and Its Impact on You, the IP
Prolonged Use of Respiratory Protection: How Does it Affect the Healthcare Worker?
A Long and Winding Road: Meeting Current Challenges, Preparing for Future
Demands: APIC Introduces a Model of IP Competency
C.diff and LTC
Planning and Implementation of an Infection Prevention and Control Training Program
Healthcare Providers in Latin America
3-4 p.m.
Ask-the-Expert
Preventing CAUTI: Disrupting the Lifecycle of the Urinary Catheter
Bloodstream Infections
The Role of the Infection Preventionist in Clostridium difficile Infection Prevention
4-4:30 p.m.
COFFEE BREAK
4:30-6 p.m.
APIC Annual Business Meeting (Members Only)
Room 217 D
Room 007
Ballroom C-3
Room 006 CD
Room 008
Room 214 CD
Room 217 A
Room 217 B
Room 214 AB
Room 217 C
Room 217 D
Room 006 AB
Room 212 B
Room 212 A
Room 210 B
Room 210 A
Hall D
Halls C-D
Halls C-D
Room 214 CD
Room 217 A
Room 217 B
Room 214 AB
Room 217 C
Room 217 D
Room 006 AB
Room 007
Ballroom C-3
Room 006 CD
Room 008
Room 214 CD
Room 217 A
Room 214 AB
Room 217 C
for
Room 217 D
Room 212 B
Room 210 B
Room 210 A
Tower View Lobby
Room 205
Wednesday, June 6
7 a.m.-1 p.m.
8-9 a.m.
Posters on Display
Hall D
Concurrent Sessions
Hand Hygiene Update
Room 214 AB
Social Networks of Infection Preventionists to Share Knowledge
Room 217 A
Antimicrobial Stewardship: Optimizing Outcomes by Improving Antimicrobial
Prescribing Practices
Room 217 B
Working Overseas in Military Infection Control
Room 214 AB
A Collaborative Approach to Prevent CLABSI in Hemodialysis Patients
Room 217 C
Innovative Devices to Reduce CLABSI: Are We Adapting Technology Fast Enough?
Room 217 D
8-10:30 a.m.
Workshops
To Lead or to Follow: That is the Question
Room 006 AB
Using Performance Improvement Tools to Drive Infection Prevention
Room 007
Gaining Analytic Insights from NHSN for Prevention: Focus on Surgical Site Infection Ballroom C-3
Innovation at the Front Line
Room 006 CD
Challenges and Success in Caring For the Immunocompromised Patients in
Low Income Countries
Room 008
9:30-10:30 a.m. Concurrent Sessions
Vaccine Preventable MDROs and HAIs
Room 214 CD
Fecal Transplants
Room 217 A
Your Infection Prevention Program: How to Size it and How to Sell it
Room 217 B
Changing Approach to VAP Surveillance
Room 214 AB
Update on HAIs in LTC
Room 217 C
Hospital Disinfection and Disinfectant Resistance: What We Know, What We Don’t, and
What We Wish We Knew
Room 217 D
9:30-10:30 a.m. Ask-the-Expert
SCIP and Beyond
Room 212 B
State HAI Prevention Programs: Why LTC Should be Engaged
Room 212 A
New Initiatives to Reduce Healthcare-Associated Infections Among Hemodialysis Patients Room 210 B
How to Develop an Infection Surveillance Program in Long-Term Care
Immune Compromised Patients
Room 210 A
10:30 a.m.-1 p.m. Exhibit Hall Open (Coffee break 10:30 a.m.; Lunch served at 11:30 a.m.)
Halls C-D
1-2 p.m.
Concurrent Sessions
Innovations in HAI Data Validation
Room 214 CD
30/30 Sessions: Two great topics in one hour
Room 217 A
-Surviving an EF-5 Tornado-Infection Prevention (IP) Required
-So You Want to Volunteer? Preparing for a Volunteer Infection Prevention Medical Mission
The Ticket for Your Leadership Journey: APIC’s Credential of Competence
Room 217 B
To End or Not to End? When Should Contact Precautions be Discontinued? National Survey
of Infection Preventionists Related to Contact Precautions for MRSA and VRE
Room 214 AB
PICU Performance Improvement in Reducing Device Rates
Room 217 D
1-3:30 p.m.
Workshops
High-Level Disinfection, Sterilization and Antisepsis
Room 007
Fearless Facilitation: How to Get Everybody Talking
Room 006 AB
Is Your Dialysis Unit on Board? CDC's Dialysis Event Surveillance Workshop
Room 006 CD
How to Report and Apply the NHSN SSI Definitions (Repeat)
Ballroom C-3
Infection Prevention, Home Care and Health Care Reform
Room 008
2:30-3:30 p.m.
Concurrent Sessions
Evolution of Long-Term Care in the US: The Expanding Scope and Complexity of
Room 214 CD
30/30 Sessions: Two great topics in one hour
Room 217 A
-Nurses Driving IP Change in the NICU
-NICU Collaborative
State HAI Prevention
Room 214 AB
Infection Prevention in Ambulatory Oncology Treatment Centers
Room 217 C
Knocking at Your Door: New CMS Hospital Care Worksheet
Room 217 D
3:30-4 p.m.
COFFEE BREAK
Tower View Lobby
4-5:30 p.m.
Closing Plenary
Ballroom C
11
2012AC_Onsite Pgm_CMYK_PRESS_Layout 1 5/10/12 7:12 PM Page 12
C O N G R AT U L AT I O N S T O T H E
2012 A P I C AWA R D W I N N E R S !
Chapter Leadership Awards
Carole DeMille Achievement
Award
Ruth Carrico, PhD, RN, FSHEA, CIC
An infection preventionist
for 20 years, Dr. Carrico’s
prolific research has
influenced the practice of
infection prevention and
has focused on many areas
of public health including infectious diseases
transmission, emergency preparedness, and
immunization. Her book on the nation’s first
drive thru immunization program became
a guide for others as they investigated the
potential for mass immunizations in the
event of a bioterrorism attack or disease
outbreak within a community.
President’s Distinguished
Service Award, in honor
of Pat Lynch
Susan Dolan, RN, MS, CIC
Healthcare Administrator
Award
Anthony Chavis, MD
Chapter Excellence Awards
Member Support and Organizational
Excellence—APIC Chapter 111 Greater
Buffalo
Member Support and Organizational
Excellence—APIC Chapter 18 Minnesota
Education, Communication and Information
Resources—APIC Chapter 15 Delaware
Valley & Philadelphia
Strategic Alliances—APIC Chapter 89 Palmetto
Strategic Alliances—APIC Chapter 10 West
Virginia
Clinical and Professional Practice—APIC
Chapter 17 Northeast Ohio
Nancy Barrett, RN, BES, MS, CIC
Kathryn Beier, BSN, CPHQ
Mary Jo Bellush, MSN, CIC
LeAnn Ellingson, BSN, CIC
Diana Korpal, RN, CIC
Larry Krebsbach, CIC, REHS
Ed Meduna, RN, CIC
Gail Morchel, RN, BSN
Marianne Pavia, BS, MT (ASCP), CLS, CIC
Ossama Rasslan, MD, PhD
Lee Sholtz, RN, MSN, CIC
Mary Jo Stokes, RN, CIC
Nancy Szilagyi, LPN, CIC
2012 Heroes in Infection
Prevention Award
Patti Bull, MS, M(ASCP), CIC - Hendrick
Medical Center, Abilene, TX
Miguela Caniza, MD & Don Guimera, BSN,
RN, CIC - St. Jude Children’s Research
Hospital, Memphis, TN
Kim Delahanty, RN, BSN, PHN, MBA/HCM, CIC
- University of San Diego, San Diego, CA
Marlene Fishman Wolpert, MPH, CIC - St.
Josephs Health Services of Rhode Island,
Providence, R.I.
Elaine Flanagan, RN, BSN, MHA, CIC - Detroit
Medical Center, Detroit, MI
Catherine Grayson, RN, MSN, CIC - Medical
Center of McKinney, McKinney, TX
Namita Jaggi, MD - Artemis Hospital,
Gurgaon, India
Katherine Rhodes, RN, BSN, CIC, COHN-S Texas Health Southwest, Fort Worth, TX
Beth Ann Rhoton, RN, BSN, MS, CIC Medical University of South Carolina
Medical Center, Summerville, SC
DeAnn Richards, RN, CIC - Agrace Hospice
Care, Madison, WI
Wynn Roberts, RN, CIC - Randall Children’s
Hospital at Legacy Emanuel, Portland, OR
Judy Warren, RN, MS, CIC, CPHQ - Tawan
Hospital, Al Ain, United Arab Emirates
2012 Elaine Larson Lectureship
William Rutala, Ph.D, MS, MPH, CIC - UNC
Health Care and UNC School of Medicine
New Investigator Abstract
Award
Kathleen Gase, MPH, CIC - New York State
Department of Health
William A. Rutala
Research Award
Alexis Price, RN, BSN - Lee Memorial Hospital
Best International Abstract
Award
Alejandro Macias, MD - National Institute of
Medical Sciences and Nutrition
Blue Ribbon Abstract Awards
Audrey Adams, RN, MPH, CIC - Montefiore
Medical Center
Gregory Gagliano, BSN, RN, CIC - Cleveland
Clinic
Kathleen Gase, MPH, CIC - New York State
Department of Health
Grace Lee, MD, MPH - Harvard Medical School
and Harvard Pilgrim Health Care Institute
Keith Kaye, MD, MPH - Wayne State University
School of Medicine and Detroit Medical Center
Kathleen McMullen, MPH, CIC - BarnesJewish Hospital
Karen Rich, RN ,BSN, MEd, CIC - Colorado Department of Public Health and Environment
Lee Reed, RN, BA, MSPH, CIC - Novant
Health, Presbyterian Hospital
Mary Cole, BSN, CIC - Grady Health System
Marc-Oliver Wright, MT(ASCP), MS, CIC North Shore University Health System
APIC/AJIC Award for
Excellence in Scientific
Research Publication
“Role of hospital surfaces in the transmission of
emerging health care-associated pathogens:
Norovirus, Clostridium difficile, and
Acinetobacter species”
David J. Weber, MD, MPH; William A. Rutala,
PhD, MPH; Melissa B. Miller, PhD; Kirk
Huslage, RN, BSN, MSPH; Emily SickbertBennett, MS
13
G E N E R A L C O N F E R E N C E I N F O R M AT I O N
Annual Business Meeting
The APIC Annual Business Meeting is on Tuesday, June 5,
from 4:30–6 p.m. in the Convention Center, Room 205.
This meeting is open only to APIC members. Associate
members may attend, but may not vote.
All questions and items for discussion at the Business
Meeting may be submitted in writing by 3 p.m., Monday,
June 4, at APIC Central.
APIC Member Services
The APIC Member Service Desk is located in the Park View
Lobby of the Convention Center, as part of APIC Central.
The Member Service Desk is an area dedicated to APIC
program teams, committees, task forces, and affiliated
organizations to display information about their programs.
APIC staff members are available to answer APIC
membership questions, troubleshoot problems and
concerns, print membership cards, and answer general
questions regarding APIC programs and services.
The Member Services Desk is open on the following
days/times:
Sunday, June 3
12-5 p.m.
Monday, June 4
7:30 a.m.-6 p.m.
Tuesday, June 5
7:30 a.m.-4:30 p.m.
Wednesday, June 6
7:30 a.m.-4 p.m.
Stop by APIC Central and enjoy an afternoon snack on
Monday and Tuesday, courtesy of Stericycle.
APIC Store
The APIC Store is located in the Tower View Lobby of the
Convention Center. The APIC Store features conference
souvenirs, APIC publications, and educational products.
APIC staff members are available to assist attendees and
answer questions regarding APIC products and services.
APIC Store Hours:
Sunday, June 3
Monday, June 4
Tuesday, June 5
Wednesday, June 6
12 -5 p.m.
7:30 a.m.-6 p.m.
7:30 a.m.-4:30 p.m.
7:30 a.m.-4 p.m.
Attendance Verification
For those attendees who do not require continuing
education contact hours, but wish to verify their attendance,
a Verification of Attendance Card can be printed out online
at www.apic.org/AC2012
For verification of attendance for continuing education
contact hours, see Continuing Education Credits on page 3.
Audio/Video Recording Devices
The use of personal tape recorders, video cameras, or
flash photography are not permitted during sessions. Most
lectures will be recorded and available on the complimentary
Conference Proceedings available to pick up at the Covidien
Booth (#703) in the exhibit hall.
14
APIC Conference Proceedings
Please stop by the Covidien booth #703 in the front of the
Exhibit Hall to pick up a complimentary copy of the APIC
2012 Conference Proceedings. The complimentary copy of
the standard conference proceedings includes all applicable
educational sessions in webinar format. Share this
information with your coworkers so that they too can benefit
from the education at APIC 2012. This is made possible
thanks to an educational grant from
Note: Not all sessions will be recorded as they either do not
lend themselves to audiotape presentation or the speaker
contract does not permit it.
Upgrade to the Premium Conference Proceedings to access
the APIC 2012 Abstract online ePoster gallery, Conference
APP, and MP4 videos. It allows you to browse through the
279 abstracts & posters from APIC 2012 with keyword
search, take notes or draw directly on the slides via your
tablet or smartphone while in a session, and transfer MP4
versions all sessions and Film Festival Videos to your
computer or portable device like a tablet or smartphone.
Upgrade to Premium Option - $50
Upgrades can be made at the Cadmium CD Conference
Proceedings booth outside the exhibit hall in the Tower
View Lobby. For post-conference orders, please visit
www.apic.org/proceedings2012.
Badges
Official APIC Conference Badges must be worn to access
the Exhibit Hall, educational sessions and social events.
Breakfast
Inexpensive, portable breakfast items are available for
purchase each morning at the Convention Center. Coffee,
hot tea, iced tea, lemonade, and water will be provided.
Business Center/UPS Store
Open daily in the Main Lobby of the Convention Center.
APIC Show Daily
This free publication contains daily news from the
convention floor, product announcements, educational
sessions, photographs, social events, and much more. The
Show Daily is available Sunday through Wednesday at
conveniently placed news stands located near APIC Central,
session rooms, and the Exhibit Hall. Be sure to grab your
copy early – they go fast!
Children
Due to the professional nature of this conference, children
under age 12 are not permitted in the educational sessions
or the Exhibit Hall. Call your hotel operator for information
on available baby-sitters/daycare in the area.
Disability Assistance
If you have a disability and require assistance in order to
fully participate in conference activities, please see the
Conference Manager at the APIC 2012 Registration Desk to
discuss your specific needs.
Exhibits
Henry B. Gonzalez Convention Center
Additional Phone Numbers
Physician Referral
Call your hotel operator
Dental Referral
1-800-DENTIST
Downtown San Antonio Urgent Care (Concentra) 210-472-0211
(1.4 miles from conv ctr)
San Antonio Convention & Visitors Bureau
1-800-447-3372
Convention Center Security
210-207-7773
Exhibit Hall C & D
Visit the exhibits daily, talk to the representatives to become
familiar with the products available, and discuss your needs.
Win prizes just by scanning your badge at the official APIC
2012 Exhibit Hall raffle stations. APIC has placed two raffle
stations at different locations within the exhibit hall. Find
them, scan your badge, and you could win educational
publications and fun prizes! Sponsored by
Exhibits are open during the following hours:
Monday, June 4
10:30 a.m.-1:30 p.m.
Tuesday, June 5
10:30 a.m.-1:30 p.m.
Wednesday, June 6
10:30 a.m.-1 p.m.
First Aid
First Aid services are available during the meeting hours
(8 a.m.-5 p.m.) each day. The First Aid office is located
inside the exhibit hall behind the APIC Village. If you require
their services any APIC staff member can contact them.
Internet Stations
Check email, browse the Internet, or complete the session
evaluation process online at the Internet Stations sponsored
by
, located in the Park View Lobby of the convention
center. Internet Station keyboards are sponsored by
,
and keyboard cleansers are sponsored by
. The Internet
Stations are open from Sunday, June 3 through Wednesday,
June 6. Access is limited to 10 minute intervals per person.
Job Notices
Job notices will be posted on notice boards in Park View
Lobby of the Convention Center.
Lost and Found
Lost and found articles should be reported or taken to the
APIC 2012 Registration Desk located in East Registration in
the convention center. At the end of each day, unclaimed
items will be turned over to convention center security.
Phone Numbers
APIC 2012 Press Office
APIC 2012 Registration/Message Desk
210-582-7009
210-582-7010
APIC 2012 Hotels
Hilton Palacio del Rio
Hyatt Place
Hyatt Regency Riverwalk
La Quinta Inn & Suites
Marriott Riverwalk
The Historic Menger Hotel
210-222-1400
210-227-6854
210-222-1234
210-222-9181
210-223-1000
210-224-4555
210-223-4361
Poster Presentations
Exhibit Hall D of the convention center.
Posters will be displayed Monday, June 4 – Wednesday,
June 6. Presenters will be in attendance to answer
questions Monday, June 4 from 12:30–1:30 p.m. and
Tuesday, June 5 from 12:30–1:30 p.m. Refer to the
abstract section of the onsite program for more detailed
information regarding each presentation.
Questions for Speakers
Conference participants may ask questions from
microphones in the aisle during the question and answer
portion of the sessions. Written questions are also accepted
and should be given to the session moderator.
Registration
The APIC 2012 Registration Desk will be located in the
East Registration area of the San Antonio Convention Center.
Onsite Registration Hours:
Sunday, June 3
Monday, June 4
Tuesday, June 5
Wednesday, June 6
10 a.m.-7 p.m.
7 a.m.-4 p.m.
7 a.m.-4 p.m.
7 a.m.-3:30 p.m.
Restaurant Reservations & Menu Information
This desk at the convention center provides restaurant
menus, restaurant recommendations, and a reservations
service. Located next to registration.
Sunday, June 3
2-6 p.m.
Monday, June 4
10 a.m.-6 p.m.
Tuesday, June 5
10 a.m.-4 p.m.
Wednesday, June 6
10 a.m.-3 p.m.
Ribbons
All Badge Ribbons will be distributed on a table next to the
Conference Tote Bag pickup station in the East Registration
area of the convention center.
Smoking Policy
Smoking is prohibited throughout the entire exhibit and
meeting area. This policy is strictly enforced.
15
G E N E R A L C O N F E R E N C E I N F O R M AT I O N
Speaker Ready Room (Check in required for all presenters)
Checking in to the Speaker Ready Room, Room 207A,
is the single most important action you will take to
ensure your presentation is a success. All speakers are
required to check into the Speaker Ready Room
preferably 24 hours before their presentation, where
they will have the opportunity to review their
presentations or make any last minute changes. The
Speaker Ready Room will be open daily during the
meeting. All meeting rooms will have presentation
computers and will be networked to a central computer
located in the Speaker Ready Room. Presentations will
be downloaded from it and sent to the respective
meeting room on a secured intranet circuit approximately
45 minutes prior to the start of each session.
Hours of Operation: (Please make it a priority to visit
one day prior to your presentation.)
Sunday, June 3
12-5 p.m.
Monday, June 4
6:30 a.m.-5 p.m.
Tuesday, June 5
7 a.m.-5 p.m.
Wednesday, June 6
7 a.m.-2 p.m.
Visitor Information Office
Located inside the San Antonio convention center near
the Lila Cochrell Theater. They can provide information
including current flight schedules, shuttle requests,
restaurant and hotel information, even downtown
special events and nightlife. Office is open during
business hours M-F.
16
Sunday, June 3
Monday, June 4
Concurrent Sessions
3:30-4:30 p.m. | Session 900
Room 214
International and New Attendee Orientation
Opening Plenary
8-9:30 a.m. | Session 1000
Ballroom C
Opening Ceremony with President’s Address
This session is designed to provide attendees with the
most current information in an informal setting. Review
conference activities of interest to international and
new attendees and guide them through the program
schedule, abstracts, and exhibits directory.
OBJECTIVES:
䡲 Enable participants to choose topics that meet their educational and
practice requirements.
䡲 Identify where and how to meet international colleagues and illustrate
suggestions for achieving a networking and educational balance
throughout the conference.
䡲 Describe the various educational opportunities available throughout the
conference.
PRESENTER:
Gertie van Knippenberg-Gordebeke
Consultant Nurse Infection Prevention
International Consultant Nurse Infection Prevention
Infection Prevention Specialist
Oregon Patient Safety Commission
Michelle R. Farber, RN, CIC
Board Certified Infection Preventionist
Mercy Hospital
9-9:30 a.m. | Session 1000
Ballroom C
Elaine Larson Lectureship - Disinfection and
Sterilization: From Benchtop to Bedside
This session will describe the current state of disinfection
and sterilization and how infection preventionists expediently transfer knowledge from the benchtop to the bedside.
This will be accomplished by reviewing how new products,
practices, principles and technology in disinfection and
sterilization have been and continue to be integrated into
practice to prevent patient exposure to pathogens from the
environment or medical/surgical instruments.
Monday, June 4
Education Program Details
OBJECTIVES:
䡲 Review the evolution of disinfection and sterilization products and
practices over 30 years.
䡲 Review the disinfectants used and how research directed their use.
䡲 Review new technologies and how these technologies are improving
practice.
Nancy Zanotti RN, BSN, MPH, CIC
Director of Infection Prevention
Westside Regional Medical Center
PRESENTER:
William Rutala, BS, MS, PhD, MPH, CIC
Director, Hospital Epidemiology; Professor; Director,
Statewide Program for Infection Control and Epidemiology
University of North Carolina Health Care and University
of North Carolina School of Medicine
17
Monday, June 4
9:30-10:30 a.m. | Session 1000
Ballroom C
From KARDEX to Bundles to....??? : In Defiance of the
Post-Antibiotic Era
Trace the history of infection prevention in the modern era
in the current context of an aging population, burgeoning
prevalence of multiple drug resistant organisms (MDRO),
decline in novel antimicrobials, and the increasingly
aggressive healthcare technology that expands immunosuppressed populations in our facilities. A successful
vision is shared.
OBJECTIVES:
䡲 Understand the maturation of infection prevention from a novel concept
into an increasingly evidence-based science.
䡲 Establish linkages with medical staff to accomplish healthcare
accountability in the modern healthcare facility.
䡲 Convert burgeoning MDRO into “rehabilitated antibiograms” using
principles of warfare.
PRESENTER:
Allan Morrison, FACP, FIDSA, FSHEA
Professor and Distinguished Senior Fellow
George Mason University Graduate School of Public Policy
Hospital Epidemiologist, INOVA Fairfax Hospital
Infectious Diseases Physicians, Inc.
Posters on Display
10:30 a.m.-5:30 p.m.
Exhibit Hall D
Exhibit Hall Open
10:30 a.m.-1:30 p.m.
Exhibit Hall C & D
Coffee break in the exhibit hall 10:30-11 a.m.
Complimentary lunch will be served in the exhibit hall
from 11:30 a.m.-1 p.m. We welcome all attendees with
a wallet-style badge to join us.
18
Knowledge Bar (APIC Village)
11 a.m.-1 p.m.
APIC Village, Exhibit Hall C
Want to tap into all the expert knowledge running around
the 2012 APIC Annual Conference? Then visit the APIC
Knowledge Bar inside the APIC Village for an informal
conversation with one or more clinical experts. Check
on-site for the most current schedule of experts.
11 a.m. EXPERTS:
Marita Nash, CHESP, MBA
Director of Environmental Services and Linen
Hunterdon Medical Center
Lillian Burns, MPH, MT, CIC
Director of Infection Control
Staten Island University Hospital
12 p.m. EXPERT:
Curtis Donskey, MD
Director of Infection Control
Louis Stokes Veterans Affairs Medical Center (Cleveland VAMC)
Poster Presentations with Presenters
12:30-1:30 p.m.
Exhibit Hall D
Posters are arranged by topic number, listed below, and
then numerically by publication number within each
category.
Antisepsis/Disinfection/Sterilization
2-007 to 2-022
Bioterrorism/Disaster/Emergency Preparedness 3-024 to 3-025
Device-Related Infections and/or
Site Specific Infections
4-026 to 4-056
Environment of Care/Construction/Remediation 6-063 to 6-072
Healthcare Worker Safety/Occupational Health
7-073 to 7-077
Product Evaluation/Cost-Effectiveness/Cost
Benefit Analysis
10-140 to 10-146
Special Populations (Infections in the
Immunocompromised Host, Pediatrics)
13-187 to 13-197
Specialized Settings (Ambulatory Care,
Behavioral Health, Long-Term Care, Home care) 14-198 to 14-205
Staff Training/Competency/Compliance
15-206 to 15-226
Thirty-two abstract presentations will be presented in
four sessions. Each presentation will be 10 minutes in
length and five minutes for Q&A.
Session 1200
Antimicrobial Resistance/Pathogens
Room 214CD
Publication 131. Validation of Infection
Preventionists Surveillance for Determining
Hospital-acquired Central Line-associated
Bloodstream Infection Using Centers for Disease
Control and Prevention Definitions
Megan J. DiGiorgio, MSN, RN, CIC
Cleveland Clinic
1:30-1:45 p.m.
Publication 128. Incidence of Healthcareassociated Infections by Pathogen at a University
Hospital from 2005 to 2011
JaHyun Kang, BSN, MPH, CIC
PhD candidate
School of Nursing, University of North Carolina at Chapel Hill
1:45-2 p.m.
Publication 113. Risk Factor Score to Predict
MRSA Colonization at Hospital Admission
2-2:15 p.m.
Publication 107. Efficacy of Various Antimicrobial
Central Venous Catheters in Mono- and Polymicrobial Environments
Shanna D. Moss, BS
Research Scientist
Teleflex Medical
2:15-2:30 p.m.
Katherine Torres, D.O.
Fellow, Infectious Diseases
Mayo Clinic
Publication 124. Culture Change and CLABSI
Reduction: Achieving Success in a Medical Center
with 10 Distinctively Different Intensive Care Units
2-2:15 p.m.
Michael Anne Preas, RN, BSN, CIC
Director Infection Prevention and Hospital Epidemiology
University Of Maryland Medical Center
Publication 100. Overuse of Topical Antibiotics
Among Inmates Entering Maximum-security
Correctional Facilities in New York State
Carolyn Herzig, MS
PhD Candidate
Department of Epidemiology, Columbia University
MODERATOR: Sasha Madison, MPH, CIC
Session 1202
Hand Hygiene
Room 217B
2:15-2:30 p.m.
1:30-1:45 p.m.
Publication 101. Infections Due to Enterobacter
Species: Epidemiology and Outcomes as a
Function of Ceftazidime Resistance
Publication 126. Active Participation from the
Hospital Executive Team Does Improve Hand
Hygiene Compliance
Odaliz E. Abreu Lanfranco
ID Fellow
Wayne State University
Jan L. Wayland
Infection Control Manager
St Vincents and Mercy Private Hospital
MODERATOR: Julia Moody, MS, SM(ASCP)
1:45-2:00 p.m.
Session 1201
Room 217A
1:30-1:45 p.m.
Publication 104. Preventing Contamination of
Central Venous Catheter Valves with the Use of an
Alcohol-based Disinfecting Cap
Marc-Oliver Wright, MT(ASCP), MS, CIC
Corporate Director of Infection Control
NorthShore University HealthSystem
Monday, June 4
1:45-2 p.m.
Oral Abstract Presentations
Publication 102. Efficacy of Novel Alcohol-Based
Hand Rubs at Typical “In Use” Volumes
David R. Macinga, PhD
Principal Microbiologist
GOJO Industries, Inc.
2-2:15 p.m.
Publication 114. Understanding Hand Hygiene
Behavior in a Pediatric Oncology Unit in a LowerMiddle Income Country: A Focus Group Approach
Kyle M. Johnson, PhD, CCRP
Clinical Research Associate II
St. Jude Children's Research Hospital
19
Monday, June 4
2:15-2:30 p.m.
Publication 116. Standardization of Hand Hygiene
Observations - An Entire State Collaborates
Session 1204
Isolation and MDROs
Room 217C
1:30-1:45 p.m.
Barbara A. MacPike, RN, BSN, CIC
Infection Preventionist
Maine Coast Memorial Hospital
Publication 130. Discontinuation of Reflex Testing
of Stool Samples for Vancomycin-Resistant
Enterococci Resulted in Increased Prevalence
MODERATOR: Amy Algazi, MS, MT(ASCP), CIC
Kathleen McMullen, MPH, CIC
Barnes-Jewish Hospital
Session 1203
Infection Prevention Programs
Room 214AB
1:30-1:45 p.m.
Publication 109. Prevention of Hospital Associated
C. difficile Infections
1:45-2 p.m.
Publication 127. Healthcare Worker Response to
Direct Monitoring of Adherence to Isolation
Precautions
Alexis Raimondi, BS, RN, BSN, MS, CIC
Infection Control Manager
Beth Israel Medical Center- Kings Highway Division
Carolyn Herzig, MS
PhD Candidate
Department of Epidemiology, Columbia University
1:45-2 p.m.
2-2:15 p.m.
Publication 110. Preventing the FLU in You: A
Three Year Experience of Sustained Seasonal
Influenza Vaccination Rates in Healthcare Workers
Publication 115. Multidrug Resistant Organisms in
Supply Carts of Contact Isolation Patients
Julia A. Moody, MS SM(ASCP)
Director, Infection Prevention
HCA Inc, Clinical Services Group
Shane Zelencik, MPH
NorthShore University HealthSystem
2:15-2:30 p.m.
2-2:15 p.m.
Publication 129. Comparison of Methods for
Surgical Site Infection Surveillance: Traditional
Report Review and Electronic Surveillance
Sarah A. Jadin, MPH, CIC
Sr. Clinical Consultant-Infection Prevention
Premier healthcare alliance
Publication 117. Should Contact Precautions be
Standard? A Community Hospital's Revised
Criterion for Methicillin Resistant Staphylococcus
aureus and Vancomycin Resistant Enterococcus
Isolation
Maureen J. Hodson, RN, ASN, CIC
HealthAlliance Hospital
2:15-2:30 p.m.
Publication 112. Changing Bedside Care by
Linking Outcome and Process Data
Kathleen R. Hartless, RN, MN, CIC, CRMST
Infection Prevention and Control Coordinator
Veterans Affairs North Texas Health Care System
MODERATOR: Karen Hoffmann, RN, MS, CIC
Session 1205
Public Reporting/Public Policy
Room 217D
1:30-1:45 p.m.
MODERATOR: Keith Howard, RN, BSN, CIC
Publication 119. The Impact of Non-Payment for
Preventable Complications on Infection Rates in
U.S. Hospitals
Grace M. Lee, MD, MPH
Associate Professor of Population Medicine
Harvard Medical School and Harvard Pilgrim Health Care
Institute
20
2:15-2:30 p.m.
Publication 120. New York State Hospital-Acquired
Infection Reporting – 2010 Audit Results: An
Inter-hospital Comparison
Publication 106. Preventing Infection in Pediatric
Spinal Fusion Surgery: A Novel Perioperative and
Postoperative Surgical Site Infection Prevention
Bundle
Kathleen Gase, MPH, CIC
HAI Reporting Regional Representative
New York State Department of Health
Patricia Hennessey, RN, BSN, MSN, CIC
Manager, Infection Prevention
St. Christopher's Hospital for Children
2-2:15 p.m.
Publication 118. Re-admissions After Diagnosis of
Surgical Site Infection Following Knee and Hip
Arthroplasty
Keith S. Kaye, MD, MPH
Professor of Medicine and Corporate Director, Infection
Prevention, Epidemiology and Antimicrobial Stewardship
Wayne State University School of Medicine and Detroit
Medical Center
MODERATOR: Sally Hess, MPH, CIC
Session 1207
Surgical Site Infection
Room 212
1:30-1:45 p.m.
2:15-2:30 p.m.
Publication 122. Rapid Cycle Process
Improvements to Decrease Surgical Site
Infections in Cardiothoracic and Vascular
Surgery Patients Between 2008 and 2011
Publication 121. Assessment of the Quality and
Accuracy of Publically Reported CLABSI Data in
Colorado
Lee Reed, RN, BA, MSPH, CIC
Novant Health, Presbyterian Hospital
Karen Rich, RN, BSN, MEd, CIC
Patient Safety Program Nurse Consultant
Colorado Department of Public Health and Environment
1:45-2 p.m.
MODERATOR: Lela Luper, RN, BS, CIC
Session 1206
Special Populations
Room 210
Publication 123. Code Flash: An Interdisciplinary
Team’s Efforts to Decrease Incidents of Flash
Sterilization
Diana K. Griffin, BSN, RN
Infection Prevention and Control Nurse
Central Arkansas Veterans Healthcare System
1:30-1:45 p.m.
2-2:15 p.m.
Publication 125. Using a Multi-Faceted Active
Change Process and Infection Prevention to
Reduce Post Op C-Section Infections
Publication 111. Monitoring the Manual
Cleaning of Flexible Endoscopes with an ATP
Detection System
Jeanette J. Harris, MS, MSM, BS, MT(ASCP), CIC
MultiCare Health System
Grace A. Thornhill, PhD
Technical Service Specialist
3M Infection Prevention
1:45-2 p.m.
Publication 105. Endemic IV Fluid Contamination
in Hospitalized Children in Mexico. A Problem of
Serious Public Health Consequences.
Alejandro E. Macias, MD
Head, Infection Control
National Institute of Med Sciences and Nutrition
2-2:15 p.m.
Monday, June 4
1:45-2 p.m.
2:15-2:30 p.m.
Publication 103. Clean Collaboration: Toward
Improving Arthroscopic Shaver Reprocessing
Methods
Jahan Azizi , BS, CBET
Risk Management Consultant/Biomedical Engineer
University of Michigan Health System
MODERATOR: Debra Johnson, BSN, RN, CIC
Publication 108. A Healthcare Worker with
Pertussis: High Cost and Lost Opportunity
Gregory C. Gagliano, BSN, RN, CIC
Cleveland Clinic
21
Monday, June 4
Concurrent Sessions
3-4 p.m. | Session 1300
Room 214 CD
Brick by Brick: Building Ontario’s First Regional
Hospital Infection Surveillance System: Technology
Enhances Patient Safety
An ambitious project resulting in the implementation of
an automated surveillance system linking multiple
hospital corporations in Southeastern Ontario will be
described. Presenters will highlight the benefits to
patient safety realized by a single regional database and
common software supporting surveillance and tracking of
patients across the region.
OBJECTIVES:
䡲 Evaluate the benefits of a regional surveillance system in enhancing
patient safety.
䡲 Recognize the many complex processes required to implement a regional
system.
䡲 Develop a strategy to establish a regional infection control system.
PRESENTERS:
Janet Allen, MLT, ART, CIC
Network Coordinator
Public Health Ontario - Regional Infection Control Network
Susan Cooper, MLT, CIC
Infection Control Consultant
Public Health Ontario- Regional Infection Control Network
MODERATOR: Kathleen Quan, RN, BSN, CIC, CPHQ
3-4 p.m. | Session 1301
Room 217 A
One Stick at a Time: A Toolkit for an Effective
Healthcare Personnel Immunization Program
An effective immunization program is essential for the
safety of the healthcare workforce. This session will
review the results of a nationwide survey among infection
preventionists regarding their knowledge, management,
and implementation of an immunization program.
Components of a comprehensive program will be
provided in a toolkit format.
OBJECTIVES:
䡲 Identify current immunizations recommended by the CDC ACIP for
inclusion in a healthcare personnel immunization program applicable in
any healthcare setting.
䡲 Identify specific areas of risk for safe vaccine handling and
management.
䡲 Discuss available resources regarding safe vaccine handling,
management, administration, and program evaluation.
PRESENTERS:
Associate Professor
School of Public Health and Information Sciences
University of Louisville
Timothy Wiemken, PhD, MPH, CIC
Instructor of Medicine
University of Louisville School of Medicine, Division of Infectious
Diseases
MODERATOR: Sue Sebazco, RN, BS, CIC
22
This session will present a unique approach to
recruitment and training of infection preventionists (IPs),
with a focus on identifying potential successful IP
candidates with non-traditional education or professional
backgrounds. Career development strategies and
mentorship systems to retain and support the early
career IP will also be discussed.
OBJECTIVES:
䡲 Identify and assess potential IP candidates from non-traditional
backgrounds.
䡲 Develop a training plan that is tailored to the new IPs education needs
and areas of strength.
䡲 Create career development strategies to support and retain the
early-career IP.
PRESENTERS:
3-4 p.m. | Session 1303
CDC Outbreak Session 2012
Room 214 AB
This session will review recent CDC outbreak
investigations of healthcare-associated infections and
will highlight the process of conducting these
investigations. Lessons learned from the field may be
helpful in successfully managing future outbreak
investigations. Attendees will be provided with useful
and practical information on conducting outbreak
investigations.
OBJECTIVES:
䡲 Describe the lessons learned from recent CDC outbreak investigations.
䡲 Describe the process measures involved in outbreak investigations.
䡲 Discuss emerging and re-emerging pathogens and common outbreak
themes in the healthcare setting.
PRESENTER:
Tara McCannell, MSc, PhD
Epidemiologist
Centers for Disease Control and Prevention
Virginia Kennedy, BS, MS
Principal
Infection Prevention and Management Associates, Inc.
MODERATOR: Kathy Arias, MS, CIC
Kelley Boston, MPH, CIC
Regional Director San Antonio, Accreditation and
Regulatory Compliance
3-4 p.m. | Session 1304
Room 217 C
Disinfection and Sterilization in Physician Practices
and Specialty Clinics
Kelly Holmes, MS, CIC
Director of Human Resources and Education
Jennifer McCarty, MPH, CIC
Director of Operations, Regional Director Texas Gulf Coast, Acute Care
and NHSN Lead
MODERATOR: Fran Feltovich, RN, MBA, CIC, CPHQ
Monday, June 4
3-4 p.m. | Session 1302
Room 217 B
How Do We Find Them and How Do We Keep Them:
Recruitment and Training of The New Infection
Preventionist
What's different about disinfection and sterilization in
ambulatory care facilities? What's the same? This session
offers guidance and explains what should be the same
and what should be different in these processes in
physician practices and specialty clinics that do not have
access to a sterile processing department.
OBJECTIVES:
䡲 List differences between disinfection and sterilization in a sterile
processing department and in a physician practice or specialty clinic.
䡲 Describe the similarities between disinfection and sterilization in a
sterile processing department and in a physician practice or specialty
clinic.
䡲 Define disinfection and sterilization in a physician's practice or
specialty clinic.
PRESENTER:
Infection Prevention Coordinator, Ambulatory Care
UNC Healthcare System
23
Monday, June 4
3-4 p.m. | Session 1305
Really, Are You Serious?
Room 217 D
This session will highlight some thought-provoking and
often unbelievable examples of issues faced by infection
preventionists. The presenters will provide an
entertaining and educational discussion of practices and
events that made them want to cry out “Really?”
OBJECTIVES:
䡲 Discuss approaches to various infection prevention challenges
encountered in a complex healthcare facility.
3-5:30 p.m. | Session 1401
Room 007
Using the Joint Commission IC Standards and NPSG 7
to Drive Practice Change and Attain Adequate
Resources: a Leadership Workshop
Joint Commission infection control (IC) standards and
National Patient Safety Goal (NPSG) 7 are designed to
allow each organization to customize an infection
prevention program that best meets its unique needs. A
customized program is necessary in order to optimize
limited resources, provide leadership and drive practice
change.
䡲 Examine unusual scenarios in infection prevention in which there is
limited evidence or guidelines regarding recommended practices.
䡲 Express an appreciation for the ingenuity of healthcare worker behaviors
that, though well-intended, may have potential harm.
OBJECTIVES:
䡲 Design or improve a cost-effective, guideline-driven infection prevention
program that complies with TJC requirements.
䡲 Identify evidence-based guidelines utilized by surveyors in evaluation of
PRESENTERS:
Titus Daniels, MD, MPH, MMHC
Vice Chair for Clinical Affairs, Department of Medicine
Vanderbilt University School of Medicine
Thomas Talbot, MD, MPH
Associate Professor of Medicine, Chief Hospital Epidemiologist
Vanderbilt University Medical Center
MODERATOR: Barb DeBaun, RN, MSN, CIC
compliance.
䡲 Describe methods for assessing resources and making a business case
for additional funding.
PRESENTER:
Barbara Soule, RN, MPA, CIC, FSHEA
Practice Leader, Infection Prevention Services
Joint Commission Resources
MODERATOR: Deanie Lancaster, RN, BSN, MHSA, CIC, CPHRM
Workshops
3-5:30 p.m. | Session 1400
Room 008
Home is Where the Germs Are: Infection Prevention
Surveillance in Home Care
Surveillance is the backbone of an effective infection
prevention program in home care settings. The presenter
will discuss the use of surveillance data including review
of outcome and process measures with the ultimate goal
of improving the safety and quality of patient care.
OBJECTIVES:
䡲 Discuss methods for identifying potential infections using the Outcome
and Assessment Information Set (OASIS) and applying the APIC-HICPAC
Surveillance Definitions for Home Health Care and Home Hospice
Infections.
䡲 Describe the use of surveillance to improve outcome and process
measures.
䡲 Analyze and report findings of the surveillance data including the
development of action plans.
PRESENTER:
Carole Yeung, RN, CIC
Clinical Practice Specialist,- Infection Prevention
Baptist Health Home Health Network
24
MODERATOR: Jennifer Geist Cox, RN, BSN, CIC
3-5:30 p.m. | Session 1402
Ballroom C-3
In 2012, CMS’s Hospital Inpatient Quality Reporting
Program expanded to include surgical site infections
(SSI) for selected operative procedures using CDC’s
National Healthcare Safety Network (NHSN) definitions.
This session will review NHSN’s SSI protocol and how to
meet the reporting mandate. Test your skills through
audience response to case studies.
OBJECTIVES:
䡲 Define resources and methods for SSI surveillance, including
requirements for SSI reporting to CMS through NHSN.
䡲 Review NHSN SSI protocol and key terms and definitions.
䡲 Apply SSI definitions using interactive case studies.
PRESENTERS:
Mary Andrus, BA, RN, CIC
President
Surveillance Solutions Worldwide, Inc
PRESENTERS:
Gloria Morrell, RN, MS, MSN, CIC
Nurse Consultant
Linda Dickey, RN, MPH, CIC
Director, Epidemiology and Infection Prevention
University of California Irvine Healthcare
MODERATOR: Barbara Rusell, RN, MPH, CIC
MODERATOR: Amy Nichols, RN, MBA, CIC
Tim Adams, FASHE, CHFM, CHC
Director, Professional Growth
American Society for Healthcare Engineering
Concurrent Sessions
3-5:30 p.m. | Session 1403
Management is More than Leading
Room 006 AB
In this session, you will explore the many elements of
management and leadership in todays evolving
workplace environment. Through reflective exercises and
engaging activities, you’ll also create your own teachable
moments about managing and leading in the context of
your own organizations. Just as important, you’ll have
fun with a purpose!
OBJECTIVES:
䡲 Learn what the experts say about managing and leading.
䡲 Articulate tangible examples of management and leadership - both
what it is and what it isn't.
䡲 Begin articulating the context for leadership and management in your
own organizations.
4:30-5:30 p.m. | Session 1500
Room 214 CD
Mandatory Reporting Of Healthcare Personnel
Influenza Vaccination Using the National Healthcare
Safety Network System
Beginning in January 2013, the Centers for Medicare &
Medicaid Services will require hospitals to report
healthcare personnel influenza vaccination through
NHSN using a standardized measure. This session
includes an overview of measure definitions and
reporting protocols. Representatives from jurisdictions
that pilot-tested the measure will share implementation
recommendations.
Monday, June 4
Teresa Horan, MPH
NHSN Education and Data Quality Assurance Team. Leader
Division of Healthcare Quality Promotion
OBJECTIVES:
䡲 Define the three groups of healthcare personnel covered by this quality
measure.
䡲 Classify the vaccination status of healthcare personnel according to the
PRESENTER:
Diana Mungai, MS, MSIR
Vice President, Consulting Operations
McManis and Monsalve Associates
MODERATOR: Tracy M. Louis, MSN, RN, CIC
3-5:30 p.m. | Session 1404
Room 006 CD
Utility Systems and Infection Prevention Implications
for the Environment of Care
The health care environment comprises complex systems
which minimize growth and transmission of airborne and
waterborne pathogens. Infection preventionists play a
vital role in design and management of these systems,
Demonstrations and exercises will allow participants to
visualize and understand how these systems function
and support infection prevention.
OBJECTIVES:
䡲 Describe air and water system engineering controls that limit the
measure specifications.
䡲 List the most common questions related to implementation of the HCP
vaccination measure.
PRESENTERS:
Faruque Ahmed, PhD
Senior Epidemiologist
Anita Geevarughese, MD, MPH
Adult Immunization Medical Specialist
New York City Department of Health and Mental Hygiene
Patricia McLendon, MPH
Epidemiologist
California Department of Public Health
Carmela Smith, MS
Healthcare Personnel Influenza Vaccination Project Manager
New Mexico Medical Review Association
MODERATOR: Terrie Lee, RN, MS, MPH, CIC
growth and transmission of airborne and waterborne pathogens.
䡲 Describe the applications of each engineering control.
䡲 Identify techniques that promote collaboration with key facility design
partners.
25
Monday, June 4
4:30-5:30 p.m. | Session 1501
Room 217 A
The Infection Preventionist’s Role in Implementation
Science: Examples From the Field
To help infection preventionists bridge the gap between
science and practice, results from the P-NICE and
CHAIPI studies will be presented. Results include:
predictors of clinician adherence to guidelines,
importance of certification of infection preventionists and
qualitative findings on the impact of mandatory reporting.
OBJECTIVES:
䡲 Describe professional characteristics and skills of IPs that prepare them
for successfully implementing and disseminating evidence-based
practice.
䡲 Identify components of practice guidelines that are appropriate for
implementation in their setting, using catheter-associated UTI
guidelines as an example.
䡲 Upon completion, participants will be able to discuss characteristics of
key leaders associated with successful implementation and support of
infection prevention strategies.
PRESENTERS:
Laurie Conway, RN, MS, CIC
PhD student
Columbia University School of Nursing
Monika Pogorzelska, PhD, MPH
Associate Research Scientist
Patricia Stone, RN, PhD
Centennial Professor of Health Policy
May Uchida, MSN, GNP-BC
Doctoral Student
Columbia University
MODERATOR: Denise Murphy, RN, MPH, CIC
Concurrent Sessions
4:30-5:30 p.m. | Session 1502
Room 217 B
Elevating Your Teaching to a New Level: Becoming a
Master Educator
Infection preventionists (IPs) frequently conduct
infection prevention education and training, yet few IPs
have formal education in adult learning principles,
instructional design and strategies. This session will
focus on writing educational objectives, selection of
instructional techniques and methods, crafting the
content to match the audience, and program evaluation.
OBJECTIVES:
䡲 Compare and contrast the different types of adult learners, and identify
approaches to teaching that best match primary learning styles.
䡲 Identify and formulate effective learning objectives e.g. Blooms
Taxonomy for infection prevention courses and lectures.
䡲 Describe general teaching, learning and evaluation strategies.
PRESENTER:
Mary Lou Manning, PhD, CRNP, CIC
Associate Professor, Director Doctor of Nursing Practice Program.
Thomas Jefferson University
4:30-5:30 p.m. | Session 1503
Room 214 AB
Updated SHEA Guidelines for HIV or Hepatitis B
Infected Workers
This session will provide an overview of the 2010 SHEA
Guidelines for the management of healthcare workers
infected with bloodborne pathogens. If you want to be up to
date and provide guidance to your employee/occupational
health service, you won't want to miss this session.
OBJECTIVES:
䡲 Compare and contrast the magnitude of risks for bloodborne pathogens
associated with exposures in the healthcare setting.
䡲 Describe historical perspectives about provider-to patient transmission
of the three primary bloodborne pathogens.
䡲 Discuss the tenets of the recently published, “SHEA Guideline for
Management of Healthcare Workers Who Are Infected with Hepatitis B
Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus.”
PRESENTER:
David Henderson, MD
Deputy Director for Clinical Care
Clinical Center, National Institutes of Health
MODERATOR: Lisa Outerbridge, RN
26
4:30-5:30 p.m. | Session 1505
Room 217 D
Infection Prevention Community Response - Germs on
Coats, Privacy Curtains
Involvement of a motivated administrator who liaisons
between your Infection Prevention Committee, physicians,
administrators, the CEO, and infection prevention staff
can move forward small tests of change, and essential
best practice program changes. Attend this session to
hear some simple steps you can implement for success.
Review the science behind environmental contamination
of patient rooms and the role of environmental
contamination in the spread of antibacterial-resistant
bacteria to healthcare workers and between patients.
OBJECTIVES:
䡲 Describe one benefit of converting an infection program goal to reduce
surgical site infections into an organization-wide strategic intent.
䡲 Describe one example when a motivated administrator can be brought in
as a project champion to improve a successful outcome.
OBJECTIVES:
䡲 Assess the likelihood contamination of healthcare worker attire after
entry into rooms of MDROs colonized patients.
䡲 Determine how often the environment of MDRO+ patient rooms
contaminated and which sites are most likely to be contaminated.
䡲 Describe how the environment and healthcare worker interact in the
spread of MDROs.
䡲 Identify one action to increase the functionality of the committee or work
group responsible for moving infection prevention changes forward.
PRESENTERS:
Anthony Chavis, MD, MMM, FCCP
Vice President, Medical Affairs and Patient Safety Officer
Community Hospital of the Monterey Peninsula
Patricia Emmett, MS, RN, CIC
Infection Prevention Coordinator
PRESENTERS:
Patti Costello
Executive Director
Association for the Healthcare Environment
Monday, June 4
4:30-5:30 p.m. | Session 1504
Room 217 C
The C-Suite Infection Preventionist Journey: Impacting
Patient Safety, Community Health, and Public Trust
Susan Huang, MD, MPH
Associate Professor of Medicine, Medical Director of Epidemiology and
University of California, Irvine Medical Center
Eli Perencevich, MD, MS
Professor of Internal Medicine
University of Iowa Carver College of Medicine
MODERATOR: Russell Olmsted, MPH, CIC
27
Tuesday, June 5
Tuesday, June 5
Posters on Display
8 a.m.-5:30 p.m.
Exhibit Hall D
Concurrent Sessions
8-9 a.m. | Session 2000
Room 214 CD
A Bundle Approach to Prevent CAUTIs
Learn how to form multidisciplinary CAUTI prevention
teams and introduce a CAUTI prevention bundle that can
be spread to all patient care units. Reductions in CAUTI
rates and device utilization will be discussed as well as
cost effectiveness of CAUTI prevention efforts.
8-9 a.m. | Session 2002
Room 217 B
Peer Reviewed Publication: Why Not Me?
Designed for those with publication aspirations beyond a
solid abstract. Without reviewing actual development of
content, this course provides a “road-map” for peerreviewed publications in a one-stop-shopping approach.
Attendees will leave with user-friendly advice, websites,
and helpful hints to maneuver their way to an initial
publication success.
OBJECTIVES:
䡲 State the basic questions and premise behind the peer reviewed
publication process.
OBJECTIVES:
䡲 Describe a model for CAUTI infection reduction that can be implemented
institutionally across a health care system.
䡲 Compare infection prevention practices and report infection data in a
timely, meaningful and understandable manner.
䡲 Demonstrate cost effectiveness of efforts.
PRESENTER:
Brian Koll, MD, FACP, FIDSA
Professor of Clinical Medicine
Albert Einstein College of Medicine
䡲 Describe resources available to use as a generic yet mandatory guide for
peer reviewed publications.
䡲 Explain the basic organizational steps to successful publication in peer
reviewed journals from idea, literature search, submission, re-submission,
toward final galley proof review.
PRESENTER:
Patti Grant, RN, BSN, MS, CIC
Director Infection Prevention & Quality
Methodist Hospital for Surgery
MODERATOR: Sharon Williamson, MT (ASCP), SM, CIC
MODERATOR: Sasha Madison, MPH, CIC
8-9 a.m. | Session 2001
Room 217 A
It's a Gas! Infection Prevention in Anesthesia
This presentation will highlight key infection prevention
challenges in anesthesiology. Recent national anesthesia
guidelines, unique issues and application of the new
guidelines will be discussed. An evaluation tool of
Anesthesiology Infection Control practices for use by
infection preventionists (IPs) will be shared.
OBJECTIVES:
䡲 Discuss the revised American Society of Anesthesiologists (ASA)
Recommendations for Infection Control for the Practice of
Anesthesiology.
䡲 Identify the role of the IP in working with anesthesia to address the
prevention of HAI in patients as well as infection transmission to the
anesthesia staff.
䡲 Incorporate a practical tool for IP use when evaluating compliance with
the above ASA Recommendations at your institution.
PRESENTER:
Susan Dolan, RN, MS, CIC
Hospital Epidemiologist
Children’s Hospital Colorado
28
MODERATOR: Linda Green, RN, MPS, CIC
8-9 a.m. | Session 2003
Room 214 AB
Talking to Patients: The Expanding Role of Infection
Preventionists in Communicating HAI Prevention
Getting an infection during medical care can be
devastating for patients and families. Infection
preventionists can play a key role in educating patients
on healthcare safety. During this presentation, we will
discuss best practices for notifying patients of infection
control breaches and provide lessons learned from
healthcare-associated infection.
OBJECTIVES:
䡲 Highlight the role of infection preventionists in educating patients about
healthcare safety.
䡲 Discuss communication best practices for patient notification events.
䡲 Provide lessons learned from healthcare-associated infection data
releases.
PRESENTER:
Abbigail Tumpey, MPH, CHES
Associate Director for Communications Science
8-9 a.m. | Session 2004
Room 217 C
SSI Prevention in Ambulatory Surgery Centers A Collaborative Project AORN/APIC
This session will describe a collaborative project which
involved development of materials, tools and support
relative to infection prevention, and CMS survey prep for
ambulatory surgery centers.
OBJECTIVES:
䡲 List two interventions designed to reduce the risk of surgical site
infections in ambulatory surgery centers.
䡲 Describe one regulatory agency involved in surveying ASCs.
䡲 Describe two methods of support provided to ASCs by the AORN/APIC
chapter collaborative project in the San Francisco Bay Area.
PRESENTERS:
Kris Anderson, RN, BS, CNOR, CASC
Independent Consultant
Sue Barnes, RN, BSN, CIC
National Program Leader Infection Prevention and Control
Kaiser Permanente
MODERATOR: Frank Myers, MA, CIC
8-9 a.m. | Session 2005
Room 217 D
Infection Preventionists Leading Change: Effects of
Healthcare Reform on Infection Prevention
Hear the SHEA President's perspective on the effect of
healthcare reform on infection prevention, and the critical
role of the infection preventionist in leading change.
OBJECTIVES:
䡲 Describe the role of infection prevention professionals in healthcare
reform.
䡲 Identify strategies to facilitate leadership of improvement efforts in your
institution.
PRESENTER:
Jan Patterson, MD, MS, FSHEA
Professor of Medicine/Infectious Diseases and Associate Dean, Quality
and Lifelong Learning
University of Texas Health Science Center at San Antonio and South
Texas Veterans Health Care System
MODERATOR: Barbara Soule, RN, MPA, CIC
Workshops
8-9 a.m. | Session 2100
Heroes of Infection Prevention
Room 006 AB
This session is a gathering of past Heroes to address the
guiding question of: “How are your respective successful
programs sustained and what is your drive to maintain the
program?” Come hear how their work has been developed
into best practices and the common challenges they faced
in finding solutions to foster a continuity in approach to
improve patient outcome across the continuum of care.
PRESENTERS:
Linda Gravies
Senior ICP
M.D. Anderson Cancer Center
Brian Koll, MD, FACP, FIDSA
Professor of Clinical Medicine
Albert Einstein College of Medicine
Tuesday, June 5
Mary Ellen Scales, RN, MSN, CIC
Director, Infection Control Program
Baystate Health, Inc.
Mary Walczak
Asst. Director Infection Control
Kingsbook Jewish Medical Center
MODERATOR: Jan Frain, RN, CIC, CPHQ, CPHRM
Sponsored by
8-10:30 a.m. | Session 2101
Room 007
Infection Prevention Risk Assessment; the Starting
Place for Your IP Program
An organizational infection prevention risk assessment
can assist in setting priorities and in energizing teams
within an organization to implement a highly effective
infection prevention plan. This workshop will take
participants through the process of conducting an
infection prevention risk assessment.
OBJECTIVES:
䡲 Use a risk assessment tool to evaluate an organization for infection
potential.
䡲 Discuss three strategies to ensure a successful risk assessment process.
䡲 Describe a risk assessment tool to evaluate an organization for infection
potential.
PRESENTER:
Terrie Lee, RN, MS, MPH, CIC
Director, Infection Prevention and Employee Health
Charleston Area Medical Center
MODERATOR: Kit Reed, RN, BSN, MPH, CIC
29
Tuesday, June 5
8-10:30 a.m. | Session 2102
Ballroom C-3
NHSN - CAUTI Workshop: Preparing for CMS Reporting
Are you confident about your CAUTI reporting to
NHSN/CMS? This interactive audience participation
session will provide you the information you need for
successful CAUTI case finding and reporting via NHSN.
OBJECTIVES:
䡲 Review requirements for CAUTI reporting to CMS through NHSN.
䡲 Apply the Centers for Disease Control and Prevention /National
Healthcare Safety Network definitions and criteria for catheterassociated urinary tract infection (CAUTI) to case studies.
䡲 Recognize the method to identify denominators for CAUTI rate
calculations.
Infection surveillance is a critical component of any
Long-Term Care (LTC) infection prevention program. In
this session, participants will learn strategies for
developing an infection surveillance plan. Based on the
needs of the resident population in their facility; discuss
ways to implement infection surveillance definitions and
preview the NHSN LTC Component.
OBJECTIVES:
䡲 Learn strategies for developing an infection surveillance plan.
䡲 Discuss ways to implement infection surveillance definitions.
䡲 Describe the NHSN LTC Component.
PRESENTERS:
Katherine Allen-Bridson, RN, BSN, MScPH, CIC
Nurse Consultant
Angela Bivens-Anttila, RN, MSN, NP-C, CIC
Nurse Epidemiologist
Connie Steed, MSN, RN, CIC
Director, Infection Prevention
Greenville Hospital System University Medical Center
MODERATOR: Suzanne Cistulli, BSN, RN, CIC
8-10:30 a.m. | Session 2103
Room 006 CD
Human Factors and Ergonomics in Infection Prevention
This workshop is designed to provide an understanding
of human factors and systems engineering and how this
approach to infection prevention can improve performance,
prevent harm when error does occur, help systems
recover from error, and mitigate further harm.
OBJECTIVES:
䡲 Promote the use of human factors and systems engineering to minimize
the risk healthcare related infection.
䡲 Understand organizational issues related to infection prevention (e.g.,
organizational resilience, communication, teamwork).
䡲 Recognize the infection prevention interfaces between the job, the
person and the environment.
PRESENTER:
Carla Alvarado, PhD
Research Scientist Emerita
University of Wisconsin-Madison
30
8-10:30 a.m. | Session 2104
Room 008
How to Develop an Infection Surveillance Program in
Long-Term Care
MODERATOR: Denise Murphy, RN, MPH, CIC
PRESENTERS:
Lona Mody, MD, MSc
Associate Professor, University of Michigan
University of Michigan and VA Ann Arbor Healthcare System
Nimalie Stone, MD, MS
Medical Epidemiologist for Long-term Care
MODERATOR: Sally Hess, MPH, CIC
9:30-10:30 a.m. | Session 2200
Room 214 CD
Immediate Use Steam Sterilization: The New Frontier
Technological advancements in instrumentation and
sterilizer equipment as well as updated published evidence
based practices, standards and recommendations that
“flash sterilization” is an inadequate term that does not
fully describe the process. Accreditation, regulatory
agencies and, professional organizations recommend
that the same critical reprocessing steps (e.g. cleaning,
decontaminating, documentation, and transporting the
sterilized items) are followed regardless of the specific
sterilization cycle used. This presentation will describe
the most current multi-society positions on Immediate
Use Steam Sterilization.
OBJECTIVES:
䡲 Discuss the Multi-Society position statement on Immediate-Use Steam
Sterilization.
䡲 Describe the most current standards and recommendations on
immediate use sterilization according to AORN, AAMI, and CDC.
䡲 Develop a policy and procedure on Immediate Use Steam Sterilization.
PRESENTER:
Rose Seavey, MBA, RN, BS, CNOR, CRCST, CSPDT
President/CEO
Seavey Healthcare Consulting, LLC
䡲 State successful strategies adopted in European countries that have
achieved a substantial trans-national reduction in MRSA prevalence
over a relatively short time span.
PRESENTER:
Michael Borg, MD, PhD
Mater Dei Hospital
MODERATOR: Nancy Zanotti, RN, BSN, MPH, CIC
9:30-10:30 a.m. | Session 2202
Room 217 B
The Infection Prevention Liaison: Your Connection to
Improve Infection Prevention at the Bedside
This session will provide an overview of how to design
and implement an infection prevention liaison program.
The speaker will address the limitations and strengths of
a liaison program and how an effective program supports
the work of the infection preventionist.
Tuesday, June 5
Concurrent Sessions
OBJECTIVES:
䡲 Describe the strengths and limitations of a liaison program.
䡲 Recognize the benefits of having an active liaison program to improve
communication and clinical practice of infection prevention measures.
䡲 Define the role of the Infection Prevention Liaison.
PRESENTER:
MODERATOR: Linda Green, RN, MS, CIC
Vickie Brown, RN, MPH, CIC
Director Infection Prevention and Control
WakeMed
9:30-10:30 a.m. | Session 2201
Room 217 A
A View Across The Pond: Europe's Challenges and
Successes in Addressing Multi-Resistant Healthcare
Infections
The session will provide an overview of the current
situation related to multi-resistant healthcare infections
in Europe, highlight possible factors behind this
epidemiological picture and identify successful
strategies that have resulted in significant improvement
in several countries. The influence of national and
organizational culture will be particularly emphasized.
OBJECTIVES:
䡲 Discuss the epidemiology of multi-resistant healthcare infections, such
as MRSA and multi-resistant Gram negative bacteria, in the different
countries of Europe.
䡲 Describe the different potential drivers behind this diversity including the
possible impact of national and organization cultural characteristics and
values on clinical practices relevant to infection prevention and control.
31
Tuesday, June 5
9:30-10:30 a.m. | Session 2203
Room 214 AB
Facility Guidelines Institute Construction Guidelines
for ASHE
9:30-10:30 a.m. | Session 2204
Room 217 C
All in the Family: Partnering With Families to Improve
Outcomes
The 2010 Guidelines for Design and Construction of
Health Care Facilities are currently “under construction”
and will be released in 2014. There are many patient
safety and infection prevention features in the physical
environment being considered to enhance the current
guidelines. This session will compare and contrast the
infection prevention features of the 2010 guidelines and
will and describe proposed changes that will be included
in the 2014 edition.
Integrating families as essential members of the care
team. presents new infection prevention challenges and
requires new approaches. Partnering with families
around strategies for facility design, transmission-based
precautions, visitor screening, and communication at the
bedside can moderate HAI risk, improve family experience,
and support the best clinical outcomes.
OBJECTIVES:
䡲 Identify the national direction being taken to increase the infection
prevention capabilities of the physical environment.
䡲 Access the FGI comment website to participate in the comment review
OBJECTIVES:
䡲 Describe, in terms of improved outcomes for patients, the critical
benefits of partnering with families on infection prevention.
䡲 Identify challenges that involving families in patient care present in terms
of potential for disease transmission and hospital acquired infection.
䡲 Identify family-centered approaches to infection prevention challenges.
process.
䡲 Define and discuss the role the physical environment has in preventing
Healthcare associated infections.
PRESENTERS:
Linda Dickey, RN, MPH, CIC
Director of Epidemiology and Infection Prevention
University of California Irvine Healthcare
Douglas Erickson, BS, FASHE, CHFM, HFDP, CHC
Senior Project Manager
Northstar Management Co. LLC
MODERATOR: Barbara Soule, RN, MPA, CIC
PRESENTERS:
Joan Heath, BSN, RN, CIC
Director, Infection Prevention Program
Seattle Children's Hospital
Lynel Westby, BA, RN
Director, Patient and Family Support Services
Seattle Children's Hospital
9:30-10:30 a.m. | Session 2205
Room 217 D
Preventing CAUTI: Disrupting the Life Cycle of the
Urinary Catheter
This session will provide an overview of current and
upcoming surveillance, public reporting, and hospital
payment changes related to catheter-associated UTI
(CAUTI), and include an overview of recent progress and
challenges impacting rates of hospital-associated CAUTI.
OBJECTIVES:
䡲 Describe how challenges in data collection, interpretation, and
documentation urinary catheter use impacts public reporting and
reimbursement regarding hospital-acquired CAUTI rates.
䡲 Discuss current surveillance, public reporting, and major hospital
payment change requirements involving CAUTIs.
䡲 Describe recent trends in rates of hospital-acquired CAUTIs, according
to surveillance data and administrative data.
PRESENTER:
Jennifer Meddings, MD, MSc
Assistant Professor
University of Michigan
32
MODERATOR: Julia Moody, MS, SM (ASCP)
9:30-10:30 a.m. | Session 2300
T's: Talk With Titus, Tom, and Tracy
Room 212 B
Come meet a team from a large academic medical
center that, includes the administrative, healthcare
epidemiology, and infection preventionist perspective.
The presenters will discuss approaches and challenges
related to the prevention of HAIs by fielding real-world
questions and scenarios from the audience. Be prepared
for a dynamic and interactive discussion that will
showcase diverse approaches on how to tackle various
infection prevention issues.
OBJECTIVES:
䡲 Describe the diverse approaches to IP challenges.
䡲 Discuss IP issues relevant to participants and provide expert response.
䡲 Describe real world issues in Infection control and Prevention with
practical and applicable solutions.
PRESENTERS:
Titus Daniels, MD, MPH, MMHC
Vice Chair for Clinical Affairs, Department of Medicine
Vanderbilt University School of Medicine
Tracy Louis, MSN, RN, CIC
Infection Prevention Consultant
Thomas Talbot, MD, MPH
Associate Professor of Medicine, Chief Hospital Epidemiologist
9:30-10:30 a.m. | Session 2301
Room 212 A
Occupational Health Issues That ‘Should’ Keep
You Up at Night
This session will provide a concise review of key
occupational health issues relevant to infection control
including an update of the recently released ACIP
immunization recommendations for healthcare providers
(HCP). We will discuss post-exposure prophylaxis for
bloodborne pathogens, screening for TB, and work
restrictions.
OBJECTIVES:
䡲 Describe current ACIP recommendations for the immunization of
healthcare personnel.
䡲 State the current recommendations for screening and treating HCP for
both latent and active TB.
䡲 Discuss the currently available post-exposure therapies for
communicable disease exposure including HIV, HBV, and HCV.
Tuesday, June 5
Ask-the-Expert
PRESENTERS:
David Henderson, MD
Deputy Director for Clinical Care
Clinical Center, National Institutes of Health
David Weber, MD, MPH
Professor
University of North Carolina at Chapel Hill
MODERATOR: Linda Gross, MSN, APRN, ANP-BC, CIC, COHN-S
MODERATOR: Barbara Russell, RN, MPA, CIC
33
Tuesday, June 5
9:30-10:30 a.m. | Session 2302
Room 210 B
Bugs Behind Bars: Infection Prevention and Control in
Jails, Prisons, and Mental Health Facilities
One percent of adults are currently incarcerated, and more
than 2 million adults are hospitalized with mental illness
annually. This session will provide useful information for
those tasked with prevention and control of MRSA, MTB,
influenza, norovirus, BBP, and other communicable
diseases in jails, prisons, and mental health facilities.
OBJECTIVES:
䡲 Describe the basic demographics of those residing in jails, prisons, and
metal health facilities in this country.
䡲 Understand the challenges and opportunities associated with prevention
and control of MRSA, gastroenteritis, tuberculosis, influenza, and other
common contagious conditions within the correctional and mental
health setting.
䡲 Have a better appreciation of how improved infection prevention and
control within jails, prisons, and metal health facilities positively
impacts upon the public health of the outside community.
PRESENTER:
Complimentary lunch will be served in the back of the
exhibit hall from 11:30 a.m.–1 p.m. We welcome all
attendees with a wallet-style badge to join us.
11 a.m.-1 p.m.
11 a.m. EXPERTS:
Ruth Carrico, PhD, CIC
Associate Professor
Marita Nash, CHESP, MBA
Director of Environmental Services and Linen
Hunterdon Medical Center
MODERATOR: Neil Pascoe, RN, BSN, CIC
12 p.m. EXPERT:
The Accountable Care Act calls for more ambulatory
care. Federal focus on ambulatory on infection prevention
programs. Federal patient safety reporting goes into
effect October 2012 The ambulatory setting infection
preventionist wears more than one hat. Let's collaborate
on dealing with these and other challenges.
OBJECTIVES:
䡲 Itemize the patient safety issues reportable to CMS beginning October 2012.
䡲 Discuss the challenges facing infection preventionists in the ambulatory
settings.
䡲 Articulate the value of colloration with risk management to address the
business/financial aspect of prevention of HAC.
PRESENTER:
Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM
Consultant, Risk Management, Infection Prevention and Patient Safety
The Kicklighter Group, LLC
MODERATOR: Kim Delahanty, RN, BSN, PHN, MBA/HCM, CIC
Exhibit Hall C & D
Joseph Bick, MD
Chief Medical Executive, Infectious Diseases Consultant
California Medical Facility, California Correctional Health Care Services
9:30-10:30 a.m. | Session 2303
Room 210 A
Ambulatory Care Challenges of the Now and the
Future. Ask the Expert. Let's Talk.
34
Exhibit Hall Open
10:30 a.m.-1:30 p.m.
Jonathan Otter, MD
Research Fellow, CIDR & Scientific Director, Bioquell
Poster Presentations with Presenters
12:30-1:30 p.m.
Exhibit Hall D
Posters are arranged by topic number, listed below, and
then numerically by publication number within each
category.
Antimicrobial Resistance
1-002 to 1-006
Emerging and Reemerging Infectious Diseases
5-057 to 5-062
Infection Prevention and Control Programs
8-078 to 8-128
Outbreak Investigation
9-129 to 9-139
Public Reporting/ Regulatory Compliance
11-147 to 11-148
Quality Management Systems/
Process Improvement/Adverse Outcomes
12-149 to 12-186
Surveillance
16-227 to 16-246
1:30-2:30 p.m. | Session 2400
Room 214 CD
MDR Gram-Negative Infections: Across the Continuum
of Care
Gram-negative infections are not just a hospital problem.
This session will focus on the impact that multi-drug
resistant Gram-negative bacilli have had on the
community and other healthcare settings. Methods for
control of spread of these pathogens will be reviewed
and opportunities and challenges pertaining to these
pathogens will be discussed.
OBJECTIVES:
䡲 Describe the epidemiology of MDR Gram-negative bacilli in community
and healthcare settings.
䡲 Discuss different methods to control the spread of these pathogens in a
variety of settings.
䡲 Describe challenges and opportunities for future management and
control for these pathogens.
PRESENTER:
Emily Rhinehart, RN, MPH, CIC, CPHQ
Vice President and Division Manager
Global Loss Prevention
Chartis Insurance
1:30-2:30 p.m. | Session 2402
Room 217 B
Molecular Tools for Outbreak Investigations
This session will showcase modern technologies and
tools to assist in outbreak investigations. Do you know
what Pulse Field Electrophoresis is? How do you use
antibiotic susceptibilities to determine the similarities of
bacteria? Come join us for this session and hear how to
apply these technologies to improve your IP program.
OBJECTIVES:
䡲 Identify and appraise the appropriate microbiological tool for
identification and investigation of an outbreak.
䡲 Compare and contrast the advantages and disadvantages of available
techniques for identification of outbreaks.
Keith Kaye, MD, MPH
Professor of Medicine
Wayne State University
䡲 Interpret findings and data from modern technologies used in clinical
MODERATOR: Titus Daniels, MD, MPH
PRESENTER:
1:30-2:30 p.m. | Session 2401
Room 217 A
Infection Prevention Programs Measured Against
Evidenced-Based Practice
MODERATOR: Neil Pascoe, RN, BSN, CIC
This session will provide the results of the assessment of
more than 20 hospital-based infection control programs.
The Best Practice Assessment for the Prevention of
Healthcare-associated Infections is based upon published
guidelines and compendiums. The standardized
assessment results in a score as well as the identification
of specific recommendations for improvement.
OBJECTIVES:
䡲 Identify sources of evidence-based practices that should be utilized to
develop and implement infection prevention programs (IPP) and how to
apply them in a standardized assessment.
䡲 Evaluate trends of non-compliance to best practices in a sample of
more than 20 US hospitals.
䡲 Develop strategies to improve best practice in IPPs.
Tuesday, June 5
Concurrent Sessions
microbiology that can assist outbreak investigations.
Luke Chen, MBBS, MPH, CIC, FRACP
Co-Medical Director
Duke Program for Infection Prevention and Healthcare Epidemiology
Duke University Medical Center
1:30-2:30 p.m. | Session 2403
Room 214 AB
Perspectives on Use of Standardized Infection Ratios
(SIRs) for Assessing Performance: A Surgeon and an
Please refer to the addendum for full session details.
PRESENTERS:
Lynn Janssen, MS, CIC
Coordinator, HAI Liaison Program
California Department of Public Health
PRESENTERS:
Betsy Hugenberg, BSN, MSA, RN, CIC
Regional Consulting Manager
Healthcare Division
Chartis Insurance
35
Tuesday, June 5
1:30-2:30 p.m. | Session 2404
Room 217 C
Living Longer But are They Better? Targeted Methods
to Improve Outcomes in Nursing Home Residents:
Modifiable Risk Factors for Respiratory Infections
The presenter will discuss key components of a structured
program proven to modify risk factors for respiratory
infections in nursing home residents. Methods of clinical
application will be described including: intensive oral
hygiene, identification of dysphagia, aspiration prevention
protocols, and a commitment to implement a universal
vaccination program.
OBJECTIVES:
䡲 Describe the rationale and apply the key components of an effective oral
hygiene program.
䡲 Implement three evidence- based interventions into actionable facility
practices shown to have a significant impact on respiratory tract
infection outcomes in long-term care residents.
䡲 Assess the effect of modifiable risk factors that increase the potential
for respiratory tract infections in nursing home residents.
PRESENTER:
Sharon Bradley, RN, CIC
Senior Infection Prevention Analyst
ECRI Institute
Pennsylvania Patient Safety Authority
MODERATOR: Alicia Halloran, RN, MSN
1:30-2:30 p.m. | Session 2405
Room 217 D
Making “Contagion” Contagious: Views from the Lab
and the Set
You may have seen the hit movie, “Contagion” but did
you take note of what worked, what didn't and why? This
session will be presented by the medical advisor who
guided the film makers. Practical and useful information
will be provided that will elevate your emergency
preparedness to a whole new level.
OBJECTIVES:
䡲 Describe the process by which the movie Contagion was made and
promoted.
䡲 Describe what worked and didn't work in the making of Contagion.
䡲 Describe why certain processes in the making of Contagion worked and
didn't work.
PRESENTER:
W. Ian Lipkin, MD
Director, Center for Infection and Immunity
Columbia University
36
Workshops
1:30-4 p.m. | Session 2700
How and Why to Write an Abstract
Room 006 AB
This workshop is designed to assist infection
preventionists in developing their skills to successfully
prepare abstracts for submission to international
scientific conferences such as APIC. This session will
provide a hands-on, mentoring approach to guide the
participants in effective technical writing through
interactive discussions and feedback on drafted
abstracts. You will leave this session with confidence
and the ability to submit an abstract to next year’s
APIC conference.
OBJECTIVES:
䡲 Describe how to conduct an electronic literature search.
䡲 Utilize real time peer review to generate submission ready abstracts.
䡲 Define the essential components of an abstract.
PRESENTERS:
Kate Ellingson, PhD
Epidemiologist
Teresa Fulton, RN, MSN, CIC
Chief Quality Officer
Whidbey General Hospital
Oregon Patient Safety Commission
1:30-4 p.m. | Session 2701
Clean Spaces, Healthy Patients
Room 007
Environmental contamination plays a key role in the
transmission of several healthcare-associated pathogens
including methicillin-resistant Staphylococcus aureus
[MRSA], vancomycin-resistant Enterococcus [VRE],
Acinetobacter, norovirus, and Clostridium difficile. All
these pathogens have been demonstrated to persist in
the environment for hours to days (in some cases
months), frequently contaminate the environmental
surfaces in rooms of colonized or infected patients,
transiently colonize the hands of healthcare personnel,
be transmitted by healthcare personnel, and cause
outbreaks in which environmental transmission was
deemed to play a role. Further, admission to a room in
which the previous patient had been colonized or
infected with MRSA, VRE or C. difficile, has been shown
to be a risk factor for the newly admitted patient to
develop colonization or infection.
of HAIs.
䡲 Identify four pathogens that have been demonstrated to persist in the
environment and potentially cause outbreaks.
䡲 Describe best practices for environmental cleaning and assessment of the
adequacy of room disinfection practices to minimize transmission of HAIs.
1:30-4 p.m. | Session 2702
Ballroom C-3
Gaining Analytic Insights from NHSN for Prevention:
Focus on CLABSI and CAUTI
This workshop will focus on analysis of HAI surveillance
data from NHSN. Presenters will demonstrate the use of
NHSN data in case-scenarios in order to apply analytic
knowledge in assessing HAI experience, internal data
quality, and HAI prevention practices.
PRESENTERS:
Director, Hospital Epidemiology; Professor; Director, Statewide Program
for Infection Control and Epidemiology
University of North Carolina Health Care and University of
North Carolina School of Medicine
Philip Carling, MD, MPH
Clinical Professor of Medicine
Boston University School of Medicine
Curtis Donskey, MD
Chair, Infection Control Committee
Cleveland VA Medical Center
Nancy Havill, MT (ASCP)
Infection Prevention and Epidemiology Program
Hospital of Saint Raphael
Jon Otter, MD
Research Fellow (CIDR) / Scientific Director (Bioquell)
Centre for Clinical Infection and Diagnostics Research (CIDR),
Kings College London & Guys and St. Thomas Hospital NHS
Foundation Trust / Bioquell
OBJECTIVES:
䡲 Apply statistical methods in the interpretation of rates and SIR
comparisons and understand methods behind statistical measures used
in NHSN and for the CMS Hospital Inpatient Quality Reporting Program.
䡲 Correctly apply NHSN analytical functions to case-scenarios to illustrate
analysis features and identify problems and successes within a
reporting facility.
䡲 Understand how various metrics obtained from NHSN can be interpreted
and used to drive prevention of HAIs.
Tuesday, June 5
OBJECTIVES:
䡲 Recognize the role of environmental contamination in the transmission
PRESENTERS:
Margaret Dudeck, MPH, CPH
Epidemiologist
Jonathan Edwards, MStat
Research Mathematical Statistician
Professor
Kelly Peterson, BBA
NHSN Data Manager/Information Technologist Specialist
MODERATOR: Shannon Oriola, RN, BSN, CIC, COHN
Sponsored by
37
Tuesday, June 5
Workshops
Concurrent Sessions
1:30-4 p.m. | Session 2703
Room 006 CD
Bored to Death? How to Sustain Quality and Safety
Improvements in the ICU
3-4 p.m. | Session 2500
Room 214 CD
The Emperor's New Clothes - CLABSI Definition and Its
Impact on You, the IP
How many times has this happened to you? You finally
managed to drop the rate of infection X/Y/Z in your ICUs.
But six months later, it's creeping back up. In this session,
ICU clinicians will focus on approaches and tools to
enhance sustainability of improvements in the ICU setting.
Attendees will review the current NHSN definition for
CLABSI, discuss potential concerns with the definition,
and upcoming changes to address these concerns. Now
that CLABSI rates are being publically reported in many
places, this issue has been elevated to new heights.
OBJECTIVES:
䡲 Summarize key ICU-specific and human-factored barriers to sustaining
OBJECTIVES:
䡲 Identify potential pitfalls with the NHSN definition for CLABSI.
䡲 Discuss the impact of the current NHSN definition on clinical activities
infection-control-related improvements from the point of view of ICU
providers.
䡲 Discuss key strategies for overcoming barriers to sustainability of
infection control-related improvements in the ICU.
䡲 Apply these strategies to increase sustainability of improvements in
their own ICUs.
PRESENTERS:
Jean Gillis, RN, MS
Clinical Nurse Specialist
Beth Israel Deaconess Medical Center
Michael Howell, MD, MPH
Director, Critical Care Quality
Beth Israel Deaconess Medical Center / Harvard Medical School
MODERATOR: Nancy Zanotti, RN, BSN, MPA, CIC
1:30-4 p.m. | Session 2704
Room 008
Beyond CMS: Assessing Your Ambulatory Facility
Utilizing a worksheet that has guided one institution's
journey through four successful accreditation surveys in
five years, you will learn to assess all aspects of infection
prevention in your physician practice or specialty clinic
from safe injection practices to disinfection and
sterilization to refrigerated medications and beyond.
attempt to address current concerns.
PRESENTER:
Dev Anderson, MD, MPH
Assistant Professor of Medicine
Duke University Medical Center
MODERATOR: Vickie Brown, RN, MPH, CIC
3-4 p.m. | Session 2501
Room 217 A
Prolonged Use of Respiratory Protection:
How Does it Affect the Healthcare Worker?
Healthcare personnel (HCP) wear respirators to protect
themselves from acquiring disease. What do we know
about the physiological and psychological effects of
long-term respirator usage, such as during outbreaks or
pandemics? Research related to long-term respirator
usage, including a surgical mask overlay as
recommended by the Institute of Medicine, will be
reviewed and health policy guidance will be provided.
OBJECTIVES:
䡲 Identify obstacles to long-term respiratory protection use among HCP.
䡲 Recognize physical, psychological, and behavioral findings that may
place HCP at risk when wearing respiratory protective equipment.
OBJECTIVES:
䡲 Utilize the provided worksheet to guide an infection prevention
䡲 Describe interventions that may protect HCP wearing respiratory
assessment of an ambulatory care facility.
䡲 Collect and analyze data as a result of implementation of the worksheet.
䡲 Conduct an effective and complete assessment of an ambulatory care
facility.
PRESENTERS:
PRESENTER:
Infection Prevention Coordinator, Ambulatory Care
UNC Healthcare System
38
and rapport between infection control and clinical teams.
䡲 Discuss upcoming changes to the NHSN definition for CLABSI that
MODERATOR: Amy Richmond, RN, BSN, MHS, CIC
protective equipment for prolonged periods.
Associate Professor
School of Public Health and Information Sciences
Terri Rebmann, PhD, RN, CIC
Associate Professor
Institute for Biosecurity
Saint Louis University School of Public Health
MODERATOR: Judith English, RN, MSN, CIC
3-4 p.m. | Session 2505
Room 217 D
Planning and Implementation of an Infection
Prevention and Control Training Program for
Healthcare Providers in Latin America
This session will review the Infection Preventionist
Competency Model developed by APIC leaders. The
model illustrates a path for current and future practice
along the infection preventionist's career span. The
design of the model will be reviewed as well as the four
competency domains and recommended areas for
professional development.
With healthcare institutions and educational centers
hosting this course, we collaboratively planned and
implemented a multinational infection prevention and
control (IPC) training course in Latin America to build
their IPC program capacity. We trained over 150
infection preventionists and most of them are improving
IPC in their country's hospitals.
OBJECTIVES:
䡲 Discuss principles behind the development of the IP Competency Model
OBJECTIVES:
䡲 Describe the historical context of the IP career development in Latin
and elements of the model's graphic design.
䡲 Identify the four key competency domains and success factors
associated with each domain.
䡲 Discuss how the competency model can support professional
development from novice to expert practice and can be applied in
diverse settings.
PRESENTERS:
Terrie Lee, RN, MS, MPH, CIC
Director, Infection Prevention and Employee Health
Charleston Area Medical Center, Charleston, WV
America.
䡲 Describe the role and responsibilities of the IP.
䡲 Upon completion the participant will be able to describe educational
resources for IPs in Latin America.
Tuesday, June 5
3-4 p.m. | Session 2502
Room 214 AB
A Long and Winding Road: Meeting Current
Challenges, Preparing for Future Demands: APIC
Introduces a Model of IP Competency
PRESENTER:
Miguela Caniza, MD
Associate Member, Department of Infectious Diseases
Director of the Infectious Disease - International Outreach
St. Jude Children's Research Hospital
MODERATOR: Barbara Bor, BSN, CIC
Denise Murphy, RN, BSN, MPH, CIC
Vice President, Quality and Patient Safety
Main Line Health System
Russell Olmsted, MPH, CIC
Director, Infection Prevention and Control Services
Saint Joseph Mercy Health System
MODERATOR: Marilyn Hanchett, RN, MA, CPHQ, CIC
3-4 p.m. | Session 2504
Room 217 C
Clostridium difficile in Long-term Care Facilities
Long-term care facilities (LTCFs) have borne a significant
proportion of the increasing burden of Clostridium
difficile infection (CDI). This session will focus on the
epidemiology of CDI in LTCFs and present scenarios
that illustrate challenges for diagnosis, prevention,
and NHSN reporting requirements in LTCF.
PRESENTERS:
Curtis Donskey, MD
Chair, Infection Control Committee
MODERATOR: D. Kirk Huslage, RN, BSN, MSPH
Ask-the-Expert
3-4 p.m. | Session 2600
Room 212 B
Preventing CAUTI: Disrupting the Lifecycle of the
Urinary Catheter
This session will describe a new conceptual model - the
lifecycle of the urinary catheter - to help frame the
discussion and organize many potential interventions for
preventing CAUTIs into a series of actionable targets.
Pearls and pitfalls for implementation shall be showcased.
OBJECTIVES:
䡲 Identify actionable targets in the lifecycle of the urinary catheter to
design and implement interventions to prevent hospital-acquired
CAUTIs.
䡲 Summarize tools and strategies available to reduce inappropriate
catheter placement and prolonged use.
䡲 Recognize common challenges in implementing CAUTI prevention
interventions, to inform and modify on-going and future interventions.
PRESENTER:
Jennifer Meddings, MD, MSc
Assistant Professor
University of Michigan
MODERATOR: Beth Ann Kavanaugh, MT (ASCP), MS, MBA, CIC
39
Tuesday, June 5
Wednesday, June 6
3-4 p.m. | Session 2602
Room 210 B
Evidence-Based Prevention of Catheter-Related BSI
Posters on Display
7 a.m.-1 p.m.
Exhibit Hall D
PRESENTER:
Dennis Maki, MD
Department of Medicine - Infectious Disease Division
University of Wisconsin School of Medicine & Public Health
Concurrent Sessions
8-9 a.m. | Session 3000
Hand Hygiene Update
Room 214 CD
MODERATOR: Carole Guinane, RN, MBA
For such a ‘simple’ and low-tech procedure, hand
hygiene (HH) has received increasing attention from both
clinicians and administrators/regulators. In the session,
we will discuss the latest thinking and research
regarding HH efficacy and behavioral strategies.
3-4 p.m. | Session 2603
Room 210 A
The Role of the Infection Preventionist in Clostridium
difficile Infection Prevention
OBJECTIVES:
䡲 Describe and assess evidence-based and indicator-based strategies for
This review of the current topics relevant to the
prevention of healthcare acquired Clostridium difficile
infections will showcase the role of the infection
preventionist. A focus on the four work streams to
prevent CDI will include hand hygiene, environmental
cleaning, isolation practices, and antimicrobial
stewardship.
OBJECTIVES:
䡲 Describe environmental cleaning practices which can reduce HAIs and
list one innovative method to improve hand hygiene adherence and
isolation practices.
䡲 Describe measures of quality to determine adequate environmental
decontamination.
䡲 Describe how the IP can contribute to the development, maintenance,
and enhancement of a successful antimicrobial stewardship program.
PRESENTERS:
Sue Barnes, RN, BSN, CIC
National Program Leader Infection Prevention and Control
Kaiser Permanente
Stephen Parodi, MD
Chairman, The Permanente Medical Group Chiefs of Infectious Disease
Kaiser Permanente
monitoring HH.
䡲 Examine the role of leadership in HH behavior.
䡲 Discuss recent information about motivators and individual differences
and perceptions regarding HH.
PRESENTER:
Elaine Larson, PhD, FAAN, RN, CIC
Associate Dean
MODERATOR: Jolynn Zeller, RN, BS, CIC
8-9 a.m. | Session 3001
Room 217 A
Social Networks of Infection Preventionists to Share
Knowledge
Many opportunities exist for the use of social networking
in sharing knowledge and initiating and maintaining
collaboration with peers across all healthcare settings.
Using the social networks identified among infection
preventionists in Kentucky and Iowa as examples, this
session will demonstrate the knowledge sharing impact
and capabilities of these networks.
OBJECTIVES:
䡲 Define social networks and demonstrate their impact on infection
prevention and control in various types of healthcare facilities.
䡲 Describe the existing knowledge sharing processes using an evaluation
of the social networks identified among IPs in Kentucky and Iowa.
䡲 Identify opportunities to improve knowledge sharing, communication,
4:30-6 p.m.
Room 205
APIC Business Meeting (Members Only)
Meeting materials can be picked up at APIC Central
starting on Sunday, June. 3.
40
and infection prevention and control practice through the use of social
networks.
PRESENTER:
Timothy Wiemken, PhD, MPH, CIC
University of Louisville School of Medicine, Division of Infectious Diseases
MODERATOR: Shannon Oriola, RN, BSN, CIC, COHN
8-9 a.m. | Session 3004
Room 217 C
A Collaborative Approach to Prevent CLABSI in
Hemodialysis Patients
The use of antimicrobial agents has been associated with
adverse consequences, including the development and
propagation of antimicrobial resistance. In this session,
we will discuss strategies that can be used to improve
antibiotic prescribing practices and practical suggestions
for implementation of these strategies in hospitals and
other healthcare settings.
This session will review the CDC’s perspective on
bloodstream infections (BSI) in hemodialysis and review
strategies for prevention, including data from the
Dialysis BSI Prevention Collaborative. The presenters will
share their experiences and interventions leading to 1) a
sustained reduction of CLABSIs and 2) overcoming
barriers and enacting change.
OBJECTIVES:
䡲 Describe the association between antimicrobial use and antimicrobial
OBJECTIVES:
䡲 Describe a collaborative approach to preventing BSIs and advantages of
resistance.
䡲 Define antimicrobial stewardship and list three benefits that
antimicrobial stewardship programs may bring to a healthcare facility.
䡲 List at least three strategies to optimize antimicrobial prescribing
practices within a healthcare facility.
this approach.
䡲 Identify several evidence-based practices that can be implemented in
your hemodialysis facilities to reduce bloodstream BSIs.
䡲 Describe how one facility overcame barriers to address practical
challenges and adopt new practices.
PRESENTER:
PRESENTERS:
David Calfee, MD, MS
Associate Professor of Medicine and Public Health
Weill Cornell Medical College
Virginia (Ginnie) Bren, RN, MPH, CIC
Infection Control Coordinator
Altru Health System
MODERATOR: Lela Luper, RN, BS, CIC,
Gemma Downham, MPH, CIC
Infection Prevention Epidemiologist
AtlantICare Regional Medical Center
8-9 a.m. | Session 3003
Room 214 AB
Working Overseas in Military Infection Control
Have you ever considered being an infection control
consultant in a foreign country? The presenter will
describe some of the challenges, successes, and rewards
encountered during her tenure providing infection
control care to wounded warriors in a Level One Trauma
Military setting in Germany.
OBJECTIVES:
䡲 Discuss challenges involved in developing MDRO screening protocols for
injured soldiers arriving from the battlefield.
䡲 Describe the utilization of evidence- based isolation principles for
developing on-the-spot solutions when facing emerging pathogens.
䡲 Utilize provided references, policies, tools, and checklists to facilitate
site assistance visits in a variety of settings.
Wednesday, June 6
8-9 a.m. | Session 3002
Room 217 B
Antimicrobial Stewardship: Optimizing Outcomes by
Improving Antimicrobial Prescribing Practices
Priti Patel, MD, MPH
Medical Officer
MODERATOR: Sue Barnes, RN, CIC
8-9 a.m. | Session 3005
Room 217 D
Prevention of Catheter Related BSI: Zero Will Not Be
Achievable Without Technology
PRESENTER(S):
Dennis Maki, MD
Department of Medicine - Infectious Disease Division
University of Wisconsin School of Medicine & Public Health
PRESENTER:
Jane Pool, RN, MS, CIC
Director, Infection Prevention and Control
Department of the Army
MODERATOR: Frank Myers, MA, CIC
MODERATOR: Mary Post, RN, MS, CNS, CIC
41
Wednesday, June 6
Workshops
8-10:30 a.m. | Session 3100
Room 006 AB
To Lead or to Follow: That is the Question
Leadership is the topic of countless books, courses, and
workshops. Followership is a topic often overlooked or
forgotten. This workshop will explore why the distinctions
among followers are every bit as consequential as those
among leaders, and have critical implications for how
leaders should lead, and managers should manage.
OBJECTIVES:
䡲 Describe the characteristics of transformational leaders and effective
followers.
䡲 Analyze the leader-follower relationship.
䡲 Enhance personal leadership and followership skills.
PRESENTER:
Associate Professor, Director Doctor of Nursing Practice Program
Thomas Jefferson University
This workshop will focus on analysis of surgical site
infection (SSI) surveillance data from NHSN. Presenters
will demonstrate the use of NHSN data in case-scenarios
in order to apply analytic knowledge in assessing SSI
experience, internal data quality, and SSI prevention
practices.
OBJECTIVES:
䡲 Apply statistical methods in the interpretation of rates and SIR
comparisons and understand methods behind statistical measures used
in NHSN and for the CMS Hospital Inpatient Quality Reporting Program.
䡲 Correctly apply NHSN analytical functions to case-scenarios to illustrate
analysis features and identify problems and successes within a
reporting facility.
䡲 Understand how various metrics obtained from NHSN can be interpreted
and used to drive prevention of HAIs.
PRESENTERS:
MODERATOR: Titus Daniels, MD, MPH
8-10:30 a.m. | Session 3101
Room 007
Using Performance Improvement Tools to Drive
Performance Improvement is a critical competency for
infection preventionists. This session will review basic
steps in the improvement process, including
implementation science, Lean and Six Sigma. Examples
of how meaningful change in process and/or behaviors to
reduce HAIs shall be shared.
OBJECTIVES:
䡲 Discuss steps involved in setting up a performance/process
improvement project.
䡲 Identify at least two different methods that have been used for
infection prevention related PI projects: Lean and Six Sigma.
䡲 Describe gaps that may be barriers to achieving zero CLABSI and
solutions for some of these barriers.
PRESENTERS:
Mustafa Abdulali, MBA
Lead Performance Improvement Engineer
Vice President, Quality and Patient Safety
42
8-10:30 a.m. | Session 3102
Ballroom C-3
Gaining Analytic Insights from NHSN for Prevention:
Focus on Surgical Site Infection
Margaret Dudeck, MPH, CPH
Epidemiologist
Jonathan Edwards, MStat
Research Mathematical Statistician
Kelley Petersen, BBA
NHSN Data Manager/Information Technologist Specialist
MODERATOR: Lynn Janssen, MS, CIC
8-10:30 a.m. | Session 3104
Room 008 AB
Challenges and Success in Caring For the
Immunocompromised Patients in Low Income Countries
The unlikely combination of design and healthcare
is yielding imaginative ideas and powerful results.
This workshop will explore design thinking and offer a
hands-on opportunity to try out a few “easy to apply”
techniques.
Infections are major reasons for failure to cure cancer
throughout the world, and more so in low income
countries (LIC). Good understanding of the rates and
types of infections, as well as risk factors for these
infections, is a required step for targeted interventions.
In these presentations we will review the most frequent
types of infections and their risks based on the types of
malignancies and phases of anticancer treatment.
Causes of these infections are multifactorial and
focusing on targeted and cost effective interventions is
feasible to improve outcomes.
OBJECTIVES:
䡲 Understand the basics of design thinking.
䡲 Ability to more fully explore problems with qualitative and creative
techniques.
䡲 Better understand how the human complexities of medication
administration and how Kaiser Permanente solved the challenge.
PRESENTERS:
Chris McCarthy, MBA, MPH
Innovation Specialist / Director
Kaiser Permanente
Stephen Szermer, MID
Collaborative Lead
Innovation Learning Network
OBJECTIVES:
䡲 Describe current challenges in infection prevention and control in LICs.
䡲 List main infectious complications in cancer and their risk factors.
䡲 List interventions feasible for LICs.
PRESENTERS:
Miguela Caniza, MD
Associate Member, Department of Infectious Diseases; Director of the
Infectious Disease - International Outreach
St. Jude Children’s Research Hospital
Wednesday, June 6
8-10:30 a.m. | Session 3103
Room 006 CD
Innovation at the Front Line: A Deep Discovery of Why
and a Firing Up the Imagination for How
MODERATOR: Amy Richmond, RN, BSN, MHS, CIC
Joanna Acebo, MD
Pediatric Infectious Diseases Physician
Hospital SOLCA-Ncleo de Quito
Sergio Gomez, MD
Hematologist/Bone Marrow Transplant
Hospital de Niños de La Plata
Alejandro Macias, MD
Head, Infection Control
National Institute of Medical Sciences and Nutrition
Elham Mandegari, MD
ID Pediatrics
Hospital Escuela, Honduras
Mario Melgar, MD
Infectious Diseases Physician
Unidad Nacional de Oncología Pediátrica
MODERATOR:
Don Guimera, BSN, RN, CIC ,CCRP
43
Wednesday, June 6
Concurrent Sessions
9:30-10:30 a.m. | Session 3200
Room 214 CD
Vaccine Preventable MDROs and HAIs
This session will review the use of influenza vaccine,
pneumococcal vaccine, and varicella/zoster vaccines to
prevent infections with multidrug-resistant pathogens. The
use of vaccines to prevent healthcare-associated infections
such as MRSA and C. difficile will also be discussed.
OBJECTIVES:
䡲 Upon completion participants will understand the key role vaccines play
in public health.
䡲 Upon completion participants will understand how vaccines can be used
to prevent infection with multidrug-resistant pathogens.
䡲 Upon completion participants will understand the current state of
research on using vaccines to prevent infections due to healthcareassociated pathogens (e.g., MRSA, C. difficile).
9:30-10:30 a.m. | Session 3202
Room 217 B
Your Infection Prevention Program: How to Size it and
How to Sell it
Infection Prevention is in the limelight--let’s take advantage
of it! Multiple agencies are increasingly interested in the
infection prevention arena. We’ll discuss some successful
strategies for determining what types and number of
resources your program needs to meet those requests,
and presenting the business case to senior leaders.
OBJECTIVES:
䡲 Define discrete tasks necessary to respond to additional requests for IP
information.
䡲 Articulate two methods for “sizing” defined tasks.
䡲 Develop escalating plans for requesting appropriate resources.
PRESENTER:
Amy Nichols, RN, MBA, CIC
Director, Hospital Epidemiology and Infection Control
University of California Medical Center and Benioff Children’s Hospital
PRESENTER:
Professor
9:30-10:30 a.m. | Session 3203
Room 214 AB
Changing the Approach to VAP Surveillance
9:30-10:30 a.m. | Session 3201
Fecal Transplants
Room 217 A
Did you ever, in your wildest dreams, imagine that stool
would be a treatment therapy? This session will review
the scientific rationale for fecal bacteriotherapy for
patients with severe Clostridium difficile disease.
Practical considerations such as the identification and
screening of suitable recipients and donors, and the
details of performing the procedure will be discussed to
aid in the development of a program.
OBJECTIVES:
䡲 Describe the role of fecal bacteriotherapy in the treatment of refractory
or relapsing Clostridium difficile disease.
䡲 Recognize the role of the IP in the development and implementation of a
fecal transplant program.
䡲 Develop a program at your facility which will allow for the practical
delivery of this important therapy.
This session will provide an overview of the development
of a new ventilator-associated event algorithm developed
in collaboration with several key societies and
organizations. Perspectives on this changing approach to
VAP surveillance will be provided by representatives from
the CDC, Critical Care and APIC.
OBJECTIVES:
䡲 Discuss the process of revising the approach to VAP surveillance in the
National Healthcare Safety Network.
䡲 Review the new approach to surveillance for ventilator-associated events.
䡲 Discuss the potential risks and benefits of the new approach from the
perspectives of infection control and prevention, critical care and public
health.
PRESENTERS:
Linda Greene, RN, MPS, CIC
Rochester General Health System
PRESENTER:
44
Stephen Parodi, MD
Chairman, The Permanente Medical Group Chiefs of Infectious Disease
Kaiser Permanente
Beth Hammer, MSN, RN, APN-BC
Nurse Practitioner
American Association of Critical-Care Nurses
MODERATOR: Barb DeBaun, RN, MSN, CIC
Shelley Magill, MD, PhD
Medical Officer
MODERATOR: Linda Goss, MSN, APRN, ANP-BC, CIC, COHN’s
Room 217 C
If you are interested in knowing about the latest efforts
being made by CMS, HHS and other partners to reduce
HAIs in long-term care facilities, this is the session for you.
OBJECTIVES:
䡲 Describe the current state of the science of HAI prevention in long-term
care facilities.
䡲 Identify research opportunities/knowledge gaps in our understanding of
HAI prevention in long-term care.
䡲 Describe several factors that may influence rates of HAIs in long-term care.
PRESENTER:
Ian Kramer, MS
Social Science Research Analyst
Office of Clinical Standards and Quality, Centers for Medicare &
Medicaid Services
Ask-the-Expert
9:30-10:30 a.m. | Session 3300
SCIP and Beyond
Room 212 B
While the SCIP process initiative represents the first step
in improving patient outcomes, additional evidence-based
practices should be embraced in our efforts to reduce risk,
improving surgical patient care. The present discussion
will focus on those adjunctive strategies that together
with SCIP provide an evidence-based care bundle.
OBJECTIVES:
䡲 Describe the pros and cons of the current SCIP process initiative.
䡲 Review the role of patient intrinsic and extrinsic risk factors in the
evolution of postoperative surgical site infections.
䡲 Discuss the evidence-based foundation for adjunctive interventional
strategies for reducing surgical patient morbidity and mortality.
PRESENTER:
Charles Edmiston, PhD, MS, CIC
Professor, Surgery and Hospital Epidemiologist
Medical College of Wisconsin
9:30-10:30 a.m. | Session 3205
Room 217 D
Hospital Disinfection and Disinfectant Resistance:
What We Know, What We Don’t, and What We Wish
We Knew
MODERATOR: Sue Barnes, RN, CIC
This session will explore the use of disinfectants and
resistance to disinfectants in the healthcare setting, with
a particular focus on chlorhexidine gluconate (CHG).
9:30-10:30 a.m. | Session 3301
Room 212 A
State HAI Prevention Programs: Why LTC Should Be
Engaged
OBJECTIVES:
䡲 Identify key products used in hospital disinfection.
䡲 Distinguish between antimicrobial resistance and disinfectant
OBJECTIVES:
䡲 Describe why state HAI programs are expanding their efforts to include
resistance.
䡲 Distinguish between disinfectant resistance and disinfectant tolerance.
䡲 Provide examples of state HAI prevention activities specific to LTC
long-term care (LTC) providers.
settings.
PRESENTER:
䡲 Discuss the benefits for LTC facilities to get involved in state HAI
James Johnson, MD, MPH
Vanderbilt University
PRESENTER:
Wednesday, June 6
9:30-10:30 a.m. | Session 3204
Update on HAIs in Long-term Care
prevention opportunities.
Nimalie Stone, MD, MS
MODERATOR: Sharon Williamson, MT (ASCP), SM, CIC
45
Wednesday, June 6
9:30-10:30 a.m. | Session 3302
Room 210 B
New Initiatives to Reduce Healthcare-Associated
Infections Among Hemodialysis Patients
Exhibit Hall Open
10:30 a.m.-1 p.m.
This session will address the role of the infection
preventionist in emerging healthcare-associated infection
prevention and surveillance efforts in outpatient
hemodialysis settings.
Complimentary lunch will be served in the back of the
exhibit hall from 11:30 a.m.–1 p.m. We welcome all
attendees with wallet-style badges to join us.
OBJECTIVES:
䡲 Identify three actions you can take to improve prevention and
surveillance of hemodialysis-related infections.
䡲 Describe national initiatives targeting hemodialysis-related infections.
䡲 List several interventions used by the CDC Dialysis BSI Prevention
collaborative to reduce hemodialysis bloodstream infections.
PRESENTER:
Priti Patel, MD, MPH
Medical Officer
Room 210 A
This session will provide an open forum for attendees to
ask questions about infection prevention specific to their
immune compromised patients.
OBJECTIVES:
䡲 Identify three abnormalities in immune system function which increase
the risk of infection.
䡲 Identify four recommended elements of Protective Isolation.
䡲 Identify two risk factors for invasive fungal disease.
PRESENTERS:
Jennie Mayfield, BSN, MPH, CIC
Clinical Epidemiologist
Barnes-Jewish Hospital/Washington University School of Medicine
Jan Patterson, MD, MS, FSHEA (2012 SHEA President)
Professor of Medicine/Infectious Diseases and Associate Dean, Quality
& Lifelong Learning
University of Texas Health Science Center at San Antonio and South
Texas Veterans Health Care System
MODERATOR: Annemarie Flood, RN, BSN, CIC
11 a.m.-1 p.m.
11 a.m. EXPERT:
MODERATOR: Beth Ann Kavanaugh, MT(ASCP), MS, MBA, CIC
9:30-10:30 a.m. | Session 3303
Immune-Compromised Patients
Exhibit Hall C & D
Nancy Havill, MT (ASCP)
Infection Prevention and Epidemiology Program
Hospital of Saint Raphael
Concurrent Sessions
1-2 p.m. | Session 3400
Innovations in HAI Data Validation
Room 214 CD
This session will describe the process New York State
employs to ensure accurate and valid hospital infection
rates in preparation for an annual public report. A
demonstration of tools used to manage the validation
process will provide the infection preventionist with
techniques to self-evaluate data quality.
OBJECTIVES:
䡲 Describe the components of a process needed to ensure accurate hospital
infection data used for creating infection rates for public reports.
䡲 Describe the techniques and tools New York State employs to validate
hospital data prior to the public release of hospital acquired infection rates.
䡲 Demonstrate tools developed to systematically collect and analyze
validation results and understand their impact on indicator specific
infection rates.
PRESENTER:
Carole Van Antwerpen, RN, BSN, CIC
Assistant Director Bureau Healthcare-Associated Infections
New York State Department of Health
MODERATOR: Linda Goss, MSN, APRN, ANP-BC, CIC, COHN’s
46
Medical Mission work provides challenges and rewards
for the nurse in infection prevention. This presentation
will showcase stories that will demonstrate what it’s like
to “be in the trenches” in underdeveloped countries,
and develop a new appreciation for the work you do.
OBJECTIVES:
䡲 Describe a typical medical/surgical environment in a less
economically developed environment/country.
䡲 Recognize and understand the impact of cultures and environments
that present infection risks and obstacles which must be overcome to
prevent the spread of infection.
䡲 Demonstrate infection control measures that adapt to the
environment with limited resources on hand.
1-2 p.m. | Session 3402
Room 217 B
The Ticket for Your Leadership Journey:
APIC’s Credential of Competence
Not Certified? This session is for you! Attend this panel
session to hear about the importance of certification as a
core component of the new APIC infection prevention
competency model. IPs across the career span (early,
middle, and advanced) will share examples of how
certification has made an impact in their professional
development and careers. The patient/consumer and a
unique Canadian perspective on the significance of the
CIC® credential will also be presented. Details of both
APIC and CBIC strategic priorities will be detailed as
they pertain to the competency model and certification
in infection prevention and control.
OBJECTIVES:
䡲 Recognize the APIC and CBIC strategic priorities for promoting the value
of certification.
PRESENTER:
䡲 Demonstrate how the CIC® credential supports the leadership and
Mary Sibulsky, RN
Nurse Manager, AAAHC Surveyor
North Idaho Eye Institute, International Eye Institute,
Medical Reserve Corps
professional journey for the novice, intermediate and advanced Infection
Preventionist.
䡲 Examine the scientific evidence for certification and the impact on
patient safety outcomes.
Surviving an EF-5 Tornado-Infection Prevention
Required
This might sound like a nightmare but imagine that
your hospital has taken a direct hit by an EF-5 Tornado.
Over one third of your city has been destroyed. Evacuation must be completed in 90 minutes. What would
you do? Come and hear how this team mobilized an
inpatient mobile medical unit in seven days and
remained fully functional for four months. You will
hear about infection prevention lessons and you will be
eager to share.
OBJECTIVES:
䡲 List three infection prevention strategies that should be incorporated
Wednesday, June 6
1-2 p.m. | Session 3401
Room 217 A
30/30 Session - Two great topics one convenient hour
So You Want to Volunteer? Preparing for a Volunteer
Infection Prevention Medical Mission
PRESENTERS:
Maria Bovee, MPH, CIC
Children’s Memorial Hospital
Michael Cloughessy, MS, BSEH, REHS, CIC
Senior Infection Control Practitioner
Cincinnati Children’s Hospital
Michelle Farber, RN, CIC
Manager, Infection Prevention and APIC President, 2012
Mercy Community Hospital
Jean Rexford, CT
Executive Director,
Connecticut Center for Patient Safety
into an evacuation plan and recovery response.
䡲 Describe the process for recognition of infection trends in the disaster
aftermath.
䡲 Describe infection prevention principles necessary to establish a fully
functioning alternate healthcare site following a disaster.
PRESENTER:
Donna Stokes, RN
Infection Control Coordinator
Mercy-St. John’s Joplin
Barbara Russell, RN, MPH, CIC
Director, Infection Prevention and Control
Baptist Hospital of Miami
Donna Wiens, RN, BN, CIC
Director, Infection Prevention and Control,
Past President CHICA-Canada
CHICA-Canada
MODERATOR: Katrina Crist, MBA
MODERATOR: Cheryl Sharp, LVN, CIC
47
Wednesday, June 6
1-2 p.m. | Session 3403
Room 214 AB
To End or Not to End? When Should Contact
Precautions be Discontinued? National Survey
of Infection Preventionists Related to Contact
Precautions for MRSA and VRE
There are currently no national guidelines with respect
to when Contact Precautions can be terminated. This
National Survey of IP’s related to practices associated
with Contact Precautions for MRSA and VRE will
showcase the current approaches to this dilemma.
The results of the survey will be discussed in the
context of strategies for addressing the growing burden
of MRSA and VRE colonized patients.
1-2 p.m. | Session 3405
Room 217 D
PICU Performance Improvement in Reducing Device
Rates
Children’s hospital patient safety and QI project preventing
VAP/CLABSI using Six Sigma methods, allowed us to go
more than 365 days without a VAP! Never heard of Six
Sigma? Come hear about how Six Sigma found the
causes of our infections allowing us to taylor solutions
specifically preventing these HAIs!
OBJECTIVES:
䡲 Learn specific ways to engage RNs, MDs, and RTs to change the culture
of a PICU to work together to prevent CLABSI and VAP.
䡲 Explain why it is important to take whatever time is necessary to define
OBJECTIVES:
䡲 Describe current national policy with regards to implementation of
Contact Precautions (CP) for MRSA and VRE.
䡲 State the results of a national survey of Infection Preventionists.
䡲 Discuss how institutions are implementing CP and methods used for
documenting clearance of colonization and discontinuation of CP.
PRESENTER:
Paula Wright, RN, BSN, CIC
Director, Infection Control Unit
Massachusetts General Hospital
MODERATOR: Suzanne Cistulli, BSN, RN, CIC
the problem causing HAI in PICU vs. adult units.
䡲 Obtain tools to measure Nursing Policy’s (e.g., Hand Hygiene, CVAD) and
unit-based process measure compliance (e.g., steps to prevent VAP)
providing feedback to bedside staff.
PRESENTERS:
Tina Adams, RN
University of North Carolina at Chapel Hill Health Care
Cherissa Hanson, MD
Assistant Professor of Anesthesiology and Pediatrics
The University of North Carolina School of Medicine
48
1-3:30 p.m. | Session 3500
Room 007
High-Level Disinfection, Sterilization and Antisepsis
Sterilization, high-level disinfection and antiseptics are
used to reduce microbial contamination on instruments
or skin. This workshop will discuss the proper use of
these methods to reduce microbial contamination and
prevent disease based on scientific studies of efficacy
and effectiveness.
OBJECTIVES:
䡲 Upon completion, participants will be able to describe the evolution of
disinfection and sterilization products and practices over 30 years.
䡲 Upon completion, participants will be able to list the disinfectants used
in health care and how research directed their use.
䡲 Upon completion, participants will be able to discuss new technologies
and how these technologies improved practice.
PRESENTERS:
Director, Hospital Epidemiology; Professor; Director, Statewide Program
for Infection Control and Epidemiology
University of North Carolina at Chapel Hill Health Care and University
of North Carolina School of Medicine
Michele Alfa, PhD
Medical Director, Clinical Microbiology
Diagnostic Services of Manitoba
Charles Edmiston, PhD, MS, CIC
Professor, Surgery and Hospital Epidemiologist
Medical College of Wisconsin
Associate Dean
Rose Seavey, MBA, RN, BS, CNOR, CRCST, CSPDT
President/CEO
Seavey Healthcare Consulting, LLC
Professor
University of North Carolina at Chapel Hill Health Care
1-3:30 p.m. | Session 3501
Room 006 AB
Fearless Facilitation: How to Get Everybody Talking
Engage your audience to make your message memorable.
You’ll learn to unify the group in the first four minutes,
use activities that honor the experience of your audience,
and inspire creative thinking at all levels. Find the
fearless facilitator in you without overused techniques,
expensive assessments or tools.
OBJECTIVES:
䡲 Describe a technique that unifies a group.
䡲 State key program points to facilitate and involve your audience.
䡲 Describe techniques designed to adapt to a variety of audience
members (jobs, levels, experiences and attitudes).
PRESENTER:
Cyndi Maxey
President, Maxey Creative Inc.
Speaker
Wednesday, June 6
Workshops
1-3:30 p.m. | Session 3502
Ballroom C-3
Is Your Dialysis Unit on Board? CDC’s Dialysis Event
Surveillance Workshop
NHSN Dialysis Event surveillance is used to monitor
hemodialysis outpatients for infection indicators. Part
of the CMS Quality Incentive Program rule incentivizes
NHSN reporting in 2012. This workshop will help users
maximize benefits of NHSN participation by providing
instruction on creating and interpreting NHSN reports
for quality improvement.
OBJECTIVES:
䡲 Develop NHSN Dialysis reports using the Analysis Function.
䡲 Interpret and use NHSN reports for quality improvement in your facility.
䡲 Assess performance relative to other facilities reporting to NHSN.
PRESENTER:
Ann Goding Sauer, MSPH
Public Health Analyst
Alicia Shugart, MA
Public Health Analyst
Contractor to Centers for Disease Control and Prevention
MODERATOR: Nancy Johnson, RN, MSN, CIC
49
Wednesday, June 6
1-3 p.m. | Session 3503
Room 006 CD
(Repeat)
In 2012, CMS’s Hospital Inpatient Quality Reporting
Program expanded to include surgical site infections
(SSI) for selected operative procedures using CDC’s
National Healthcare Safety Network (NHSN) definitions.
This session will review NHSN’s SSI protocol and how to
meet the reporting mandate. Test your skills through
audience response to case studies.
OBJECTIVES:
䡲 Define resources and methods for SSI surveillance, including
1-3:30 p.m. | Session 3504
Room 008
Infection Prevention, Homecare and Healthcare Reform
These are exciting times for health care with
unprecedented and transformational change happening
all across the country. As home care providers work to
navigate through opportunities and challenges, infection
prevention will be of the utmost importance in the
achievement of high quality care and significant vertical
and horizontal integration. This workshop will focus on the
development of best practices in hand hygiene, providing
care to patients with MDROs, and patient immunizations
which is a key component of quality measures for
accountable care organizations that include home care.
requirements for SSI reporting to CMS through NHSN.
䡲 Review NHSN SSI protocol and key terms and definitions.
䡲 Apply SSI definitions using interactive case studies.
PRESENTERS:
Mary Andrus, BA, RN, CIC
President
Surveillance Solutions Worldwide, Inc.
Teresa Horan, MPH
NHSN Education and Data Quality Assurance Team Leader
Gloria Morrell, Rn, MS, MSN, CIC
Nurse Consultant
MODERATOR: Nancy Zanotti, RN, BSN, MPH, CIC
OBJECTIVES:
䡲 Develop a patient immunization program for home care.
䡲 Develop a hand hygiene program for home care.
䡲 Develop practices for the prevention of transmission of MDROs in the
home care setting.
PRESENTERS:
Barbara Citarella, RN,MS,CHCE,CHS-V
President/CEO
RBC Limited
Mary McGoldrick, MS, RN, CRNI
Home Care and Hospice Consultant
Home Health Systems, Inc.
Carole Yeung, RN, CIC
Clinical Practice Specialist - Infection Prevention
Baptist Health Home Health Network
MODERATOR: Mary Post, RN, MS, CNS, CIC
50
2:30-3:30 p.m. | Session 3600
Room 214 CD
Evolution of Long-term Care in the US: The Expanding
Scope and Complexity of Infection Prevention
Nursing homes (NH’s) have become a crucial part of the
US healthcare system, with 1.5 million residents in
16,100 NHs at any given time, and a burgeoning shortstay population. This session will discuss the changes in
the nursing home industry and its implications on scope
and practice of infection prevention.
OBJECTIVES:
䡲 Illustrate the changes in long-term care including expansion of post-
Reducing Central Line Infections and
Transforming Perinatal Care Through Quality
Improvement Collaboratives
Using the experience developed in state and national
projects to reduce catheter associated bloodstream
infection prevention, we will define the tremendous
opportunity that exists to radically transform health
care delivery via the development of state and national
quality collaborative organizations.
OBJECTIVES:
䡲 Upon completion participants will be able to identify elements which
acute care and rehabilitation and their expanding role in the process of
infection prevention.
䡲 Define high risk population and design an individualized infection
control program.
䡲 Identify practical tools, resources and collaboratives to implement
infection prevention practices.
are critical to the success of state and national neonatal quality
improvement collaborative development.
䡲 Upon completion participants will be able to describe elements that
are unique to reducing catheter associated line infection rates in
NICU patients.
䡲 Upon completion participant will be able to define methods to
partner with families and patients in order to accelerate quality
improvement as it relates to central line infection prevention.
PRESENTER:
PRESENTER:
Lona Mody, MD, MSc
Associate Professor, University of Michigan
University of Michigan and VA Ann Arbor Healthcare System
MODERATOR: D. Kirk Huslage, RN, BSN, MSPN, CIC
Wednesday, June 6
Concurrent Sessions
Martin McCaffrey, MD, CAPT, USN (Ret)
Director of the Perinatal Quality Collaborative of North Carolina,
Clinical Professor of Pediatrics
University of North Carolina School of Medicine
MODERATOR: Linda J. Barton, RN, BSN, CIC
2:30-3 p.m. | Session 3601
Room 217 A
30/30 Session - Two great topics one convenient hour
Nurses Driving IP Change in the NICU
This presentation will showcase the significance of
nurse-driven interventions and their integral roles in
the success of reducing VAP and CLABSI rates within
a NICU. The focus will be on development of NICU
specific bundles and the implementation process
moving forward.
OBJECTIVES:
䡲 Describe the role of a nurse-driven team approach to health-care
acquired infection reduction.
䡲 List necessary pieces to the neonatal CLABSI and VAP bundles.
䡲 Describe challenges faced when addressing the neonatal population.
PRESENTER:
Teri Hulett, RN, BSN
University of Colorado Hospital
2:30-3:30 p.m. | Session 3603
State HAI Prevention
Room 214 AB
This presentation will discuss the growing role of state
public health agencies and other state-based efforts in
HAI prevention.
OBJECTIVES:
䡲 Describe how the state public health approach to HAIs is evolving.
䡲 Describe some state based resources for HAI prevention.
䡲 Describe potential opportunities for partnership around state-based HAI
prevention.
PRESENTER:
Arjun Srinivasan, MD
Associate Director for Healthcare Associated Prevention Programs
MODERATOR: Carole Guinane, RN, MBA
51
Wednesday, June 6
2:30-3:30 p.m. | Session 3604
Room 217 C
Infection Prevention in Ambulatory Oncology
Treatment Centers
More and more cancer care is being provided in the
outpatient setting. This session will review recently
released resources and guidelines, developed by the
CDC aimed at preventing infections in cancer patients
in the ambulatory care setting.
OBJECTIVES:
䡲 Identify three program elements required to meet minimal expectations
of patient safety in an ambulatory oncology treatment setting.
䡲 Describe two actions that can help identify potentially infectious
patients in the ambulatory oncology treatment setting.
䡲 List three key elements of a cleaning and disinfection program in the
ambulatory oncology treatment setting.
PRESENTER:
Jennie Mayfield, BSN, MPH, CIC
Clinical Epidemiologist
Barnes-Jewish Hospital/Washington University School of Medicine
MODERATOR: Ann Marie, Pettis, RN, BSN, CIC
2:30-3:30 p.m. | Session 3605
Room 217 D
Knocking at Your Door: New CMS Hospital Care
Worksheet
Do you wonder whether you are prepared to respond to
the new CMS Hospital Care survey? Participants will
understand how the new hospital infection control survey
tool was developed and the change in survey strategy.
There will be a review of the various sections and
structure of the tool. Finally, the pretest phase will be
explained along with the next steps to implementation.
OBJECTIVES:
䡲 Describe key components of the CMS Hospital Care Worksheet.
䡲 Define the new CMS survey strategy for infection control.
䡲 Discuss the utilization of the CMS worksheet as a self-assessment tool.
PRESENTER:
Daniel Schwartz, MD
Chief Medical Officer
Survey and Certification Group
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
52
Closing Plenary
4-5:30 p.m. | Session 3700
Ballroom C
Learn It, Lead It, Live It: Strategies for Driving Change
to Eliminate HAIs
This session will focus on methodologies to help achieve
sustained change of improvement initiatives that reduce
or eliminate HAIs. Key care practices to reduce HAIs will
be used to demonstrate principles around the
consultation model and a culture of safety. The session
will conclude with an assessment of essential knowledge
and skill to transition to create an environment of safety
and sustainability of new evidence based practices
around eliminating HAIs.
OBJECTIVES:
䡲 Describe the forces within the current health care environment that are
driving the need resuscitate the basics with evidence to create a safer
patient environment.
䡲 Discuss use of an internal consultation structure to help the ICP lead
or participate in practice and culture change at the frontline.
䡲 Identify key care practices based on the evidence that can HAI’s.
PRESENTER:
Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN
Clinical Nurse Specialist/Educator/Consultant
Advancing Nursing, LLC
Exhibitor-Sponsored Symposia
Exhibit Sponsored Symposia are an excellent opportunity for APIC 2012
attendees to receive additional education during the conference. These events
are wholly sponsored by exhibitors and not endorsed by APIC.
Please review the listing to see which events you might like to attend.
Sunday, June 3, 2012
Monday, June 4, 2012
Implementing an Effective Hand Hygiene Program:
Current Thought Leader Perspectives
What Good are Clean Hands if the Environment
Isn’t Clean? Achieving Hospital Hygiene through
Collaboration
Sponsored by
12-3 p.m.
Marriott Riverwalk | Alamo Ballroom
Sponsored by
6-7:30 a.m.
San Antonio Convention Center | Room 008
SPEAKERS:
John Boyce, MD
Hospital of Saint Raphael in New Haven, CT
William Jarvis, MD
Consultant in Epidemiology and Infectious Diseases
David R Macinga, PhD
Principal Scientist, Microbiology
GOJO Industries, Inc.
Didier Pittet, MD, MS, CBE
Director of the Infection Control Programme and WHO Collaborating
Centre on Patient Safety
University of Geneva Hospitals and Faculty of Medicine
Nimalie Stone, MD
Division of Healthcare Quality Promotion of the Centers for Disease
Control and Prevention
SPEAKER:
Curtis J. Donskey, MD
Associate Professor of Medicine, Case Western Reserve University
Staff Physician, Infectious Disease Section,
Louis Stokes Cleveland VA Medical Center
How well do your infection prevention and environmental
services departments collaborate to achieve the best
possible results in reducing the risk of hospital acquired
infections? At this session, Dr. Curtis Donskey will
introduce the concept of hospital hygiene. His presentation
will then be followed by a panel discussion of infection
prevention and environmental services leaders who have
collaborated in their facilities on successful hand and
environmental hygiene programs. Two continuing
education credits are available with this session.
With introduction by:
Associate Dean for Research and Professor of Pharmaceutical and
Therapeutic Research,
Columbia University School of Nursing and Professor of Epidemiology,
Columbia University Mailman School of Public Health
Thought leading experts in hand hygiene will be together
at this June 3 continuing education-accredited session to
provide their insights on the latest developments within
the hand hygiene category. Key objectives are to review
the science of alcohol-based hand rubs (ABHR) and the
critical variables which influence their antimicrobial
efficacy and clinical effectiveness; to understand the key
principles of point of care hand hygiene implementation;
to review strategies and recent advances in hand hygiene
compliance monitoring; and to understand the challenges
and opportunities of hand hygiene implementation in
long-term care settings. Attendees will also have the
opportunity to speak with the experts.
53
Current Trends in Environmental Decontamination:
Effective Use of Guidelines, Evidence, and Newer
Technologies – Are We There Yet?
Sponsored by
6-7:30 a.m.
SPEAKER:
Russell Olmsted, MPH, CIC
The environment of care is an important reservoir of
pathogens that can potentially contribute to healthcareassociated infections. Ensuring that cleaning and
disinfection is done safely and appropriately is an
ongoing challenge in busy healthcare facilities. There are
several guidelines and practice recommendations for
environmental decontamination, but they can be
complicated and offer outdated references. Approaches
to improved disinfection of patient areas include
monitoring and education of staff, patients, and families.
New technologies such as automated whole-area
disinfection are available and increasingly being used.
This symposium will identify ongoing challenges in
environmental decontamination, appraise its growing
importance, and provide insights into new augmentation
strategies to for current environmental cleaning and
disinfection practices with an emphasis on hydrogen
peroxide-based automated technology.
Intraoperative Infection Control: A Paradigm Shift
Sponsored by
6-7:30 a.m.
transmission and have confirmed that intraoperative
bacterial transmission events serve as a primary cause of
30-day postoperative HAIs. The results of our work
strongly suggests that a maximal decrease in operating
room bacterial transmission will require a multi-modal
program targeting patients, providers, the patient
environment and improvements in the design and
handling of patient intravascular devices in parallel
during the process of intraoperative patient care.
Infection Prevention Textiles:
The New Language in Healthcare
Sponsored by
5:30-8:30 p.m.
Marriott Rivercenter | Grand Ballroom Salon G-M
SPEAKER:
Peggy Prinz Luebbert MS, MT(ASCP),CIC
Studies prove that soft surfaces textiles can harbor
bacteria and pathogens, causing recontamination during
frequent contact; however, they’re often ignored by
today’s infection prevention protocols. Soft surface
textiles cover 90 percent of a patient’s contact
environment in a healthcare setting and are constantly
exposed to bacteria between launderings. Peggy Prinz
Luebbert will lead a clinical review of key findings from
current data on contamination of soft surface textiles.
She will speak about the limited regulation and lack of
standardized protocols for laundering. An overview of
clinical data will show the ineffectiveness of laundering
alone and will underscore the need for a better and more
efficient solution.
SPEAKERS:
Randy W. Loftus, MD
Assistant Professor of Anesthesiology
Matthew D. Koff, MD, MS
Assistant Professor of Anesthesiology
The problem of healthcare-associated infections (HAIs)
is widely known by both medical and lay communities
because HAIs injure an alarming number of patients in
healthcare facilities. Over the last five years, we have
systematically evaluated the incidence, mechanisms and
clinical implications of intraoperative bacterial
54
PDI’s 5th Annual New York Cheesecake
Extravaganza!
Sponsored by
7-10 p.m.
Marriott Rivercenter | Grand Ballroom Salon I-J
Last year over 600 people joined us for a night of fun!
Back by popular demand, illusionist Ryan Oakes will
perform while you enjoy delicious New York style
cheesecake, a chocolate fountain, drinks and more!
Updated as of May 1, 2012
Tuesday, June 5, 2012
Infection Control and Injectable Drug Delivery
Sponsored by
6-7:30 a.m.
Improving Hand Hygiene Compliance Through
Electronic Monitoring: Technical and Behavioral
Considerations
Sponsored by
SPEAKERS:
6-7:30 a.m.
Allen Vaida, PharmD, FASHP
Executive Vice President of the Institute for Safe Medication Practices
SPEAKER:
Mark Siska
Assistant Director Informatics & Technology Pharmacy Services
Mayo Clinic
Kathy Warye
Vice President of Infection Prevention, BD
A robust discussion featuring leaders in medication
safety practices will present new ideas for reliable,
consistent solutions that reduce risks and allow for
better, safer care. News at the session will reveal
healthcare professionals’ perceptions of the need for new
tools to eliminate mistakes, dosage errors, and wasted
time. BD is hosting this session to identify the steps
needed to achieve greater patient safety for nurses,
pharmacists, and public health professionals.
Reliable Culture of Safety: Strategies to Eliminate
HAI and Other Adverse Events
Emily Landon Mawdsley, MD
Join us for breakfast and a discussion about the
challenges and opportunities when implementing
electronic solutions to monitor hand hygiene. This
symposium will provide an overview of the technical and
behavioral aspects of electronic monitoring, as well as
real-world examples from three hospitals that have
implemented systems. Hear from your peers how they
have improved hand hygiene compliance and patient
satisfaction through improved monitoring methods.
Breakthrough Research in Vascular Access Cocktail
Reception
7-10 p.m.
Marriott Rivercenter Grand Ballroom | Salon C-D
SPEAKER:
Marcia Ryder, PhD, MS, RN
Sponsored by
6-7:30 a.m.
SPEAKER:
Please join us to enjoy some hors d’oeuvres and cocktails
where Marcia Ryder, PhD, MS, RN will be informally
discussing her breakthrough research in vascular access.
Dr. Ryder will informally discuss in vivo research
examining both the antimicrobial and antithrombogenic
properties of chlorhexidine.
This presentation will focus on the importance of a
culture of safety as it relates to the prevention and
elimination of healthcare-associated infections. The
speaker will review successful initiatives that addressed
culture and impact on reduction of HAIs, define culture
of reliability, discuss safety behaviors, error prevention
tools, and their application to infection prevention, and
examine the leader methods for reliability.
55
Wednesday, June 6, 2012
Chlorhexidine Across Healthcare: A Partnership to
Protect Patients
Sponsored by Chlorhexidine Partners Network
6-7:30 a.m.
SPEAKER:
Reducing SSI: What Can You Do Differently Tomorrow?
Keith Kaye, MD, MPH
Corporate Director, Infection Prevention,
Epidemiology and Antimicrobial Stewardship
Detroit Medical Center and Wayne State University
Sponsored by
Chlorhexidine is a safe, efficacious antimicrobial, and its
use as an antimicrobial is well documented. The
antiseptic molecule has been used for decades by the
healthcare industry as a skin prep, hand sanitizer,
surgical prep, on vascular catheters, wound care, oral
care, and many other uses. Chlorhexidine has prevented
countless nosocomial infections, and it will continue to
be an important tool in protecting patients as we march
toward zero infections. Companies from across the
healthcare sector have partnered together to discuss the
importance of chlorhexidine in protecting patients and to
drive zero infections. This educational symposium will
provide an overview of chlorhexidine’s efficacy against
microorganisms, its many uses in healthcare, and how
best to work with industry to implement greater patient
protection solutions.
Mucocutaneous Blood Exposure and Peripheral
Catheters - Acknowledging the Risk, Documenting
Occurrences
Sponsored by
6-7:30 a.m.
SPEAKER:
Lynn Hadaway, M.Ed., RN, BC, CRNI
Discussions among nurses and two recent published
surveys reveal anecdotal reports of blood exposure to
mucous membranes during peripheral IV catheter
insertion; however, an integrative literature review found no
documented reports of these events. Reports of all
percutaneous injuries are about four times greater than
those from all mucocutaneous blood exposures, indicating
the continued need for improvements in, and correct use
of engineered safety devices. The same level of details
about mucocutaneous exposure is required to quantify and
56
reduce these risks. A brief overview of the known data will
be presented followed by a group discussion of what
should be done to improve documentation and appropriate
reporting of mucocutaneous exposure.
6-7:30 a.m.
SPEAKERS:
Peter Marcello, MD, FACS, FASCRS
Vice Chairman of Colon & Rectal Surgery
Lahey Clinic
Dale W. Bratzler, DO, MPH
Professor and Associate Dean
Department of Health Administration and Policy
University of Oklahoma Health Sciences Center
Deborah Hobson, BSN
Patient Safety Clinical Specialist
Armstrong Institute for Patient Safety and Quality Surgical Intensive
Care Nurse
Johns Hopkins Hospital
E. Patchen Dellinger, MD, FACS
Professor and Vice Chairman, Department of Surgery
University of Washington
Elizabeth C. Wick, MD
Assistant Professor of Surgery and Oncology
Johns Hopkins University
A panel of leading surgeons and healthcare professionals
will discuss the scope of the surgical site infection issue
and give attendees insight on clinically proven infection
prevention implementation methods, such as SSI bundles,
mechanical bowel preparation and antibiotics, wound
protection and teamwork. A thorough review of the clinical
data will reveal current practices that may not be effective,
as well as evidence-based practices that can result in
significantly improved patient outcomes and reduced
costs. The discussion will include challenges and
upcoming changes for SSI surveillance and the
achievements of the Surgical Unit-based Safety Program
(SUSP) in empowering the frontline. Attendees will also
have the opportunity to participate in a question and
answer session. Join us at this symposium and see what
you can do differently tomorrow.
Speaker Disclosures
All speakers have been requested to provide financial disclosures or indicate that there is nothing to disclose.
Michelle Alfa
Healthmark, 3M Healthcare
3M Healthcare
3M Healthcare
3M Healthcare
Healthmark
Consultant
Honoraria
Research Grant
Speaker’s Bureau
Royalties for license of ATS
Carla Alvarado
Teleflex
CareFusion
Honoraria
Speaker’s Bureau
Mary Andrus
CareFusion
Honoraria
Michael Borg
CareFusion
Honoraria
Kelley Boston
Infection Prevention and
Management Associates, Inc.
(IP&MA)
Ruth Carrico
Sanofi Pasteur
MedImmune
CareFusion
CareFusion
Honoraria
Honoraria
Honoraria
Speaker’s Bureau
Other Research Support
Speaker’s Bureau
Charles Edmiston
Sage Products
Ethicon, Inc
CareFusion
Speaker’s Bureau
Speaker’s Bureau
Speaker’s Bureau
Nancy Havill
3M Healthcare
Speaker’s Bureau
Joan Heath
Merck
Honoraria
Kelly Holmes
(IP&MA)
Betsy Hugenberg
Chartis Insurance,
Virginia Kennedy
Consultant
Consultant
Consultant
Consultant
Consultant
Advisory Committee/Board Member
Honoraria
Research Grant
Speaker’s Bureau
Consultant
Employment (includes retainer)
Ownership Interest
Luke Chen
Merck
Cubist Pharmaceuticals
Daverick Henderson
Merck
Keith Kaye
Pfizer
Merck
forrest pharmaceuticals
Sage Products
Brian Koll
Merck
Partner Employment
Elaine Larson
GOJO Industries
Deb Healthcare
Consultant
W. Ian Lipkin
Tetragenetics
Prosetta Corporation
Pathogenica
Akonni Corporation
Agilent
Tracy Louis
MediMedia USA
Honoraria
Jennifer McCarty
(IP&MA)
Mario Melgar
3M Healthcare
Research Grant
Allan Morrison
Sage Products
Pfizer
Optimer
CareFusion
Speaker’s Bureau
Speaker’s Bureau
Speaker’s Bureau
Speaker’s Bureau
Speaker’s Bureau
Denise Murphy
3M Healthcare
Speaker’s Bureau
57
Speaker Disclosures
Russ Olmsted
APIC
Arizant Healthcare, Inc
Arizant Healthcare, Inc
Mintie, Inc.
Premier Inc.
Trademark Medical, LLC
Applied Epidemiology Solutions, Inc.
Hinshaw & Culberston LLP
Ecolab
Ecolab
Carefusion
Ethicon
Advanced Sterilization Products, Inc.
Sage
Consultant
Research Grant
Consultant
Consultant
Consultant
Research Grant
Honoraria
Honoraria
Honoraria
Honoraria
Honoraria
Jon Otter
Bioquell
Pfizer
Bioquell
Ownership Interest
Jan Patterson
Astellas
Basilea
IHI
Merck
Pfizer
Toyoma
UT System
Consultant
Consultant
Consultant
Consultant
Consultant
Eli Perencevich
PurThread, LLC
Consultant
Emily Rhinehart
Chartis Insurance,
William Rutala
Clorox
Clorox, Advanced
Sterilization Products
Advanced Sterilization Products
Advanced Sterilization Products
58
Consultant
Consultant
Honoraria
Rose Seavey
Ultra Clean Systems
Key Surgical
BioSeal
Kimberly Clark
3M Healthcare
3M Healthcare
3M Healthcare
Key Surgical
Consultant
Consultant
Consultant
Consultant
Consultant
Honoraria
Speaker’s Bureau
Ownership Interest
Connie Steed
Medline
Thomas Talbot
Joint Commission Resources
Sanofi Pasteur
Sanofi Pasteur
Consultant
Research Grant
Gertie van Knippenberg-Gordebeke
MEIKO Maschinenbau, Germany
Consultant
MEIKO Maschinenbau, Germany
Honoraria
Kathleen Vollman
Sage Products Inc
Hill-Rom Inc
Consultant
Speaker’s Bureau
David Weber
Sanofi pasteur
Pfizer
Merck
Merck
Merck
Merck
Consultant
Consultant
Consultant
Honoraria
Speaker’s Bureau
Acknowledgments
The following speakers had nothing to disclose:
Joanna Acebo
Tim Adams
Tina Adams
Faruque Ahmed
Janet Allen
Katherine Allen-Bridson
Kris Anderson
Sue Barnes
Joseph Bick
Angela Bivens-Anttila
Sharon Bradley
Virginia (Ginnie) Bren
Judie Bringhurst
Vickie Brown
David Calfee
Miguela Caniza
Anthony Chavis
Barbara Citarella
Michael Cloughessy
Laurie Conway
Susan Cooper
Patti Costello
Titus Daniels
Linda Dickey
Susan Dolan
Curtis Donskey
Gemma Downham
Margaret Dudeck
Jonathan Edwards
Kate Ellingson
Patricia Emmett
Douglas Erickson
Michelle Farber
Teresa Fulton
Anita Geevarughese
Jean Gillis
Patti Grant
Linda Greene
Beth Hammer
Marilyn Hanchett
Cherissa Hanson
Teresa Horan
Michael Howell
Susan Huang
Teri Hulett
James Johnson
Leilani Kicklighter
Louise Kuhny
Terrie Lee
Alejandro Macias
Shelley Magill
Dennis Maki
Elham Mandegari
Mary Lou Manning
Cyndi Maxey
Jennie Mayfield
Martin McCaffrey
Tara McCannell
Chris McCarthy
Mary McGoldrick
Patricia McLendon
Jennifer Meddings
Lona Mody
Gloria Morrell
Amy Nichols
Stephen Parodi
Priti Patel
Kelly Peterson
Monika Pogorzelska
Jane Pool
Mary Post
Terri Rebmann
Amy Richmond
Barbara Russell
Daniel Schwartz
Alicia Shugart
Mary Sibulsky
Carmela Smith
Barbara Soule
Arjun Srinivasan
Donna Stokes
Nimalie Stone
Patricia Stone
Stephen Szermer
Abbigail Tumpey
May Uchida
Carole Van Antwerpen
Lynel Westby
Timothy Wiemken
Donna Wiens
Paula Wright
Carole Yeung
We wish to thank the following
individuals for their contributions to
APIC 2012!
BOARD OF DIRECTORS
President
Michelle R. Farber, RN, CIC
President-Elect
Patricia S. Grant, RN, BSN, MS, CIC
Secretary
Linda R. Greene, RN, MPS, CIC
Treasurer
Jennie L. Mayfield, BSN, MPH, CIC
Immediate Past President
Russell N. Olmsted, MPH, CIC
BOARD MEMBERS
Vickie M. Brown, RN, MPH, CIC
Linda J. Burton, RN, BSN, CIC
Linda K. Goss, MSN, APRN, CIC, COHN-S
Carole S. Guinane, RN, MBA
Clifton N. Orme, MBA
Neil P. Pascoe, RN, BSN, CIC
Marcia R. Patrick, RN, MSN, CIC
Connie Steed, RN, MSN, CIC
Sharon A. Williamson, BSMT(ASCP)SM,CIC
Jolynn C. Zeller, RN, BS, CIC
Ex Officio Board Member
Katrina Crist, MBA
APIC Chief Executive Officer
BOARD ADVISORS
AJIC Editor
Auditor
Leonard Pepe, Grant Thornton, LLP
Legal Counsel
Ralph Rivkind, JD, LLM
EDUCATION DEPARTMENT STAFF
The following speakers did not indicate whether or not there
were financial disclosures:
Mustafa Abdulali
Philip Carling
Ian Kramer
Diana Mungai
Shawn Boynes, CAE, Senior Director, Education
Sara Haywood, CMP, Associate Director, Education
Marci Thompson, Associate Director, Online Education
Marteniz Brown, Education Program Manager
Kathryn Hitchcock, Education Project Manager
Walter Josephs, Education Project Manager
Natalie Jenkins, Education Project Coordinator
Nicole Guy, Conference Manager
Colleen Campbell, Exhibits Manager
Jennifer Kerhin, Marketing and Sponsorship Manager
59
2012
Online Evaluation and
Continuing Education
Instructions
Now that you are home and rested from APIC’s 39th
Annual Educational Conference and International Meeting,
don’t forget to log in and complete your evaluations to
receive your contact hours. Simply complete the
following three easy steps to receive your credits:
1
Go to https://www.mylibralounge.com/regeng/apic2012/ and log in
using the following information, as provided with your registration:
• First Name
• Last Name
• Email Address
2
Complete the overall conference evaluation and individual session
evaluations for each of the sessions that you attended.
3
Download your certificate and VOA transcript once complete.
(Please note that you must self-submit your contact hours to your
professional organization.)
The site will stay open until July 31, so be sure to log in and download your certificate of completion before that date. If
you have questions please contact [email protected].
Session
Tracking Form
The Association of Professionals
in Infection Control and
Epidemiology, Inc. (APIC) is
accredited as a provider of
continuing nursing education by
the American Nurses Credentialing
Center’s Commission on
Accreditation (ANCC).
The APIC 2012 educational
content is also recognized by
The American Association for
Clinical Chemistry, Inc. (AACC)
as meeting the criteria for
ACCENT® credit hours.
INSTRUCTIONS:
Check each session attended.
Keep this form for your records
and reference it when you visit
https://www.mylibralounge.com/
regeng/apic2012/ to complete
the online sessions valuations
and claim your contact hours.
Session Time
Session Number
Credit
Hours
(per session)
8-10:30 a.m.
1:30-2:30 p.m.
3-4 p.m.
3-5:30 p.m.
4:30-5:30 p.m.
n 1000*
n 1200
n 1300
n 1400
n 1500
n 1201
n 1301
n 1401
n 1501
n 1202
n 1302
n 1402
n 1502
n 1203
n 1303
n 1403
n 1503
n 1204 n1205 n1206 n1207
n 1304 n1305
n 1404
n 1504 n1505
n 2002
n 2102
n 2202
n 2302
n 2402
n 2502
n 2603
n 2702
n 2003
n 2103
n 2203
n 2303
n 2403
n 2504
n 2004 n 2005
n 2104
n 2204 n 2205
n 3002
n 3102
n 3202
n 3302
n 3402
n 3502
n 3603
n 3003
n 3103
n 3203
n 3303
n 3403
n 3503
n 3604
2
1
1
2.5
1
Tuesday, June 5, 2012
8-9 a.m.
8-10:30 a.m.
9:30-10:30 a.m.
1:30-2:30 p.m.
3-4 p.m.
1:30-4 p.m.
n 2000
n 2100
n 2200
n 2300
n 2400
n 2500
n 2600
n 2700
n 2001
n 2101
n 2201
n 2301
n 2401
n 2501
n 2602
n 2701
n 2404 n 2405
n 2505
n 2703 n 2704
1
2.5
1
1
1
1
1
2.5
Wednesday, June 6, 2012
8-9 a.m.
8-10:30 a.m.
9:30-10:30 a.m.
1-2 p.m.
1-3:30 p.m.
2:30-3:30 p.m.
4-5:30 p.m.
n 3000
n 3100
n 3200
n 3300
n 3400
n 3500
n 3600
n 3700*
* ACCENT Credit Hours Only
n 3001
n 3101
n 3201
n 3301
n 3401
n 3501
n 3601
n 3004 n 3005
n 3104
n 3204 n 3205
n 3405
n 3504
n 3605
1
2.5
1
1
1
2.5
1
1
Abstracts Book
2012
NOTES
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APIC 2012 ABSTRACTS
APIC 39th Annual Educational Conference & International Meeting
San Antonio, TX l June 4-6, 2012
CONTENTS
Abstract Awards (denoted by *) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9–11
Poster Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Oral Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Future APIC Conference Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
POSTER ABSTRACTS
Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1-001
1-002
1-003
1-004
1-005
1-006
Risk Factors for Vancomycin-Resistant Enterococcus faecalis bacteremia: A Case-Case-Control Study
Emergence of IMP-1 Producing Escherichia coli in a Tertiary Hospital in Japan
Escalation and De-Escalation Plan for Carbapenem-Resistant Gram Negative Organisms in Critical Care*
Risk Factors for the Isolation of Vancomycin-Resistant Enterococcus faecalis from Wound Site: A Case-Case Control Analysis
The Cephalosporin Use in the Penicillin Allergic Patient
Risk Factors to Acquire Vancomycin-Resistant Enterococcus faecium (VRE) Infection in Pediatric Patients
Antisepsis/Disinfection/Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2-007
Disinfect to Protect- Developing a System to Enhance Disinfection of Patient Care Equipment
2-008
A Comparative In-Vivo Study on Persistent Effects of Chlorhexidine Gluconate in Alcohol Formulations and a Povidone-Iodine Solution as Skin Preparations
2-009
Review of Proper Reprocessing of Reusable Medical Equipment in VHA Facilities
2-010
Targeted, Daily Environmental Disinfection with Clorox® Dispatch® for the Prevention of Hospital-Associated Clostridium difficile and Acinetobacter baumannii
2-011
Comparison of the Surface Disinfection Capabilities of Two Different Methods using Automated Devices: Ultraviolet Light Versus Hydrogen Peroxide Fogging Machine
2-012
A Comparison of the Surface Disinfection Capabilities of Two Different H2O2 Based Disinfectants used in an Automated Fogging Machine in a 72 Cubic Meter Room
2-013
Influence of Alcohol-Based Hand Rub Format on Dry Time and Efficacy
2-014
Innovative Additions to Central Line Bundle Reduce Bloodstream Infections in Vulnerable Pediatric Patient Population and Improve Catheter Care
2-015
A Multi-Site Study Evaluating the Effectiveness of Terminal Cleaning in Patient and Operating Rooms using an ATP Monitoring System
2-016
Quantitative Analysis of Materials and Methods in Cleaning and Disinfection of Environmental Surfaces: Microfiber vs. Cotton and Spray vs. Soak
2-017
Partnering With Environmental Services to Drive Infection Control Excellence
2-018
Hydrogen Peroxide Patient Privacy Cubical Curtain Cleaning Study*
2-019
Evaluation of Liquid Hydrogen Peroxide to Clean Surfaces in Patient Rooms using Aerobic Colony Counts and Adenosine Triphosphate Bioluminescence Assay
2-020
Effect of Disinfectants on Clinically Relevant Bacteria Under Planktonic and Biofilm Conditions
2-021
Cleaning Practices for Hospital Mattresses in Top US Adult Hospitals
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The Influence of ABHR Product Format on In Vivo Efficacy: A Meta-Analysis
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A Multi-Disciplinary Team Tackles Standardization of Endoscope Practices in a Tertiary Care Setting: Finding Common Ground for Patient Safety
Bioterrorism/Disaster/Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
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U.S. School/Academic Institution Disaster and Pandemic Preparedness and Seasonal Influenza Vaccination Among School Nurses
Maintaining Isolation Precautions During a Hurricaine Evacuation
APIC 39th Annual Educational Conference & International Meeting | San Antonio, TX | June 4-6, 2012
1
Contents
Device-Related Infections and/or Site Specific Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
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Reduction in Catheter-Associated Urinary Tract Infections by Bundling Interventions in a Community Hospital
A Multi-Interventional, Multi-Disciplinary Effort to Reduce Hospital-Acquired Central Line-Associated Blood Stream Infections
A Multi-Disciplinary Performance Improvement Project to Reduce Craniotomy Surgical Site Infections
Sedation Reduction Leads to Reduction in Ventilator Associated Pneumonia
Reducing Ventilator Associated Pneumonia - Goal - Zero
A Multifaceted Approach Reduces Surgical Site Infection Rates, Incidents, and Associated Costs for Abdominal Hysterectomy and Caesarean Section Patients
Reducing Peripherally Inserted Central Line Associated Blood Stream Infections (CLA-BSI): Targeting 0 in Non-Critical Care Medical Surgical Units
Is Antimicrobial Closure Technology A Clinically Effective Strategy For Reducing the Risk of Surgical Site Infections - A Meta-Analysis?
Pediatric Ventilator Associated Pneumonia (VAP) Prevention Bundle: 5 Years Later
When a Central Line Bundle is Not Enough: Sustaining Gains and Striving for Zero
Multifaceted Interventions to Prevent Central Line Associated Blood Stream Infections in a New York City, Neonatal Intensive Care Unit
Ventilation Associated Pneumonia Caused by Acinetobacter baumanii at a Tertiary Hospital in Vietnam: Clinical And Molecular Patterns
Patient Education as a Means to Reduce Methicillin-Resistant Staph Aureus Surgical Site Infections in Patients with Known Colonization
An Interdisciplinary Approach Toward Reducing the Incidence of Catheter-Associated Urinary Tract Infections in a Post-Acute Facility
Incidence of Hypothermia under Perioperative Standard Thermal Management in patients with abdominal surgery and Its Effect on Surgical Site Infections
Vascular Access Associated Blood Stream Infections in Patients Undergoing Plasmapheresis Compared with those in Patients with Hemodialysis
Total Burden Assessment Of Surgical Site Infections in Initial Admissions and Readmissions Using National Administrative Claims Data
Challenges in Adherence with National Healthcare Safety Network Definitions: A Central Line-Associated Bloodstream Infection Conundrum
Shared Successes for Surgical Site Infection Reduction: Utilization of CHG-impregnated Cloths as an Adjunct to the Pre-op Shower
Micro-Patterned Surfaces for Reducing Platelet Adhesion and Bacterial Attachment Associated with Catheter-Associated Blood Stream Infections
Our Journey to Eliminate Central Line Associated Blood Stream Infections in our NICU
Activity of Dynamic Concentrations of Silver and Chlorhexidine Against Common Bacterial Pathogens
Comparison of Antimicrobial Needleless I.V. Connectors in a Septum Contamination Assay
Micro-Patterned Surfaces for Reducing Biofilm Formation in an Endotracheal-Tube-Like Environment
A Novel Chlorhexidine Hydrogel Coating for Peripheral Venous Catheters
Our Journey to Zero: Preventing Central Line Associated Bloodstream Infections in the Pediatric Intensive Care Unit
Prevention of Central Line Associated Bloodstream Infections by Implementation of Central Line Bundle
Targeting Zero Central Line Associated Blood Stream Infection: Innovative Prevention Initiatives toward desired Outcomes
Reduction In Duration Of Post-Operative Catheter Use Following Imiplementation Of An Electronic Reminder System
Canaries in a Coal Mine: a Case Report of Increased Incidence of Clostridium difficile in a Pediatric Oncology Patient Population
Device-Related Infections and/or Site Specific Infections Differentiating Infection from Inflammation after Total Knee Arthroplasty
Emerging and Reemerging Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
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The Effect of Chlorhexidine Gluconate Bathing on MRSA/VRE Acquisition Rates in Medical ICU Patients
Developing an Emergency Department Tuberculosis Triage Screening
Incidence of Klebsiella pneumoniae Carbapenemase (KPC)-producing Multidrug-Resistant Bacterial Infections in a Teaching Hospital in SouthEast
Current Epidemiology and Clinical Impact of Extended-Spectrum β-Lactamase-Producing Escherichia coli at a Tertiary Medical Center
Measles Outbreak Management at a Minnesota Children’s Hospital in 2011
Developing an ESBL Program
Contents
Environment of Care/Construction/Remediation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
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Impact of Equipment with Fans in the Operating Room
Environmental Hygiene Sustainability - Is It Possible?
Navigating through the Construction Zone
Infection Prevention and Control Planning for Development of a New Bone Marrow Transplant Unit is NOT a Lone Star Production
Construction and Renovations using a Checklist Tool for Safety : Laborers and Patients
Preliminary Assessment: Efficacy of Room Sanitizing With Controlled Exposure to UVC Light
Microbial Load of Reusable Cleaning Towels used in Hospitals
The Safety Dance: Establishing a Comprehensive Safety Program to Ensure Contractor Compliance
Measuring the Effect of Hospital Cleaning Intervention to Prevent Health Care Assocaiated Infections
The Development of An Environmental Audit Program
HealthcareWorker Safety/Occupational Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
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Healthcare Worker (HCW) Pertussis (Tdap) Vaccine Compliance Improves During a Statewide Pertussis Epidemic
Development of Point of Use Sharps Disposal Unit- A Simple Solution to a Difficult Problem
Isolation Gown Use, Performance and Potential Compliance Issues Identified by Infection Control Professionals
Implementing a Mandatory Influenza Vaccination Program in a University-Affiliated Teaching Hospital
A Comparison of Anti-Microbial Scrubs and Cotton Scrubs in a Hospital
Infection Prevention and Control Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
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Success in Preventing Catheter Associated Urinary Tract Infections–What Works?
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Seasonal and H1N1 Influenza Vaccine Compliance and Intent to be Vaccinated Among Emergency Medical Services Personnel
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Unleashing the Positive Deviants at the Frontline: More than just Sparking Change
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Expanding the Clostridium difficile Infection Prevention Bundle to Include Patient Hand Hygiene
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Hand Hygiene Opportunities in Pediatric Extended Care Facilities
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A CAUTI Bundle with a Twist.
8-084Managing Clostridium difficile using a Bundled Approach
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What’s for Dinner?
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A Model of a Longstanding State Infection Prevention Collaborative
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Annual Outcomes for Infection Prevention: Going in the Right Direction by Using Data, Knowledge and Rules to Improve Outcomes
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Can We Reduce Surgical Site Infections?
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Increasing Hand Hygiene Compliance By Changing the Culture
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Survey of Literature, Patient Advisory Councils, and 440 Members Leads to New Flu Campaign and Increased Flu Vaccination Rates
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Control of Legionella Contamination with Monochloramine Disinfection in a Large Urban Hospital Hot Water System
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First Do No Harm - Efficacy of Influenza Vaccine Mandate or Mask Mandate for the Healthcare Worker
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Intervention to Reduce Central Line Associated Blood Stream Infections in Adult Critical Care Hospital
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Hand Hygiene: There’s an APP for that?
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Emergence of Klebsiella pneumoniae Producing KPC-Type Enzymes and Infection Control Measures for Containing Hospital Spread
8-096
Repeated Intervention Programs to Reduce VAP Rates and Focus on Effective Components of the Prevention Bundle in an Indian ICU
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Hand Hygiene Rates for Rehabilitation and Long Term Care Facilities: One Hospital’s Journey through the National Goal and Benchmarks
8-098
Attaining Zero Catheter Associated Bloodstream Infections in a Level III Nursery
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Taxonomical Risk Assessment
8-100
Detection Capabilities of an ATP (Adenosine Triphosphate) Based Monitoring System for Clinically Relevant Sources of ATP
8-101
Monitoring the Cleaning of Surgical Instruments with an ATP Detection System
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From Good to Great with Strategic Planning
8-103
A Nurse Driven Foley Catheter Removal Protocol Proves Clinically Effective to Reduce the Incidents of Catheter Related Urinary Tract Infections
8-104
Enhancing Infection Prevention’s Role during Construction in a University Medical Center
8-105
Personal and Household Hygiene, Microbial Contamination, and Health Status in Undergraduate Residence Halls in New York City
8-106
You are What You Eat: Engaging Long-Term Care Residents in Meal Time Hand Hygiene
8-107
The STOP (Staff Taking Ownership for Prevention) FLU Initiative: Improving Influenza Vaccination Rates among Staff in a Long-
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Term Care Facility
Automatic Foley Catheter Stop Order
Clostridium difficile Infection Prevention Initiative to Reduce the Incidence and Prevalence of Clostridium difficile among Veterans in Acute-Care Inpatient Facilities
Utilizing Electronic Surveillance to Enhance Patient Safety
Re-Ingineering Hand Hygiene Surveillance: Shifting the Focus, Sharing the Responsability.
Developing an Infection Prevention Program as a Result of a Transition From a Level II to a Level III NICU
Successful Implementation Of A Mandatory Influenza Vaccination Program Across A 12 Hospital System
Resistant Organisms: An Innovative Approach to Preventing Healthcare Transmission
The Dynamics of a Hand Hygiene Program in a Pediatric Oncology Service in El Salvador: Success Factors and Lessons Learned
A Multidisciplinary Team Approach to Reducing Ventilator Asscociated Pneumonia
Building and Maintaining Best Practices to Decrease Vascular Access-Associated Infections in the Use of Peripherally Inserted Central Catheters
Implementing Mandatory Influenza Vaccination policy for Health Care Workers at a Long Term Acute Care Facility
Education and Communication: Improving Patient Safety and Increasing Employee Knowledge in an Acute Hospital Setting
Infection Control Liaisons: Weapons Against Hospital Acquired Infections
Hospital Hand Hygiene Compliance Improves with Increased Monitoring and Immediate Feedback
Using Infection Surveillance to Improve the Quality of Care in a Cancer Unit in a Children’s Hospital in Argentina
Impact of a Rapid Cycle Hand Hygiene Initiative in a Pediatric Emergency Department
The Quest to Reach Zero Central Line-Associated Bloodstream Infections
Embedding Hand Hygiene into a Patient Centric Communication Model: C-I-CARE
Interventions to Improve Ventilator-Associated Pneumonia in the Intensive Care Unit of a Pediatric Hospital in Nicaragua
Reporting Capabilities and Data Extrapolation Using an Electronic Hand Hygiene System Versus the Traditional Covert/Secret Shopper Visual Observation Method
Infection Prevention and Control Program in a Public Pediatric Hospital in Argentina: Opportunities for Improvement
Outbreak Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
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Outbreak management of Norovirus in a Pediatric Behavioral Health setting
9-130Methicillin-resistant Staphylococcus aureus Outbreak in the Neonatal Intensive Care Unit
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Why Every Hospital Should Be A “No Fly Zone”
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Norovirus Outbreak in a Long Term Care Facility
9-133
A Multidisciplinary Approach toward Successful Bed Bug Elimination in a Homeless Domiciliary Setting
9-134
Outbreak of Enterococcus faecium with Low-Level Resistance to Vancomycin in Japan
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Reported Endoscope Reprocessing Breaches, Minnesota, 2010-2011
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Outbreak Investigation at a Dialysis Center Associated with a Multi-use Dialyzer with Removable Headers and O-rings, Los Angeles County
9-137
Use of Molecular Biology to Confirm a Bacteremia Outbreak Caused by Burkholderia cepacia in a Pediatric Intensive Care Unit
9-138
Characterization of Two Outbreaks of Vancomycin Resistant Enterococcus faecium in a Pediatric Care Center in Mexico City
9-139The C. diff Cycle: The Necessity of Going Beyond the Basics
Product Evaluation/Cost-Effectiveness/Cost Benefit Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
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Closing the Gap of Inconsistent Hand and Surface Sanitation
The Role Appropriate Isolation Precautions Contributes to Cost Avoidance: Conducting Active and Retrospective Isolation Precaution Surveillance
Avoiding Unintentional Hypothermia During Prosthetic Joint Replacement Surgery
Effectiveness of an electrochemically activated saline solution for disinfection of hospital equipment
Financial implications of VRE screening intensive care units
Determining an Effective Measure of Testing for MRSA Colonization for Timely Placement in Appropriate Isolation Precautions
Cost Effectiveness of an Electronic Hand Hygiene Monitoring System (EHHMS) in the Prevention of Healthcare-Associated Infections
Public Reporting/Regulatory Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
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Who Should Be in Charge of What? (Components of a State-Level Healthcare-Associated Infections Prevention Effort)
California State Mandated MRSA Screening: Healthcare Dollars Down the Drain!
Contents
Quality Management Systems/Process Improvement/Adverse Outcomes . . . . . . . . . . . . . . . . . . . . . . . .105
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Utilizing Lean Analysis to Conduct a Horizontal Value Stream focusing on the Reduction of Orthopedic Surgical Site Infections
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Communicating Critical Surveillance Data for Improved Outcomes
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Reproducibility of Results in Decreasing Healthcare-Associated Infections with the Use of Electronic Hand Hygiene Surveillance Technology
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Development of a Health Care Providers Quality Improvement Team in a Small, Rural Community
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Process Improvement: Facility Wide Reduction in Hospital-Associated Infections Utilizing CHG for Oral Care and Preoperative Preparation
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Design and Implementation of a Web Application for Real-Time Display of Hand Hygiene Performance Data
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Three Interventions=Zero Infections
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Measurement and Analysis of Foot Traffic in a University Hospital Operating Room
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Improving the Management of Orthopedic Surgical Patients with Indwelling Urinary Catheters Using a Systematic Evidence Based Approach
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The Impact of Improperly Collected Urine Cultures on Patient Treatment in the Emergency Department
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Making it Personal: Utilization of an Electronic Personal Hand Hygiene System to Increase Hand Hygiene
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Impact of a Hospital Wide Policy on Clostridium difficile Testing using Cepheid System®
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Reducing Transmission of Multi-Drug Resistant Organisms in Procedural Areas
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It’s Contagious! CLABSI Prevention is Spreading
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Infection Prevention Component of Process Improvement Project to Reduce Regulated Medical Waste
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A Norovirus Cluster Reveals a Big Stink: A Communication Failure Between Infection Prevention and the Laboratory
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The Development of a Process Improvement Tool: The SWAT Approach to Surgical Site Infection Analysis
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Decreasing Catheter Associated Urinary Tract Infections (CAUTI) using the BREAKTHROUGH (LEAN) Method
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Improving Antimicrobial Stewardship in the Neonatal ICU with Computer Decision Support
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Evaluating the Primary Outcomes of W.H.O Surgical Safety Checklist 2009 Application in an Obstetrics and Gynecology Hospital of Vietnam
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A Process Improvement Project Decreases Blood Culture Contamination Rates in the Emergency Room
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Reaching Zero Central Line Associated Infections by Improving Compliance to Aseptic Technique
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Quantitative Evaluation of Environmental Surface Cleanliness in Pediatrics Intensive Care Unit
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Collaborative to Decrease Central Line Associated Blood Stream Infection (Clabsi) in a Neonatal Unit (NICU): An Urban Teaching Hospital Experience
Attaining and Sustaining Hand Hygiene Compliance. Patient/Family, Sr. Leadership to Front-line Staff. A Winning Combination!
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Standardizing Environmental Cleaning Procedures and Measurement Across a 12-Hospital System
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Reducing Blood Culture Contamination in the Emergency Department
A Lean Surveillance Transformation
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Clinical Attributes of Non Ventilator-Associated Hospital-Acquired Pneumonia
Successful Nurse-driven Improvement Team Raises Postpartum Tdap Rates and Surpasses Target Goal
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Blood Culture Procedures and Results in a Pediatric Hospital in La Paz, Bolivia: Opportunities for Improving Efficiency and Decreasing Cost
A Multi-faceted Approach to Increase and Sustain Hand Hygiene Compliance in a Military Treatment Facility
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A Quality Assurance Project to track Compliance with Autoclave Maintenance and use of Biological Indicators in Outpatient Physician Offices
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Data, Dollars, and Determination.....
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Lessons Learned from 5-yrs of Central Line-Associated Bloodstream Infection Real-Time Event Reviews
Real-Time Event Reviews: A Useful Tool for the Prompt Identification of System Failures
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12-186Colorado Clostridium difficile Infection Prevention Collaborative
Special Populations (Infections in the Immunocompromised Host, Pediatrics) . . . . . . . . . . . . . . . . . . . .127
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Isolation Precaution Guidelines in NICU: Breast Milk Storage
Relationship Between Wait-Time for Antibiotic Initiation and Outcomes of Hospitalization Among Children with Cancer Admitted to an Oncology Ward in a Hospital in the Philippines
Epidemiological Patterns and Characteristics Associated with Clostridium difficle Infection at the Largest Freestanding Pediatric Hospital
Sustaining Zero Central Line-Associated Blood Stream Infections in Pediatric Intensive Care Unit: A Light at the End of the Tunnel?
Outpatient Adult Hematopoietic Stem Cell Transplant Visits: Respiratory Season Interventions
Influenza Immunization of Medical/Surgical and Hematology/Oncology Pediatric Inpatients
5
Contents
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Breaking the Bloodstream Infection Connection: Utilizing a Swab containing Chlorhexidine Gluconate (3.15%) and Isopropyl Alcohol (70%), Chlorascrub™
Improving the Quality of Care by Reducing Contamination when Drawing Blood Cultures in the Neonatal Intensive Care Unit
Race and Ethnic Disparities in Hospitalizations with Community-Acquired Infections
Epidemiology of Nosocomial Infections in Selected Neonatal Intensive Care Units in Children Hospital No1, South Vietnam
Gender Differences in Risk of Bloodstream Infection
Specialized Settings (Ambulatory Care, Behavioral Health, Long Term Care, Home Care) . . . . . . . . . .133
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Seasonal Influenza Vaccine Compliance Among Hospital and Non-Hospital-Based Healthcare Workers
Infection Prevention Communication Within a Health Sytem’s Ambulatory Surgery Centers
What Is Wrong with Using a Dishwasher to Clean My Instruments?
Effectiveness of a Comprehensive Hand Hygiene Program for Reduction of Infection Rates in a Long-Term Care Facility: Lessons Learned
Keeping our Eyes on TASS: Our Experience in the Ambulatory Care Setting
Strengthening Healthcare-Associated Infection Prevention Efforts in Rural, Small, and Critical Access Hospitals in California through Collaboration
Sustained Reduction in Methicillin-Resistant Staphylococcus aureus Incidence in a Geriatric Setting by Implementing Daily Bathing with 2% Chlorhexidine Gluconate Cloths
Possible Rabies Exposure in a Community Living Center: Considerations and Decisions for Post-Exposure Prophylaxis
Staff Training/Competency/Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
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Increasing Nurses’ Hand Hygiene Adherence in Acute Care Settings
Bath Basins: Who Knows Where Evil Lurks
Improving Hand Hygiene Practice through Utilization of Automated Hand Hygiene Monitoring and Feedback Technology
Use of an Electronic Survey Instrument to Determine Barriers to Certification in Infection Control
Food for Thought: The Cafeteria Quiz; an Educational and Engaging Approach to Reinforce Infection Prevention Concepts During Infection Prevention Week
Results of a Hospital-wide Initiative to Decrease CAUTIs
Competence Based Orientation Program
Engaging Staff to be Responsible for Surgical Site Infection Prevention in a Large Academic Tertiary Hospital
When You Don’t Know, What You Don’t Know (Healthcare-Associated Infection (HAI) Knowledge in Ambulatory Surgery Centers (ASC))
Hand Hygiene Compliance and Variables of Interest at Neonate Intensive Care Unit in a Brazilian Hospital
Maintenance of Environmental Services Cleaning and Disinfection in the ICU After a Performance Improvement Project
State Public Health Department Performs External Observations of Hand Hygiene Compliance in All Maine Acute Care Hospitals, 2011
Transforming Regulatory Guidelines to Infection Prevention Guidance
Using Electronic Counter Device to Monitor Hand Hygiene Frequency at Neonate Intensive Care Unit in a Brazilian Hospital
Infection Prevention and Pharmacy Compounding for Regulatory Compliance
The Small Group Role-Playing Educations Improved Hand Hygiene Compliance in Intensive Care Unit
Collaboration Impacting Patient Safety: Infection Control and a Unit Based Performance Improvement Team Reducing Healthcare Associated Urinary Tract Infections
Development of Index for Compliance on Hand Hygiene Using a Nursing Need Degree and Hand Hygiene Product Usage
Development of an Introductory Disinfection/Sterilization Class in the Physician Office Setting
It’s Everybody’s Problem: A Collaborative Approach to Hand Hygiene
A Ticket To Ride: A Colloborative Approach To Infection Control Initiatives For A Hospital Relocation
Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
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6
Streamlined Emergency Department Post-Discharge Surveillance Reduces Rehospitalizations
Healthcare Associated Legionellosis Prevention Within a Large Acute Care Center
Communication of MRSA status upon transfers of LTCF residents to an acute care hospital
In Situ Detection of Residual Protein Contamination on Surgical Instruments for On-The-Spot Monitoring of Decontamination Procedures
Multicenter Study of Hand Carriage of Potential Pathogens by Neonatal ICU Providers
Survey to Determine Compliance with Center For Disease Control Recommendation for Vaccination of Adolescents
Nurse Jackson–A Positive Deviance Success Story
Contents
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Utilizing an Electronic Surveillance System to Automate Identification and Electronically Submit LabID Event Data to the National Healthcare Safety Network
Using an Electronic Surveillance System to Generate Facility Specific Antibiogram Provides an Accurate and Time Saving Tool for Clinical Providers
Apples to Apples: A Model for Standardizing Surveillance Throughout a Healthcare System after Implementation of an Electronic Surveillance System
Dirty Laundry? Evaluation of Clostridium difficile Contamination in the Laundry at a Long-Term Care Facility
Use of an Electronic Surveillance System to Further Refine MDRO Isolation Categorization
Examining Processes for Identifying Central Line Associated Bloodstream Infections and Variation in a Large Acute Care Facility
The Incidence of Coccidioidomycosis in San Luis Obispo, California
Implementing an Active Surveillance Program with Multi-Site Swabbing for Methicillin-Resistant Staphylococcus aureus in a Community Hospital
Is it necessary to determine skin closure status for all operative procedures prior to entering SSI denominator data into NHSN?
Control of MRSA Colonization in a Teritiary NICU
The Impact of Using Chlorhexadine Gluconate Products in the Adult Critical Care Setting*
Epidemiology of Infections in a Pediatric Oncology Service in Guatemala
Comparison of LAB ID and Traditional Surveillance for C difficile, are Proxy Measures Effective Tools for Identifying Performance Improvement Opportunities?
ORAL ABSTRACTS
Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
100
101
Overuse of Topical Antibiotics Among Inmates Entering Maximum-Security Correctional Facilities in New York State
Infections due to Enterobacter Species: Epidemiology and Outcomes as a Function of Ceftazidime Resistance
Antisepsis/Disinfection/Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
102
103
Efficacy of Novel Alcohol-Based Hand Rubs at Typical “In Use” Volumes
Clean Collaboration: Toward Improving Arthroscopic Shaver Reprocessing Methods
Device-Related Infections and/or Site Specific Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
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Preventing Contamination of Central Venous Catheter Valves with the Use of an Alcohol-based Disinfecting Cap*
Endemic IV Fluid Contamination in Hospitalized Children in Mexico. A Problem of Serious Public Health Consequences.*
Preventing Infection in Pediatric Spinal Fusion Surgery: A Novel Perioperative and Postoperative Surgical Site Infection Prevention Bundle
Efficacy of Various Antimicrobial Central Venous Catheters in Mono- and Poly-Microbial Environments
Healthcare Worker Safety/Occupational Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
108
A Healthcare Worker with Pertussis: High Cost and Lost Opportunity*
Infection Prevention and Control Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
109
Prevention of Hospital Associated C. difficile Infections
110
Preventing the FLU in You: A Three Year Experience of Sustained Seasonal Influenza Vaccination Rates in Healthcare Workers
111
Monitoring the Manual Cleaning of Flexible Endoscopes with an ATP Detection System
112
Changing Bedside Care by Linking Outcome and Process Data
113
Risk Factor Score to Predict MRSA Colonization at Hospital Admission
114
Understanding Hand Hygiene Behavior in a Pediatric Oncology Unit in a Low Middle Income Country: A Focus Group Approach
115
Multidrug Resistant Organisms in Supply Carts of Contact Isolation Patients
116
Standardization of Hand Hygiene Observations - an Entire State Collaborates
117
Should Contact Precautions be Standard? A Community Hospital’s Revised Criterion for Methicillin-Resistant Staphylococcus aureus and Vancomycin Resistant Enterococcus Isolation
Product Evaluation/Cost-Effectiveness/Cost Benefit Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
118
Re-Admissions After Diagnosis of Surgical Site Infection Following Knee and Hip Arthroplasty*
7
Contents
Public Reporting/ Regulatory Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
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The Impact of Non-Payment for Preventable Complications on Infection Rates in U.S. Hospitals*
New York State Hospital-Acquired Infection Reporting – 2010 Audit Results: An Inter-Hospital Comparison*
Assessment of the Quality and Accuracy of Publically Reported CLABSI Data in Colorado*
Quality Management Systems/Process Improvement/Adverse Outcomes . . . . . . . . . . . . . . . . . . . . . . .180
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Rapid Cycle Process Improvements to Decrease Surgical Site Infections in Cardiothoracic and Vascular Surgery Patients between 2008 and 2011*
Code Flash: An Interdisciplinary Team’s Efforts to Decrease Incidents of Flash Sterilization
Culture Change and CLABSI Reduction: Achieving Success in a Medical Center with 10 Distinctively Different Intensive Care Units
Special Populations (Infections in the Immunocompromised Host, Pediatrics) . . . . . . . . . . . . . . . . . . . .183
125
Using a Multi-Faceted Active Change Process and Infection Prevention to Reduce Post Op C-Section Infections
Staff Training/Competency/Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
126
127
Active Participation from the Hospital Executive Team Does Improve Hand Hygiene Compliance
Healthcare Worker Response to Direct Monitoring of Adherence to Isolation Precautions
Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
128
129
130
131
8
Relative Frequency of Healthcare-Associated Pathogens and Incidence of Healthcare-Associated Infections by Pathogen at a University Hospital from 2006 to 2010
Comparison of Methods for Surgical Site Infection Surveillance: Traditional Report Review and Electronic Surveillance
Discontinuation of Reflex Testing of Stool Samples for Vancomycin-Resistant Enterococci Resulted in Increased Prevalence*
Validation of Infection Preventionists Surveillance for Determining Hospital-Acquired Central Line-Associated Bloodstream Infection Using Centers for Disease Control and Prevention Definitions
Abstract Awards
William A. Rutala Research Award
Purpose: This award is given in the name of William A. Rutala, PhD, MPH, for the best abstract on the subject of
disinfection, sterilization, or antisepsis.
Selection Criteria: To be considered for this award, applicants must: 1) submit an abstract to the APIC Annual Educational
Conference & International Meeting in the year the award is to be given; 2) have not received the award within the last 3 years;
3) submit a Format I abstract in the Antisepsis/Disinfection/Sterilization category, written in a clear, logical and concise manner
which communicates the principal objectives, methodology, results and conclusions in a straightforward fashion; 4) submit
research that is limited to the study and understanding of the principles and practices of disinfection, sterilization, and antisepsis;
5) submit an abstract that will reflect original research or (if not entirely new should supplement existing data), is conducted
with appropriate data analysis, and is of major importance to the field of disinfection, sterilization, and antisepsis; 6) abstract
is innovative, employs sound methodology, and represents a potentially significant, scientific contribution to the principles
and practices of disinfection, sterilization and antisepsis; and 7) all abstract submitters who meet the above criteria during the
abstract submission process will be considered for the “William A. Rutala Research Award.”
Award: Plaque, $1,000, and recognition in the publication of abstracts in AJIC online, the onsite Annual Conference Program,
and conference CD-ROM.
2012 Winner:
Publication Number: 2-018
sponsor: clorox
Alexis Price, RN, BSN
Hydrogen Peroxide Patient Privacy Cubical Curtain Cleaning Study
9
Abstract Awards continued
Blue Ribbon Abstract Award
Purpose: Blue Ribbon Awards are given to a limited number of abstracts considered by the Abstract Selection Committee to be of
exemplary scientific and/or educational quality. Investigators are encouraged to emulate the qualities evident in these abstracts. Among
the criteria considered by the committee in awarding Blue Ribbons are the following; 1) the abstract is presented in a clear, logical and
concise format and communicates the major ideas of the work in a straightforward fashion; 2) if scientific research findings are presented,
the abstract demonstrates a high quality of research design and methodology and includes sufficient data to support the conclusions; 3) the
work is timely, novel, and represents a potentially significant, scientific or educational contribution to the field; 4) abstract submission rules
have been followed. All abstract submitters who meet the above criteria during the abstract submission process will be considered for the
Blue Ribbon Abstract Award.
Award: A plaque and recognition in the publication of abstracts in AJIC online, onsite Annual Conference Program, and conference CD-ROM.
2012 Winners:
Presentation Number: 120
New York State Hospital-Acquired Infection Reporting – 2010 Audit Results: An Inter-Hospital Comparison
Kathleen McMullen, MPH, CIC
Discontinuation of Reflex Testing of Stool Samples for Vancomycin-Resistant Enterococci Resulted in Increased Prevalence
Lee Reed, RN, BA, MSPH, CIC
Rapid Cycle Process Improvements to Decrease Surgical Site Infections in Cardiothoracic and Vascular Surgery Patients between 2008 and 2011
Gregory Gagliano, BSN, RN, CIC
A Healthcare Worker with Pertussis: High Cost and Lost Opportunity
Mary Cole, BSN, CIC
Escalation and De-Escalation Plan for Carbapenem-Resistant Gram Negative Organisms in Critical Care
Marc-Oliver Wright, MT(ASCP), MS, CIC
Preventing Contamination of Central Venous Catheter Valves with the Use of an Alcohol-based Disinfecting Cap
Grace Lee, MD, MPH
The Impact of Non-Payment for Preventable Complications on Infection Rates in U.S. Hospitals
Keith Kaye, MD, MPH
Re-Admissions After Diagnosis of Surgical Site Infection Following Knee and Hip Arthroplasty
Audrey Adams, RN, MPH, CIC
The Impact of Using Chlorhexadine Gluconate Products in the Adult Critical Care Setting
Karen Rich, RN, BSN, MEd, CIC
Assessment of the Quality and Accuracy of Publically Reported CLABSI Data in Colorado
10
Abstract Awards continued
New Investigator Award
Purpose: The New Investigator Award encourages research by APIC members by recognizing outstanding scientific research
by an APIC member presenting for the first time at the APIC Annual Educational Conference and International Meeting.
Selection Criteria: To be considered for the New Investigator Award, applicants must be: 1) a current APIC member; 2) the
first or presenting author on a scientific paper (Format I) selected for presentation; and 3) a first-time presenter of a scientific
paper in either an oral or poster session; 4.) Authors must indicate they are applying for the New Investigator Award during
the abstract submission process by clicking the check box labeled “New Investigator Award.” This is a one time award, and
winners may not apply for this award in the future. However, other individuals from the same institution are eligible to apply
for their scientific research.
Award: $1,500, a plaque and recognition in the publication of abstracts in AJIC online, onsite Annual Conference Program
and Abstract Publication, and conference CD-ROM.
2012 Winner:
Publication Number: 120
SPONSOR: ASP
New York State Hospital-Acquired Infection Reporting – 2010 Audit Results: An Inter-hospital Comparison
Best International Abstract Award
Purpose: This award recognizes the best abstract from outside the United States
Selection Criteria: Abstracts will be judged on scientific merit, interest, and relevance to the infection prevention and control
community. To be considered for this award, applicants must meet the following requirements: 1) the applicant resides
outside the United States; 2) the research was conducted outside the United States; 3) the applicant is able to present the
paper at the APIC Annual Conference; 4) the applicant follows all online submission procedures. All abstract submitters
who meet the above criteria during the abstract submission process will be considered for the Best International Abstract
Award. However, abstract submitters who will not be considered for this award are those submitters who check the box
labeled “DO NOT consider for the Best International Award.”
Award: $1,000 travel stipend to APIC Annual conference, recognition in the publication of abstracts in AJIC online, onsite
Annual Conference Program and Abstract Publication, and conference CD-ROM.
2012 Winner:
Publication Number: 105
Alejandro Macias, MD
Endemic IV Fluid Contamination in Hospitalized Children in Mexico. A Problem of Serious Public Health Consequences.
11
Abstracts and Posters Were Submitted in Two Different Formats
FORMAT I
This format is intended for abstracts involving scientific research, such as randomized clinical
controlled trials, case-controlled studies, cohort, observational, descriptive studies, and/or
experimental design. Abstracts should disclose primary findings and should not discuss works
in progress with preliminary results.
Format I abstracts contain the following:
•
Background/Objectives: Outline study objectives, hypothesis tested, or problem
addressed.
•
Methods: Describe study design. NOTE: When using trade names, several companies’
trade names should be used, not just trade names from a single company.
•
Indicate the setting for the study, study design, sample, sample size, study procedure,
outline, subjects, intervention, and type of statistical analysis.
•
Results: Summarize essential results with appropriate statistical analysis (p-value
confidence intervals, odds ratio, relative risk, rate ratio, etc.). Present as clearly as
possible the outcome of the study and statistical significance if appropriate.
•
Conclusions: Conclusions should be supported by the findings. Summarize findings
(as supported by results), implications, and conclusions. Emphasize the significance of
the results.
FORMAT II
This format is intended for abstracts describing educational programs, observations, case
studies, outbreak investigations, or other infection prevention or quality improvement
activities, including descriptions of facility- or community-based programs or interventions,
infection prevention policies, and prevention models or methods.
Format II abstracts contain the following:
12
•
Issue: Identify specific problem or need addressed. Provide a brief introduction and
include important background information
•
Project: Describe the setting, intervention, and significant detail of the program
•
Results: Summarize results
•
Lessons Learned: Outline lessons learned and implications.
Poster Abstracts
Location: Exhibit Hall D, San Antonio Convention Center
Presentation Number 1-001
Posters are arranged by topic number (see below) and then
numerically by Publication Number within each category. The
poster hall will be open for the duration of the conference, Friday,
June 4 – Sunday, June 6.
Risk Factors for Vancomycin-resistant
Enterococcus faecalis bacteremia: a case-casecontrol study
Kayoko Hayakawa, MD, PhD - Fellow, Wayne State University,
Detroit Medical Center; Dror Marchaim, MD - Post Doctoral
Fellow Infection Control and Epidemiology, Detroit Medical
Example, Poster 1-005 is in the Antimicrobial Resistance
Center/Wayne State University; Mohan B. Palla, MBBS - Research
category and precedes poster 1-006.
Assistant, Wayne State University, Detroit Medical Center; Uma
Mahesh, MBBS - Research Assistant, Wayne State University,
Detroit Medical Center; Harish Pulluru, MBBS - Research
Poster Categories
Assistant, Wayne State University, Detroit Medical Center; Kyeong
Pyo Lee, MD - Research Assistant, Wayne State University, Detroit
Medical Center; Srinivasa Kamatam, MBBS - Research Assistant,
CATEGORY TOPIC
Wayne State University, Detroit Medical Center; Manit Singla,
1.
MBBS - Research Assistant, Wayne State University, Detroit
2.Antisepsis/Disinfection/ Medical Center; Mayan Ajamoughli, MD - Research Assistant,
Wayne State University, Detroit Medical Center; Pradeep Bathina,
Sterilization
MBBS - Research Assistant, Wayne State University, Detroit Medical
3. Bioterrorism/Disaster/
Center; Khaled Alshabani, MD - Research Assistant, Wayne State
Emergency Preparedness
University, Detroit Medical Center; Aditya Govindavarjhulla,
4.
Device-Related Infections and/
or Site Specific Infections
Center; Ashwini Mallad, MBBS - Research Assistant, Wayne
State University, Detroit Medical Center; Kevin Ho, BA - Medical
5.
Emerging and Reemerging student, Wayne State University, Detroit Medical Center; Deepika
Infectious Diseases
Reddy Abbadi, MBBS - Research Assistant, Wayne State University,
6.
Environment of Care/Construction/
Detroit Medical Center; Deepti Chowdary, MBBS - Research
Remediation
Assistant, Wayne State University, Detroit Medical Center; Hari
Kakarlapudi, MBBS - Research Assistant, Wayne State University,
7.
Healthcare Worker Safety/
Detroit Medical Center; Harish Guddati, MBBS - Research
Occupational Health
Assistant, Wayne State University, Detroit Medical Center; Manoj
8.
Infection Prevention and Das, MBBS - Research Assistant, Wayne State University, Detroit
Control Programs
Medical Center; Naveen Kannekanti, MBBS - Research Assistant,
9.
Wayne State University, Detroit Medical Center; Balaji Ramasamy,
10. Product Evaluation/Cost-
Medical Center; Amber Khan, MD - Research Assistant, Division of
Effectiveness/Cost Benefit Analysis
Infectious Diseases, Wayne State University; Praveen Vemuri, MBBS
11. Public Reporting/Regulatory - Research Assistant, Division of Infectious Diseases, Wayne State
Compliance
University; Rajiv Doddamani, MBBS - Research Assistant, Division
12. Quality Management Systems/
of Infectious Diseases, Wayne State University; Venkat Ram Rakesh
Process Improvement/
Mundra, MBBS - Research Assistant, Division of Infectious Diseases,
Adverse Outcomes
Wayne State University; Raviteja Reddy Guddeti, MBBS - Research
Assistant, Division of Infectious Diseases, Wayne State University;
13. Special Populations (Infections in Rohan Policherla - Medical Student, Wayne State University, School
the Immunocompromised Host, of Medicine; Sarika Bai, MBBS, MD - Research Assistant, Division
Pediatrics)
of Infectious Diseases, Wayne State University; Sharan Lohithaswa,
14. Specialized Settings (Ambulatory MD - Research Assistant, Division of Infectious Diseases, Wayne
Care, Behavioral Health, Long Term State University; Shiva Prasad Shashidharan, MBBS - Research
Care, Home Care)
Sowmya Chidurala, MBBS - Research Assistant, Division of
15. Staff Training/Competency/
Infectious Diseases, Wayne State University; Sreelatha Diviti, MBBS
Compliance
- Research Assistant, Division of Infectious Diseases, Wayne State
16.Surveillance
University; Dipenkumar Patel, MBBS - Research Assistant, Detroit
Medical Center; Gayathri Vadlamudi - Research Assistant, Division
13
Poster Abstracts: Antimicrobial Resistance
of Infectious Diseases, Wayne State University; Tarek Obeid Research Assistant, Division of Infectious Diseases, Wayne State
University; Jason Pogue, PharmD - Infectious Diseases Pharmacist,
Detroit Medical Center; Paul R. Lephart, PhD - Associate Technical
Director of Microbiology, Detroit Medical Center University
Laboratories; Emily Toth Martin, MPH, PhD - Assistant Professor,
Department of Pharmacy Practice, Wayne State University College
of Pharmacy and Health Sciences; Elaine Flanagan, BSN, MSA,
CIC - Director Epidemiology, Detroit Medical Center; Michael J.
Rybak, PharmD, MPH - Associate Dean for Research, Professor
of Pharmacy and Medicine Director, The Anti-Infective Research
Laboratory, Eugene Applebaum College of Pharmacy and Health
Science; Keith Kaye, MD, MPH - Corporate Director of Infection
Prevention, Hospital Epidemiology and Antimicrobial Stewardship,
Detroit Medical Center/Wayne State University
Background/Objectives: Published cohorts of patients
with bacteremia due to vancomycin-resistant Enterococcus (VRE)
have predominantly consisted of E. faecium. Little is known about
the epidemiology associated with bacteremia due to VR E. faecalis
(VREF). VREF is unusually common at DMC, and has been
growing in prevalence; in 2009, 530 of 4,377 (12.1%) isolates of E.
faecalis were VRE. In the majority of cases of vancomycin-resistant
Staphylococcus aureus (VRSA), VREF has served as the vanA donor
to S. aureus. Better understanding the epidemiology of infection
due to VREF is an essential first step in limiting the continued
proliferation and spread of these organisms, which might also
help to prevent emergence and spread of VRSA. MEthods:
A case-case-control study was conducted to identify independent
risk factors for bacteremia due to VREF. Unique patients with
bacteremia due to VREF from 2008 to 2009 were matched to cases
with bacteremia due to vancomycin-sensitive E. faecalis (VSEF)
and to uninfected controls in a 1:1:1 ratio. Results: Seventy-six
cases of bacteremia due to VREF were identified and were matched
to 76 VSEF bacteremia cases and 76 uninfected controls. The mean
age of the study cohort was 61.9+-15.7 years, 133 (58.3%) were
male, 186 (81.6%) were African American. Eighty-nine subjects
(39.2%) resided in institutions (nursing homes or hospitals) prior to
admission (44 [57.9%] of VREF, 27 [36%] of VSEF, 18 [23.7%] of
controls; p < 0.001 for VREF compared to controls:). One hundred
fifty-two (66.7%) had dependent functional status on admission (60
[78.9%] of VREF, 56 [73.7%] of VSEF, 36 [47.4%] of controls; p
< 0.001 for VREF compared to uninfected controls, p=0.002 for
VSEF compared to controls). The Charlson’s median weighted index
comorbidity (IQR) scores were 5.4 (3.3-8.3), 4.5 (2.6-6.7), and 2.2
(0.8-4.3) for VREF, VSEF and controls (p < 0.001 for VREF cases
compared to controls). Thirty-one (40.8%) of the patients with
VREF and 35 (46.1%) of the patients VSEF had pathogens that were
hospital-acquired, defined as isolated from a culture obtained after 2
days of hospitalization. Independent risk factors for the isolation of
VREF and VSEF were determined by multivariate analysis (Table).
In multivariate analysis, vancomycin was the only variable that was
associated with VREF but not with VSEF. The presence of indwelling
permanent devices was associated with VREF to a stronger degree
than VSEF. Conclusions: Vancomycin exposure was a strong,
unique predictor of VREF. The presence of permanent indwelling
devices, such as tracheotomies, central lines, urinary catheters, and
hemodialysis catheters at the time of admission was also associated
14
with bacteremia due to VREF. In order to control the continued
spread of VREF, and possibly VRSA, a combined approach of
infection control focusing on care for and removal of permanent
devices and antimicrobial stewardship focusing on limiting
vancomycin is necessary.
Emergence of IMP-1 Producing Escherichia coli in
a Tertiary Hospital in Japan
Kei Kasahara - Associate Professor, Center for Infectious Diseases,
Nara Medical University; Yuko Komatsu - Postgraduate student,
Center for Infectious Diseases, Nara Medical University; Akifumi
Nakayama - Microbiologist, Department of Clinical Microbiology,
Nara Medical University; Koji Ui - Microbiologist, Department
of Clinical Microbiology, Nara Medical University; Fumiko
Mizuno - Associate Professor, Department of Microbiology,
Nara Medical University; Keiichi Mikasa - Professor, Center for
Infectious Diseases, Nara Medical University; Reiko Sano - Director,
Department of Clinical Microbiology; Eiji Kita - Professor,
Department of Microbiology, Nara Medical University
Background/Objectives: Cephalosporin resistance
due to extended beta lactamases have been a serious problem in
enterobacteriaceae such as E. coi. In addition to this, emergence
of carbapenem resistant strains such as KPC or NDM producing
ones has made the situation much more complicated. The resistance
pattern and recommended antibiotics may vary depending on the
resistant mechanisms and there is a need to evalulate the situation
in each geographic area. Methods: A total of 256 E. coli strains
isolated between November 2010 and October 2011 in out hospital
(a tertiary hospital with 800 beds in Nara, Japan) were evaluated
for antibiotic resistance, ESBL genes, and carbapenemase genes.
Results: There were 37 isolates (14.4%) that produce ESBL. All
of the ESBL producing E. coli possessed CTX-M gene. Four isolates
produced IMP-1, a metallo beta lactamase in addition to ESBL.
Isolates with only ESBL were resistant to all cephalosporins but
susceptible to cefmetazole (antibiotic that belongs to cephamycins),
whereas isolates with both ESBL and IMP-1 were resistant to all
cephalosporins and cefmetazole. Even IMP-1 producing strains were
susceptible to imipenem and meropenem according to the CLSI
2012 criteria. All of the ESBL and/or IMP-1 producing strains were
susceptible to fosfomycin. No isolates with KPC or NDM were
detected. Conclusions: The carbapenem resistance genes in
Japan (ie. IMP-1) may vary from those in the United States (NDM
or KPC). Most of the IMP-1 producins strains were shown to
be susceptible to carbapenems in vitro, but the clinical efficacy of
carbapenem on these strains is yet to be elucidated.
Escalation and De-Escalation Plan for
Carbapenem-Resistant Gram Negative Organisms
in Critical Care
Mary A. Cole, BSN, CIC - Director of Infection Prevention and
Control, Grady Health System
Issue: Infections with carbapenem-resistant gram-negative
organisms are emerging as an important challenge in healthcare settings. The purpose of this initiative was to decrease the
transmission of these infections and colonization in the ICUs by
implementing consistent multi-disciplinary activities. Project: A
multidisciplinary team formed to devise an improved, more highlystructured schematic for controlling and preventing the infections
throughout the critical care division of the hospital. Establishing an
algorithm of activities reduced confusion and guess-work, allowing
healthcare workers to respond to the outbreak based solely on
outcome results. Results: Since the implementation of this plan,
carbapenem-resistant Acinetobacter infections decreased 70.8%,
from 24 cases in July 2010 to 2 cases in December 2011. During
this time frame, intense focus has also increased hand hygiene
compliance rates by 14%. Since the height of the outbreak our central
line associated blood stream infection (CLABSI) rate has decreased
87.3% in the intensive care units. Due to the decrease in transmission,
cost savings was also incurred. Lessons Learned: This plan
is both measurable and user friendly, giving guidance and structure
as the number of new clinical cases governs the interventions rather
than subjective discretion. All stakeholders’ roles are clearly defined,
delineating responsibilities across many departments (patient care,
infection control, EVS) and levels ranging from front line staff to
senior administration. Although the initial intent was to provide
consistency to infection control activities during an outbreak, staff
reports an increased sense of empowerment and accomplishment
in controlling infection transmission, thereby, positively impacting
patient outcomes. Job satisfaction and patient satisfaction is improved
with fewer patients in contact isolation. The units are competitive
with de-escalation being a common goal. While the plan is currently
utilized for carbapenem-resistant gram negative infections, its
universality allows it to be applied to other resistant organisms as
well. This plan can easily be adapted to fit other clinical intensive care
settings and can be extended to other facilities.
15
Risk factors for the isolation of Vancomycinresistant Enterococcus faecalis from wound site: A
case-case control analysis
Mohan B. Palla, MBBS - Research Assistant, Wayne State University,
Detroit Medical Center; Kayoko Hayakawa, MD, PhD - Fellow,
Wayne State University, Detroit Medical Center; Dror Marchaim,
MD - Post Doctoral Fellow Infection Control and Epidemiology,
Detroit Medical Center/Wayne State University; Uma Mahesh,
Medical Center; Harish Pulluru, MBBS - Research Assistant,
Wayne State University, Detroit Medical Center; Kyeong Pyo
Lee, MD - Research Assistant, Wayne State University, Detroit
Medical Center; Srinivasa Kamatam, MBBS - Research Assistant,
Wayne State University, Detroit Medical Center; Manit Singla,
Medical Center; Mayan Ajamoughli, MD - Research Assistant,
Wayne State University, Detroit Medical Center; Pradeep Bathina,
Center; Khaled Alshabani, MD - Research Assistant, Wayne State
University, Detroit Medical Center; Aditya Govindavarjhulla,
Center; Ashwini Mallad, MBBS - Research Assistant, Wayne
State University, Detroit Medical Center; Kevin Ho, BA - Medical
student, Wayne State University, Detroit Medical Center; Deepika
Reddy Abbadi, MBBS - Research Assistant, Wayne State University,
Detroit Medical Center; Deepti Chowdary, MBBS - Research
Assistant, Wayne State University, Detroit Medical Center; Hari
Kakarlapudi, MBBS - Research Assistant, Wayne State University,
Detroit Medical Center; Harish Guddati, MBBS - Research
Assistant, Wayne State University, Detroit Medical Center; Manoj
Das, MBBS - Research Assistant, Wayne State University, Detroit
Medical Center; Naveen Kannekanti, MBBS - Research Assistant,
Wayne State University, Detroit Medical Center; Balaji Ramasamy,
Medical Center; Amber Khan, MD - Research Assistant, Division of
Infectious Diseases, Wayne State University; Praveen Vemuri, MBBS
University; Rajiv Doddamani, MBBS - Research Assistant, Division
of Infectious Diseases, Wayne State University; Venkat Ram Rakesh
Mundra, MBBS - Research Assistant, Division of Infectious Diseases,
Wayne State University; Raviteja Reddy Guddeti, MBBS - Research
Rohan Policherla - Medical Student, Wayne State University, School
of Medicine; Sarika Bai, MBBS, MD - Research Assistant, Division
of Infectious Diseases, Wayne State University; Sharan Lohithaswa,
MD - Research Assistant, Division of Infectious Diseases, Wayne
State University; Shiva Prasad Shashidharan, MBBS - Research
Sowmya Chidurala, MBBS - Research Assistant, Division of
Infectious Diseases, Wayne State University; Sreelatha Diviti, MBBS
University; Dipenkumar Patel, MBBS - Research Assistant, Detroit
Medical Center; Gayathri Vadlamudi - Research Assistant, Division
of Infectious Diseases, Wayne State University; Tarek Obeid Research Assistant, Division of Infectious Diseases, Wayne State
University; Jason Pogue, PharmD - Infectious Diseases Pharmacist,
16
Detroit Medical Center; Paul R. Lephart, PhD - Associate Technical
Director of Microbiology, Detroit Medical Center University
Laboratories; Emily Toth Martin, MPH, PhD - Assistant Professor,
Department of Pharmacy Practice, Wayne State University College
of Pharmacy and Health Sciences; Michael J. Rybak, PharmD,
MPH - Associate Dean for Research, Professor of Pharmacy and
Medicine Director, The Anti-Infective Research Laboratory, Eugene
Applebaum College of Pharmacy and Health Science; Elaine
Flanagan, BSN, MSA, CIC - Director Epidemiology, Detroit
Medical Center; Keith Kaye, MD, MPH - Corporate Director of
Infection Prevention, Hospital Epidemiology and Antimicrobial
Stewardship, Detroit Medical Center/Wayne State University
Background/Objectives: VRE are most commonly
E. faecium. However, in our health system in Southeast Michigan
(SEMI), VR E. faecalis (VREF) is unusually common; more than
38% of VRE were E. faecalis in 2009. VREF is associated with
development of vancomycin-resistant Staphylococcus aureus (VRSA)
via transfer of the vanA plasmid to S. aureus. Wounds have been
reported as the anatomic culture source of VRSA in 10 of 12 patients
with VRSA, of which 8 cases were reported from SEMI. A recent
study suggested wounds were an important risk factor of MRSA and
VRE co-colonization. We conducted a retrospective case-case control
study to evaluate the independent risk factors specifically associated
with VREF isolation from wounds, which has important implications
regarding the continued emergence of VRSA in SEMI. Methods:
Unique patients with VREF isolation from a wound during the study
period (2008-2009) were matched to two groups of patients in a
1:1:1 ratio: the first, with isolation of vancomycin-sensitive E. faecalis
(VSEF) from a wound; and the second, uninfected controls. A
case-case-control analysis was conducted. Results: One hundredsixteen VREF cases were identified and matched to 116 VSEF cases
and to 116 uninfected controls. The mean age of the study cohort
was 60.7+-17.1 years, 167 (48%) were males, 266 (76.4%) were
African American. Seventy-four (62.2%) cases with VREF and 58
(50%) VSEF patients had hospital-acquired pathogens, (isolated
from a culture > 2 days after hospital admission). Eighty-four subjects
(24.1%) resided in institutions (nursing home or hospitals) prior to
admission (46 [40%] of VREF, 25 [21.6%] of VSEF, 13 [11.2%] of
controls; p<0.001 for VREF vs uninfected controls; p=0.044 for
VSEF vs controls). One hundred seventy-two (49.4%) subjects had
dependent functional status on admission (74 [64.9%] of VREF
cases, 50 [43.1%] of VSEF cases, 48 [41.4%] of uninfected controls;
p=0.001 for VREF vs uninfected controls). The Charlson’s combined
comorbidity score (median, [IQR]) were 6.0 (3.2-8.6), 5.5 (2.87.6), and 4.8 (1.8-7.8) for VREF, VSEF, and controls respectively
(p=0.03 for VREF compared to uninfected controls). Independent
risk factors for the isolation of VREF and VSEF were determined by
multivariate analysis (Table). Conclusions: The presence on
admission of permanent indwelling devices (e.g. central lines, urinary
catheters, hemodialysis catheters, tracheotomies, percutaneous
endoscopic gastrostomy [PEG] tubes) and past exposure to Betalactam antibiotics were uniquely associated with isolation of VREF
but not VSEF. Chronic skin ulcers were associated with the isolation
of both VREF and VSEF. The results of this study are in accordance
of reported risk factors for VRE and MRSA cocolonization in SEMI,
and might explain in part the endemicity of VRSA in this region.
Surveillance, proactive infection control measures and antimicrobial
stewardship are key methods to control the spread of VREF and
continued emergence of VRSA.
The Cephalosporin Use in the Penicillin
Allergic Patient
Peggy Prinz Luebbert, MS, MT(ASCP)SC, CIC, CHSP - Owner
and Consultant, Healthcare Interventions; Infection Preventionist,
Nebraska Orthopaedic Hospital; Infection Preventionist-Consultant,
Select Specialty Hospital; Chris Vollmuth - Pharmacist, Nebraska
Orthopaedic Hospital
Issue: Issue:Many patients present for orthopedic surgeries with
penicillin or cephalosporin allergies. These allergies are unbiquous
and range from hives, shortness of breath to an upset stomach. The
pre –operative antibiotic of choice for these procedures is Ancef. In
the past, these “allergic” patients would be treated with vancomycin
or clindamycin pre-operatively. This last minute antibiotic change
lead to increase in pre-op nursing and pharmacy staffing time,
delayed surgeries, operating room scheduling issues and increased
risk of complications for the patient ( I.e. MDRO, renal issues or
c-diff infections etc. Project: In response to some complications
when managing these allergic patients, our pharmacist noted in his
research that true penicillin allergies tend to be IgE mediated (type
I hypersensitivity reaction) that occur within minutes to hours
after exposure and include anaphylaxis, bronchospasm, angioedema
,hypotension or hives. He also discovered that early literature noted a
cross-reactivity between penicillin and cephalosporins was originally
thought to be anywhere between 1% and 18% . However, these rates
may have been overestimated due to reporting of symptoms that
were not truly allergies and to the less refined manufacturing process
that lead to the presence of penicillin in early cephalosporins. More
recent research is showing that cross-reactivity is dependent on the
similarity of the side chains at position 6, 7 and 3 on these antibiotics.
Therefore, drugs with similar chains at these positions are more likely
to exhibit cross-allergenicity with each other. Cefazolin( Ancef ),
cefonicid , cefotiam and moxalactam do not share a structural
relationship with other drugs ( including penicillin) and therefore
cross-reactivity would be extremely unlikely. Therefore, a history of
penicillin should not predict an allergy to Ancef. With the approval
of the P&T, Infection Prevention Committee and Medical Executive
Committee, all standing orders were change so that only patients
who noted a specific allergy to Ancef – not penicillin – were given
other antibiotics. Results: Physicians and clinical staff were
educated to new processes by email, personal letters and one on one
conversations. All preoperative patients were asked if they have a
history of an Ancef allergy. If noted, vancomycin or clindamycin
were used. Fifty seven percent (57%) less vancomycin as well as 63%
less clindamycin was used todate in comparison to same period prior
to this initiative implementation. Since implementation, no allergic
reactions were reported by staff or patients. Lessons Learned:
Nursing and pharmacy staff reported less anxiety with perceived
allergic patients, calmer pre-op setting and less delayed surgeries (
due to vancomycin infusion time). Process noted a decrease in the
amount of vancomycin and clindamycin was used leading to less risk
of patients developing multidrug resistant organisms.
Risk factors to acquire Vancomycin-Resistant
Enterococcus faecium (VRE) infection in
pediatric patients
Alejandra Nava Ruiz, MD - Chief of services, Hospital Infantil de
Mexico Federico Gomez
Background/Objectives: In 2009, we characterized the
first strain of VRE implicated in an outbreak by using molecular
techniques. Since then, we had been isolating VRE considered those
strains endemic as infecting and colonizing agent. The aim of this
study is to identify the risk factors for VRE infection in pediatric
patients in order to design epidemiological control measures.
Methods: A retrospective case-control study was performed in
a terciary children hospital in Mexico City from January 2010 to
April 2011. Demographic data, clinical characteristics and risk factors
like antibiotic exposure (cephalosporins, clindamycin, vancomycin),
surgical procedures, care in an intensive care unit (UCI), use of
steroids, use of medical devices, and underlying conditions. We
compared variables in paired groups regarding age, underlying
diseases in a multivariate logistic regression model. Each case was
matched with 4 control patients. Antibiotic susceptibility profile
was performed with Kirby-Bauer method according with Clinical
and Laboratory Standars Institute (CLSI) recommendations.
The VRE strains genotype clonal pattern were analyzed with
pulsed-field electrophoresis (PFGE). For schematic representation
through a phylogenetic tree, the genomic profiles of isolated of
VRE were grouped first by visual inspections and subsequently
analyzed with the program NTSYS 2.02. Results:We identify
63 patients with VRE, only 12 (20%) developed infection; 5
patients (41%) had central-line associated bloodstream infection
17
Poster Abstracts: Antisepsis/Disinfection/Sterilization
(CLABSI) and 8 patients (58%) urinary tract infection; 5 (42%)
patients with infection had cancer and all infected or colonized.
(100%) patients had linezolid. Three patients (5%) died for VRE
septic shock. Increment of risk for VRE infections was found
statistically significant with vancomycin exposure Odds Ratio (OR)
10 [95%Confidence Interval = 2.4-41.3 (p=0.001)]. Other risk
factors that were not statistically significant, but highly associated
with VRE were ICU hospitalization and use of steroids. Hematooncology ward and ICU had highest incidence of cases. VRE strains
were identified as phenotype A: minimal inhibitory concentration
(MIC) > 64mcg/ml and teicoplanin MIC > 16mgc/ml, high
resistance to aminoglycosides (>500mg/dl gentamicin). Those
strains exhibited full susceptibility to linezolid, daptomycin and
quinupristin-dalfopristin. PFGE shown similar clonal pattern of VRE
strains according Tenover’ s criteria. Dendrogram analysis display
strains of VRE highly epidemiological related. Conclusions:
Incidence of VRE infections in our center is increasing. We found
that vancomycin exposure is frequent in those who develop VRE
infection, unclear is if use of vancomycin is a marker of overall host
susceptibility and propensity to acquire the infection and/ or favor
colonization. Because the VRE endemicity in our institution, we
are optimizing infection prevention and control practices and VRE
surveillance in high risk patients while using vancomycin when this is
indicated.
found that equipment disinfection occurred only 47% of the time.
Lack of available of disinfectant to clean equipment was a factor in
suboptimal compliance. Wall mounted brackets were installed to
hold disinfectant wipes. Education on equipment disinfection was
provided and an equipment disinfection grid listing equipment,
cleaning responsibility, and method was widely distributed. A post
intervention audit was perfomed, showing increased compliance of
74.3% Ongoing departmental monitoring of equipment disinfection
to maintain improvement was recommended. Lessons
Learned: What was initially expected to be a 6 month effort
turned into a 2 year project. Chosing a proper and cost effective
disinfectant and agreeing on a safe yet convenient location was
challenging in light of our patient population. Teamwork and
involving senior administration were key to the success of our project.
Maintaining compliance by ongoing monitoring will be a long range
challenge.
Antisepsis/Disinfection/Sterilization
Disinfect To Protect- Developing a System To
Enhance Disinfection of Patient Care Equipment
Judy Latham, RN, BSN, CRRN - Nurse Manager, Bryn Mawr
Rehabilitation Hospital; Hillary B. Cooper, RN, MS, CIC - Lead
Infection Preventionst, Main Line Health System
Issue: Disinfection of patient care equipment is important to
prevent the spread of infections between patients. Our goal was to
put in place a process to ensure that equipment disinfection routinely
occurs between patients. We looked at equipment disinfection
to measure compliance with best practice and determine needed
interventions. Project: Our 148 bed acute care rehabilitation
hospital serves brain injury, stroke, orthopedic, and medical
rehabilitation adults. We formed a multidisciplinary performance
improvement team to review and evaluate the current state of
equipment disinfection, and make recommendations to ensure
that a workable system for equipment disinfection is in place.
Equipment disinfection after use on each patient was our goal to
maintain best practice . The team perfomed an initial compliance
audit and based interventions on the findings. Brackets for
disinfectant wipes were then installed near point of use locations,
alcohol wipes dispensers were placed in physician charting rooms,
and traveling multipatient BP cuffs were replaced with permanent
room based BP cuffs for each patient. Housewide education on
the disinfection process was provided, and a post intervention
compliance audit was performed. Results: Initial audit results
18
A Comparative In-Vivo Study on Persistent
Effects of Chlorhexidine Gluconate in Alcohol
Formulations and a Povidone-Iodine Solution as
Skin Preparations
Yutaka Nishihara, PhD - Deputy General Manager, R&D Div,
Yoshida Pharmaceutical Co., Ltd.; Takumi Kajiura, PhD - General
Manager, R&D Div, Yoshida Pharmaceutical Co., Ltd; Katsuhiro
Yokota - Director, R&D Div, Yoshida Pharmaceutical Co., Ltd;
Hiroyoshi Kobayashi, MD, PhD - Chancellor, Tokyo Healthcare
University and Postgraduate School; Takashi Okubo, MD, PhD Professor, Tokyo Healthcare University and Postgraduate School;
Robert R . McCormack - Principal Study Director, BioScience
Laboratories, Inc.
Background/Objectives: Reducing the microbial
population on the skin is critical for reducing the risk of catheterrelated blood stream infections (CRBSIs). The CDC guideline
issued in 2011 recommends skin preparations containing > 0.5%
Chlorhexidine Gluconate (CHG) in alcohol. With a focus on
prolonged catheter care in medical practice, we conducted a study per
ASTM Standard Method E1173-09 to compare the antimicrobial
efficacy among two formulations of CHG in alcohol and a PovidoneIodine (PVP-I) solution. OBJECTIVE: To compare the immediate
and persistent antimicrobial effects of a 79% (v/v) ethanol containing
1% (w/v) CHG (CHG-ethanol), a 70% (v/v) Isopropanol
containing 2% (w/v) (CHG-Isopropanol), and a marketed 10%
(w/v) PVP-I solution, when used for preoperative/precatheterization
preparation on healthy human subjects. Methods: 55 healthy
adult subjects meeting criteria for minimum baseline bacterial
counts on test sites were enrolled to evaluate the immediate and
persistent effects of the test formulations on the abdominal site at
post-treatment time points of 30 seconds, 72 hours, and 168 hours
(7 days). Testing procedures were performed according to ASTM
Standard Method E1173-09. RESULTS: Three blocked, two-factor
ANOVAs showed that all test formulations produced significant
reductions in the microbial populations on abdominal sites at all
sample times. The persistent effects of the 1% CHG-ethanol on
the abdominal site 72 hours and 168 hours post-treatment were
significantly superior to those of the 10% PVP-I solution (p < 0.05;
Table 1). The 1% CHG-ethanol preparation and the 2% CHGIsopropanol formulation produced statistically equivalent persistence
72 hours and 168 hours post-treatment. Subjects experienced no
adverse events over the course of the study. CONCLUSIONS:
As relates to long-term catheter care in medical practice, the two
tinctures of CHG produced and maintained greater mean log10
reductions in microbial flora at all sample times greater than did
the PVP-I solution (p < 0.05; Table 1). Considering that Japanese
pharmaceutical regulations limit CHG content in antiseptics to
a maximum of 1%, it is reasonable to expect that the 1% CHGethanol preparation will perform well in-use as a preoperative
skin preparation and have promising potential as a catheter prep/
maintenance preparation to reduce the risk of CRBSIs and/or central
line-associated blood stream infection.
Review of Proper Reprocessing of Reusable
Medical Equipment in VHA Facilities
Kathleen J. Shimoda, BSN - Healthcare Inspector, VA Office
of Inspector General - Office of Healthcare Inspections; George
Wesley, MD - Director, Medical Consultation and Review of
the Department of Veterans Affairs Office of Inspector General.,
VA Office of Inspector General Office of Healthcare Inspections;
Deborah Howard, BSN, MSN - Regional Director, San Diego
Office of Healthcare Inspections, VA Office of Inspector General
Office of Healthcare Inspections
Issue: Proper reprocessing of reusable medical equipment (RME)
has been an area of major concern in Veterans Health Administration
(VHA) hospitals and clinics. In 2009, both VHA’s Secretary and
the U.S. Congress requested VA’s Office of Inspector General
(OIG) to review VHA’s performance in the area of reprocessing
of endoscopic equipment. OIG’s Office of Healthcare Inspections
(OHI) undertook an inspection to determine the extent to which
VA facilities were in compliance with directives regarding endoscope
reprocessing. In a sample of VA medical centers, widespread
non-compliance was identified. After extensive education and
senior VA leadership declaring proper RME reprocessing to be an
organizational priority, a follow-up OHI inspection three months
later showed significant improvement, although issues remained.
OHI then incorporated review of RME reprocessing into its routine
VA medical center inspections. This presentation discusses results
generated from these inspections. Project: OHI Inspectors
evaluated RME processes at 45 VA medical centers during routine
OHI VA inspections performed from January 1 through September
30, 2010. In the course of these inspections, we interviewed selected
program managers and reviewed documents, including facility
self-assessments; RME-related policies and Standard Operating
Procedures (SOPs), manufacturers’ instructions; meeting minutes;
employee training records and competency folders; and other
documentation related to RME reprocessing. We also observed
employees clean or reprocess non-critical, semi-critical, and
critical RME. We conducted physical inspections of reprocessing
areas. We utilized relevant VHA Directives, OSHA regulations,
Joint Commission standards, and CDC recommendations as our
references. Results: Consistent with the three month follow-up
inspection cited above, we found that VHA had made extensive
efforts to improve its reprocessing of RME. Nevertheless, problems
remained. Six areas where compliance with RME requirements
still needed improvement included SOPs, employee training and
competency assessments, flash sterilization, personal protective
equipment (PPE), environmental controls, and senior management
oversight of RME activities. We made recommendations in these
areas including that VHA ensure that SOPs are current and
consistent with manufacturers’ instructions, and located within the
reprocessing areas; that VHA ensures that its employees consistently
follow SOPs, that supervisors monitor compliance, and that
annual training and competency assessments are completed and
documented; that VHA ensure that flash sterilization is used only in
emergent situations, that supervisors monitor compliance, and that
managers assess and document annual competencies for employees
who perform flash sterilization; that PPE is utilized appropriately
in decontamination areas; that the heating, ventilation, and air
conditioning systems are maintained; and that there is ongoing senior
management involvement in internal oversight of RME activities.
Lessons Learned: Proper RME reprocessing can be a
continuing challenge for large healthcare organizations. The fact that
this work reflects oversight over a three-year period is indicative of
the efforts and continuing vigilance required in this area.
Targeted, Daily Environmental Disinfection with
Clorox® Dispatch® for the Prevention of HospitalAssociated Clostridium difficile and Acinetobacter
baumannii
Timothy L. Wiemken, PhD, MPH, CIC - University of Louisville
19
Instructor of Medicine, University of Louisville Division of
Infectious Diseases
Background/Objectives: Environmental contamination
with microorganisms is of growing concern in many healthcare
facilities due to the risk of healthcare-associated infections. C. difficile
and A. baumannii are two organisms that have shown increasing
incidence in healthcare facilities and have extended resistance to
many commonly used environmental disinfectants. Environmental
contamination with these two organisms may therefore pose an
infection risk to patients. Daily disinfection of the environment with
chemicals capable of killing these organisms may reduce the bioburden
of these organisms and decrease risk of transmission to subsequent
patients. The objective of this study was to determine if daily
disinfection of patient rooms is associated with decreased transmission
of C. difficile and A. baumannii. Methods: We conducted an
interventional study in a long-term acute care hospital in Louisville
KY from September 1, 2011 through November 31, 2011. The first
phase utilized a one-step hypochlorite disinfectant (Clorox Dispatch)
for daily cleaning and disinfection of all patient rooms housing
patients known to be colonized or infected with either C. difficile or
A. baumannii. The second phase (December 1, 2011 – February 28,
2012) will include cleaning and disinfection of all patient rooms in
the facility (data not yet collected). The Mid-P exact test was used
to evaluate the difference in infection rates for both organisms from
three months prior to the study and the first interventional period. No
other infection prevention interventions were introduced during the
study period. Results: For the three months prior to the start of
the study, there were 14 cases of C. difficile infection and 8,494 patient
days. After the first three months of the intervention, there were 4
cases of C. difficile and 8140 patient days (P<0.001). There were 11
infections and 8,948 patient days for the second intervention period
(P=0.111). For A. baumannii infection, there were 33, 42, and 53
cases, respectively for the same numbers of patient days (P=0.224 and
P= 0.506).. Conclusions: Targeted, daily disinfection with a
one-step hypochlorite solution was effective at decreasing C. difficile,
but not A. baumannii in the absence of other targeted infection
prevention interventions.
Comparison of the Surface Disinfection
Capabilities of Two Different Methods using
Automated Devices: Ultraviolet Light Versus
Hydrogen Peroxide Fogging Machine
Harriet Chan-Myers, BS, RM - Manager Microbiology, Advanced
Sterilization Products; Gladys Chang - Senior Scientist, Advanced
Background/Objectives: The prevalence of healthcare
associated infections has given rise to the need for additional surface
disinfection of high-touch areas. Manual cleaning and disinfection
from the housekeeping staff has proved insufficient and would greatly
benefit from the supplementation of an automated disinfection
machines that facilitate disinfection of hard to reach surfaces and
provide thorough disinfection of environmental services. Two
methods of automated surface disinfection evaluated here are
20
chemical (hydrogen peroxide fog) and non-chemical (ultraviolet
light) means of disinfection. Methods: This study compared
the efficacy of both methods of automated surface disinfection and
the effect of orientation of the contaminated surface, either direct
line of sight or indirect facing away from the device. Stainless steel
carriers each inoculated separately with 4-log10 clinically significant
microorganisms (Staphylococcus aureus, Pseudomonas aeruginosa,
Aspergillus niger, and Clostridium difficile spores) were placed 3
meters away from the automated device with the inoculated surface
facing the source of disinfection and another set facing away from
the source of disinfection. The room was sealed and locked and
the automated disinfection machine was set to run a disinfection
cycle. For the automated fogging machine tests, we used a diluted
(approximately 2.6%) hydrogen peroxide (H2O2) based solution
sprayed into the air as a fine mist or fog. The total cycle time was
approximately 2 hours. For the UV testing, we used a set timed
exposure to the UV lamps and we measured the UV dosage amounts
with a UV detector. The exposure times were 15, 30, and 60 minutes.
At the completion of cycle, , either once the H2O2 level in the
surrounding air reached 1 ppm or when the UV exposure time was
reached, the stainless steel carriers were retrieved. The stainless steel
carriers were then processed to determine the concentration of
surviving microorganisms by carrier elution and serial dilution/pour
plate methodology. Results: There was a 3 – 4 log reduction of
organism with the automated fogging machine for all tests. For the
UV device, it was evident that the orientation of the carriers (direct
line of sight or indirect) affected the disinfection efficacy and log
reduction ranged from 1 – 4 logs. Conclusions: Our study
shows that the automated fogging machine was more consistent and
efficacious than the UV device, where efficacy was dependant on the
orientation of the contaminated surfaces, with indirect exposure with
UV showing minimal efficacy.
A Comparison of the Surface Disinfection
Capabilities of Two Different H2O2 Based
Disinfectants used in an Automated Fogging
Machine in a 72 Cubic Meter Room
Gladys Chang - Senior Scientist, Advanced Sterilization Products;
Harriet Chan-Myers, BS, RM - Manager Microbiology, Advanced
Background/Objectives: The prevalence of healthcare
associated infections has given rise to the need for additional
surface disinfection of high-touch areas. Manual cleaning and
disinfection from the housekeeping staff has proved insufficient and
would greatly benefit from the supplementation of an automated
disinfection machines that facilitate disinfection of hard to reach
surfaces and provide thorough disinfection of environmental
services. Methods: In this study, we evaluate the efficacy of an
automated fogging machine that uses a hydrogen peroxide (H2O2)
solution which is sprayed into the air as a fine mist for the purpose of
disinfecting surfaces. In our study, we evaluated two different types
of H2O2 based disinfecting solutions: one at 6.4-7.1% H2O2 by
volume, and the other at 4.8-5.5% H2O2 by volume with 90-110
parts per million (ppm) of silver. The automated fogging machine
was placed in one corner of a 72 m3 room. Stainless steel carriers
inoculated with clinically significant microorganisms (separate
carriers each inoculated with 4-log10 of Staphylococcus aureus,
Pseudomonas aeruginosa, Aspergillus niger, Acinetobacter baumannii,
Clostridium difficile spores or Enterobacter faecalis and dried
completely) were placed 3.9 meters away from the automated fogging
machine with the inoculated surfaces facing away from the sprayer.
The room was sealed and locked and the automated fogging machine
was set to run a standard decontamination cycle. A standard cycle
for a 72 m3 room runs for a total cycle time of approximately 170
minutes. After the cycle, the stainless steel carriers were retrieved once
the H2O2 level in the surrounding air reached 1 ppm. The stainless
steel carriers were then processed to determine the concentration
of surviving microorganisms by carrier elution and serial dilution/
pour plate methodology. We then repeated this process using the
second disinfectant. Results: Both H2O2 based disinfectants,
with and without silver, were efficacious on the clinically significant
microorganisms used for this study. Both demonstrated a greater
than 4-log reduction for each microorganism. Conclusions:
Our study shows that we are able maintain the efficacy levels of our
disinfectant even at lower concentrations of H2O2 if we add silver to
supplement a more dilute H2O2 disinfectant..
volume of product determined to dry in 30 seconds. Results:
For all ABHR tested, the mean product volumes which dried in 30
seconds ranged from 1.7-2.1 ml. The mean product volumes which
dried in 30 seconds of identical 70% ethanol formulations, differing
only in product format, were 1.7ml, 1.9 ml, and 1.7 ml, for the foam,
gel, and rinse, respectively, and were statistically equivalent. None of
the products met the efficacy requirements of EN 1500 when tested
at volumes which rub-in dry in 30 seconds. However, all products
tested according EN 1500 were statistically equivalent to each other
by repeated measures ANOVA (P>0.05), irrespective of alcohol
concentration or product format. Conclusions: The results
of this study demonstrate that product format does not significantly
influence ABHR dry time. The data directly refutes previous
speculations, showing that ABHR foams do not take longer to dry
and will not encourage the use of inadequate volumes. In conclusion,
product application volume was found to have a greater impact
on efficacy than either product format or alcohol concentration.
Further research is warranted to understand the impact of alcohol
concentration, product formulation, and application volume on
clinical efficacy and healthcare worker behavior and acceptance.
Innovative Additions To Central Line Bundle
Reduce Bloodstream Infections In Vulnerable
Pediatric Patient Population & Improve Catheter
Care
Influence of Alcohol-Based Hand Rub Format on
Dry Time and Efficacy
David J. Shumaker, BS in Microbiology - Laboratory Technician
III, Microbiology, GOJO Industries, Inc.; David R. Macinga, PhD Principal Microbiologist, GOJO Industries, Inc.; Adjunct Professor,
Northeast Ohio Medical University; Sarah Edmonds, MS in Biology
- Clinical Scientist, GOJO Industries, Inc.; James W. Arbogast, PhD
- Skin Care Science and New Technology Vice President, GOJO
Industries, Inc.
Background/Objectives: Alcohol-based hand rubs
(ABHRs) are one of the most important tools to prevent hospital
acquired infections. They are available in a variety of formats
including gels, rinses, and foams. A recent publication has suggested
that foam ABHRs dry more slowly than ABHR gels and rinses,
which encourages health care workers (HCWs) to use smaller,
ineffective volumes. However, analysis of ABHR gels and rinses was
not included for comparison to the foams. The objective of this study
was to determine whether there are significant dry time differences
between rinse, gel, and foam ABHR formats. A secondary objective
was to determine the antimicrobial efficacy of various formats of
ABHRs at volumes which dry in 30 seconds. Methods: Dry
times were determined for two ABHR rinses, two ABHR gels, and
two ABHR foams by applying specific volumes, ranging from 0.5 ml
to 3 ml, to subjects’ hands and having them rub in the product until
dry. A digital timer was used to record the interval from when the
subject began rubbing to when the subject indicated that their hands
felt dry. Linear regression analysis was performed to determine a
slope (dry time per unit volume), and to calculate the volume drying
in 30 seconds for each product. A subset of products, including a
90% ethanol gel, 80% ethanol rinse, and 70% ethanol foam, were
evaluated for antimicrobial efficacy according to EN 1500, at the
Marianne Pavia, MT(ASCP), CLS, CIC - 2011 President-Elect,
APIC Greater New York Chapter 13; Associate Director Infection
Control, Bellevue Hospital Center
Issue: A pediatric hospital with a vulnerable patient population
faced significant challenges in its efforts to minimize central-lineassociated bloodstream infections (CLABSIs). Patient conditions
include short bowel syndrome, long-term intravenous nutrition,
and the increased contaminants and line accesses entailed by those
conditions. CLABSI rates at the hospital were high even though
surveillance showed consistent compliance with manual disinfection
of IV connectors. Project: During 2009-2010, the hospital made
additions to its central line bundle. This multi-pronged approach was
intended to improve catheter care and reduce the troublingly high
CLABSI rate. Interventions included: 1) Addition to protocol –
Nurses began scrubbing patients’ lines with chlorhexidine gluconate
(CHG) following diaper changes to reduce exposure to fecal bacteria.
2) Protective vest for patients– This vest, the hospital’s invention,
decreases the risk of catheter displacement caused by the inherent
restlessness of young children. 3) Disinfection cap – The evidencebased device, which is designed to keep the connector hub bathed
in isopropyl alcohol (IPA) between central-line accesses, improves
disinfection by prolonging the connector’s contact with IPA. It
also protects the hub from touch and airborne contamination by
staying on the connector between accesses. This provides additional
prevention beyond what manual disinfection could provide. 4)
Anti-microbial patch – At the insertion site, nurses began placing
an evidence-based foam patch that secretes CHG to combat
infection from skin flora. The device secretes CHG for seven days,
inhibiting bacterial growth under the dressing between dressing and
21
administration set changes. Results: The disinfection cap was
trialed alone in Q3 2010 and reduced CLABSIs by 54.7% (Q3 2010
vs. previous six quarters). The patch, scrubbing, and vest were added
in Q4 2010, with cap use also continuing. The four interventions
together reduced CLABSIs by 53.1% (Q4 2010 & Q1-3 2011
compared to previous six quarters). Lessons Learned: The vest
and scrubbing protocol are applicable to pediatric patient populations
similar to the hospital’s. The disinfection cap and foam disc can reduce
CLABSIs in both pediatric and adult patients with central lines
because they address issues common to all central line therapy.
new insights into the levels of contamination observed in different
locations of a hospital, as well as from hospital to hospital. It also
demonstrates that ATP monitoring can be very useful in determining
quantitatively the effectiveness of terminal cleaning. The ability to
quantify contamination in the manner exemplified by this study may
be foundational to a process improvement program for the hospital’s
environmental services.
A Multi-site Study Evaluating the Effectiveness of
Terminal Cleaning in Patient and Operating Rooms
using an ATP Monitoring System
Erin A. Satterwhite, MS - Technical Supervisor - Discovery Lab, 3M
Company; Marco Bommarito, PhD - Senior Research Specialist, 3M
Infection Prevention Division; Dan J. Morse - Senior Biostatistical
Specialist, 3M Infection Prevention Division
Background/Objectives: The primary objective of
the study was to compare the level of contamination measured
using an ATP (Adenosine Tri-Phosphate) bioluminescent assay in
patient and operating rooms, before and after terminal cleaning.
The data was obtained from six hospitals across the US. A second
objective of the study was to assess the effectiveness of terminal
cleaning as a function of location in a given hospital (patient versus
operating rooms) as well as across the various sites included in the
study. Methods: Test plans for patient and operating rooms
were developed for each site and included well-known high touch
surfaces and surfaces that were of particular concern to a given
hospital site. Surfaces were tested using a swab based ATP surface
test, before and after terminal cleaning, yielding a paired data set.
ATP contamination levels in RLUs (Relative Light Units) were
determined using a hand-held luminometer. Mean RLU values and
the difference (after-before), were determined using paired t-tests
of the logarithmically transformed RLU values. The study included
a total of 33 patient rooms and 22 operating rooms. The total
number of surfaces tested was 1322. Results: Figure 1 shows the
mean levels of contamination (ATP) in RLUs observed by hospital
site and by location before and after terminal cleaning. There are
significant differences by hospital site and by location. In operating
rooms, before terminal cleaning, RLU means vary from a high of
1202 to a low of 262 RLUs. After terminal cleaning the observed
range decreases: the high value is 661 and low value is 113 RLUs.
In patient rooms, the before cleaning RLU range goes from a high
value of 513 to a low value of 295. After cleaning, the range is 219 to
52 RLUs. Importantly, we note that at given sites (see sites 1 and 2)
contamination levels in operating rooms can be three times the levels
observed in patient rooms. Furthermore, there is a clear correlation
in the before and after readings: a site with high RLU values before
cleaning also shows higher RLU values after cleaning. The table at
the bottom of Figure 1 shows the mean difference (after-before)
in RLUs and the corresponding p-values. With two exceptions,
the net decreases in contamination are statistically significant
(p<0.05).Conclusions: The results of this study provide
22
Quantitative Analysis of Materials and Methods
in Cleaning and Disinfection of Environmental
Surfaces: Microfiber vs. Cotton and Spray vs. Soak
Salah Qutaishat, PhD, CIC, FSHEA - Director, Infection Prevention,
Columbia St. Mary’s; Sr. Clinical Advisor, Infection Prevention,
Diversey Inc; Director, Epidemiology and Surveillance Systems,
Premier Inc; Senior Infection control Epidemiologist, Saint Joseph’s
Hospital; Peter Teska, BS, MBA - Americas Portfolio Lead for
Infection Prevention, Diversey Inc
Background/Objectives: In the USA, healthcareassociated infections (HAIs) affect over 1.7 million patients at an
estimated cost of 40 billion dollars annually. Studies demonstrated an
association between contaminated environmental surfaces (ES) and
HAIs. This has lead healthcare facilities to enhance the effectiveness of
environmental cleaning and disinfection. Currently, the most common
methods of ES cleaning and disinfection are spray and wipe (SPW)
and soak and wipe (SOW). To the best of our knowledge, no published
studies have demonstrated superiority of either method. This has led
us to perform a study comparing the amount of cleaner/disinfectant
used and associated cost. Methods: This study was performed at
four extended care facilities (totaling 243 beds) in the Northeast. The
ES in each room were cleaned according to facility cleaning policy
with a quaternary disinfectant. Two groups were created, one using
cotton cloths and the second using microfiber cloths. For SPW, the
disinfectant is sprayed onto high-touch surfaces and then wiped. In
SOW, the cloth is immersed in a bucket of disinfectant, wrung out, and
then used to wipe surfaces. We measured the amount of disinfectant
used calculated the cost. Results: As seen in table 1 below, the
SOW method uses approximately twice as much disinfectant as SPW.
For SOW applications, microfiber consumed 34% more disinfectant
than cotton. The ratio of costs correlates directly to the amount used.
Conclusions: Proper cleaning and disinfection of high-touch
ES may play a significant role in preventing HAIs. In our study,
we compared the amount of disinfectant used with two common
wiping cloth materials and two different methods of application. Our
results show that the SOW consumes more disinfectant than the
SPW method. It also shows greater consumption of the disinfectant
by the microfiber cloth, possibly due to its increased absorptivity.
Consequently, switching to the SPW method may reduce the cost of
cleaning and disinfection of ES. Further studies should be performed
to evaluate the effectiveness of both methods on reduction of bio
burden and the amount of disinfectant applied by each method.
(both ATP and Blacklight monitoring). The 2nd Phase included
training of EVS front line staff in Leadership Development principles
using an on-line course available from the national organization for
environmental services in healthcare environments. Once a core
group of staff had been trainined, individuals were selected from this
group of frontline staff to develop standardized written processes,
skills lab and competency program, based off of the traditional
model used in nursing staff development. Lessons Learned:
Lessons learned included that more time was required to develop and
implement the program than originally anticipated. Frequent turn
over in the staff members of the EVS department created a need to
provide core classes more frequently than originally expected by the
IP. Also, creating an effective communication system between the
IPP and the EVS leadership took time to develop and put into place.
Partnering With Environmental Services to Drive
Infection Control Excellence
Debbie Hurst, RN, BSN - Manager Infection Prevention & Control,
Rogue Valley Medical Center; Charlene Stewart, RN, MPA/HSA,
CHSP - Infection Preventionist, Rogue Valley Medical Center; Bella
Lucas, RN, BSN - Infection Preventionist, Rogue Valley Medical
Center; Carol Worden, RN, MPA - Director of Nursing Operations,
Rogue Valley Medical Center
Issue: An effective infection prevention and control program (IPP)
is critically dependent upon the duties performed by individuals
assigned to environmental cleaning in a healthcare environment.
Unfortunately, deparments such as Environmental Services (EVS)
have not traditionally received the support and resources necessary
to develop an evidenced based, robust staff development and
compliance monitoring program in most hospitals. Although the
Infection Preventionist (IP) has the background and skill sets needed
to assit the EVS department in development of Infection Control
training and competencies, often they too lack the resources (i.e.
staffing) to support taking on this additional role. By utilizing a
creative “out of the box” approach, grant funds were utilized by the
IPP to create a “Six Step Program to Infection Control Excellence”
for the EVS Department. Project: A six step program was
implemented over a period of 2 years at our 378 bed facility. It
allowed the opportunity for our current and newly hired EVS staff
to learn the basics of infection control, cleaning and disinfection
in a variety of settings including classroom, skills lab and patient
care areas. Results: The outcome obtained included a successful
formal IC Environmental Training Program that was implemented
in 2 Phases. Phase 1 included the establishment of basic training in
infection control and cleaning fundamentals for the patient care
areas and the launching of the environmental monitoring systems
Hydrogen Peroxide Patient Privacy Cubical Curtain
Cleaning Study
Alexis Price, RN, BSN - Infection Preventionist, Lee Memorial
Hospital; Cynthia Knoke, MT, BS, CIC - Infection Preventionist,
HealthPark Medical Center; B. Joann Andrews, RN, MS, CIC
- Senior Infection Preventionist, Lee Memorial Health System;
Stephen Streed, MS, CIC - System Director, Epidemiology and
Infection Prevention, Lee Memorial Health System; System Director,
Epidemiology and Infection Prevention, Lee Memorial Health
System, Ft. Myers, FL
Background/Objectives: Collaboration between
Infection Prevention and Environmental Services (EVS) is becoming
more important on a national level and in our healthcare system.
With patient safety in the forefront of healthcare, it’s imperative
to have better control over potential environmental reservoirs of
pathogenic organisms. The Infection Preventionists (IPs) and EVS
performed a literature review to assess for standards regarding patient
privacy curtain cleaning. Little evidence was found from scientific
investigation, regulatory agencies or in standards of practice. It was
determined that hydrogen peroxide (H2O2) has been utilized to
clean various hospital fabrics, however little evidence was available
to support the efficacy of H202 curtain cleaning in a clinical setting.
23
This hospital system wanted to know if the 100% polyester
patient privacy curtains carried a bio-burden and if a spray of
3% H2O2 applied to the touch points could effectively decrease
the microbial counts and have an extended residual kill effect.
Methods: A double blind study was carried out involving
IPs, EVS and the microbiology department. The study consisted
of an experiment group (n=28) and a control group (n=11).
Rooms were excluded if previously treated with H2O2. Five “high
touch” grab locations and culturing time frames were established.
In the experimental group cultures were obtained pre-H202
treatment, and post treatment at 5 minutes, 10 minutes, one hour
and two hour intervals. The control group did not receive any
H2O2 treatment and cultures were taken at identical locations.
This process occurred in the clinical setting in between patient
room turnover. Results: In the experimental group the
mean colony forming units (CFU’s) were as follows: pre H2O2
= 21.679, five minutes post = 5.179, ten minutes post = 4.393,
one hour post = 0.714, and two hours post = 0.464. Paired
t-test indicated statistically significant decreases in the microbial
counts after 5 minutes of dry time (p = 0.0016) and again at 1
hour dry time (p = 0.0027). The decreases in microbial counts
were not significant from 5 to 10 minutes and from 1 to 2 hours
dry time. In the control group the mean CFU’s are as follows:
20.727, 15.727, 15.636, 16.364, and 19.000. There was not a
significant change in the microbial counts at any culture site
when not sprayed with H2O2. Statistical analysis was used to
evaluate the data and the paired t-test used to evaluate each sample
set. See figure 1. Conclusions: This study suggests that a
treatment of 3% H2O2 is an effective cleaning process in-between
routine laundering of 100% polyester patient privacy curtains.
The bio-burden significantly decreases after just 5 minutes of dry
time and continues to decrease up to the 2 hour time period thus
allowing better control of this potential environmental reservoir
of pathogenic organisms.
24
Evaluation of Liquid Hydrogen Peroxide to
Clean Surfaces in Patient Rooms using Aerobic
Colony Counts and Adenosine Triphosphate
Bioluminescence Assay
Nancy L. Havill, MT(ASCP) - Infection Prevention and
Epidemiology Program, Hospital of Saint Raphael; Heather L.
Havill, BA - Laboratory Assistant, Hospital of Saint Raphael;
Abigail Lipka - Laboratory Assistant, Hospital of Saint Raphael;
John M. Boyce, MD - Hospital Epidemiologist, Hospital of Saint
Raphael; Clinical Professor of Medicine, Yale University School of
Medicine
Background/Objectives: Current guidelines recommend
cleaning of non-critical items in patient rooms in healthcare facilities
on a regular basis. Disinfectants used in hospitals include quaternary
ammonium compounds, bleach and more recently hydrogen
peroxide. We conducted a prospective study to evaluate the efficacy
of a new liquid hydrogen peroxide disinfectant using aerobic colony
counts and adenosine triphosphate (ATP) bioluminescence assay.
Methods: In a convenience sample of 72 patient rooms, 10
surfaces were sampled immediately before and 10-15 minutes after
cleaning by 2 trained individuals using a liquid hydrogen peroxide
disinfectant (Clorox HealthcareTM , Oakland, CA). Samples were
taken with an ATP bioluminescence assay (3M, St. Paul, MN) and
results were recorded as relative light units (RLUs). Aerobic colony
counts (ACCs) were determined using D/E neutralizing contact
agar plates (BD or Remel). We defined surfaces as being clean if
the relative light unit (RLU) reading was <250 for ATP. Surfaces
that yielded a RLU of <250 or no growth on the agar plate before
cleaning were omitted from further analysis. The proportion of sites
yielding ACC <2.5/cm2, which is a proposed definition of “clean,”
was calculated. Differences in proportion were analyzed with the Chi
Square test. Results: 99% (698/704) of cultures yielded ACCs
<2.5/cm2 after cleaning. 96% (679/704) of cultures yielded ACCs <
10 per contact plate. No growth was detected from 75% (528/704)
of the cultures with a range from 53-89% for the 10 sites. There was
a significant difference among sites with the chair arms having the
lowest proportion achieving no growth and the bedside panels having
the greatest proportion achieving no growth (P <0.001). The median
colony count per contact plate before cleaning was 63.1 with a range
of 15-119 colonies for the 10 sites. The median colony count after
cleaning was 0.0 for all 10 sites. 69.7% (388/557) of sites yielded
RLU values <250 after cleaning, with a range from 43.3-96.8% for
the 10 sites. There was a significant difference among the 10 sites with
the bedside rail having the lowest proportion achieving <250 RLUs
and the blood pressure cuff having the greatest proportion achieving
<250 RLUs after cleaning (P = <.0.001). Conclusions:
The liquid hydrogen peroxide product tested is a very effective
disinfectant against aerobic bacteria. ATP bioluminescence assays
can be used as a tool to monitor the effectiveness of cleaning practices
using liquid hydrogen peroxide. Further studies are warranted to
determine if the ATP cut-off used to classify surfaces as clean should
vary depending on the composition of the surface sampled and type
of disinfectant used.
Effect of Disinfectants on Clinically Relevant
Bacteria Under Planktonic and Biofilm Conditions
Dean Swift, BSc, BEd, FADM, Cert. Tox. - Technical Director,
Biolennia Laboratories
Background/Objectives: Microbial biofilms are now
recognized as playing a major role in the progression of infection and
disease. Current research has shown that biofilms are more difficult to
eradicate than their planktonic counterparts; however, the majority
of standardized methods used to test the efficacy of disinfectants
rely on the use of planktonic bacterial cultures. Recently, a new
experimental device has been developed to determine the minimum
biofilm-eliminating concentration (MBEC) of antimicrobial agents
and disinfectants: the Calgary Biofilm Device (CBD). The MBEC
Assay allows for rapid, high-throughput assessment of the antibiofilm
activity of antibiotics, disinfectants, biocides and metals at varying
concentrations. The main objectives of this study are to compare the
effectiveness of various disinfectants on bacteria grown planktonically
and in biofilms, and to compare the minimum inhibitory concentration
(MIC) and MBEC methods for testing the efficacy of disinfectants.
Methods: Overnight cultures of Pseudomonas aeruginosa MPAO1,
Bacillus atropheus JH642 and clinical isolates of Escherichia coli and
Staphylococcus aureus were grown aerobically in brain heart infusion
(BHI) medium at 37C. For MIC assays, diluted overnight cultures
were added to 96-well plates containing serially diluted disinfectants
including ethanol, bleach, glutaraldehyde and several commercial
products. The plates were incubated for 24 hours and visually inspected
for growth, spot plated and quantitatively measured at OD590nm.
For the MBEC assay, biofilms were grown in the CBD for 48 hours.
The MBEC lids were then placed in a similar serially diluted 96-well
plate containing disinfectants and incubated for 24 hours. The biofilms
were subsequently washed twice in phosphate-buffered saline and
re-immersed in fresh BHI, sonicated, incubated for 24 hours and
quantitatively measured at OD590nm for regrowth. Both assays were
performed in triplicate. MIC and MBEC values were determined as
the lowest concentration of disinfectant that inhibited growth of the
bacteria. Results: Each strain exhibited different susceptibility
profiles to the disinfectants tested. B. atropheus was the most resistant,
while the clinical isolates were most susceptible. In addition, biofilms
were more resistant to the disinfectants compared to planktonic cultures.
Conclusions: Since biofilms are the primary mode of growth for
most bacteria, it is important to recognize their role in the vast majority
of medically relevant infections. The results of this study support the use
of the MBEC method to test the efficacy of disinfectants, as it presents
the most relevant results of antimicrobial activity. This will allow for
further development of standardized test methods that more accurately
reflect conditions found in the field, thus leading to more effective
strategies for controlling the spread of infection.
Cleaning Practices for Hospital Mattresses in Top
US Adult Hospitals
Edmond A. Hooker, MD, DrPH - Associate Professor- Department
of Health Administration, Xavier University; Kristen Leigh. Jones,
BS - Master’s of Health Services Administration Student, Xavier
University
Background/Objectives: Manufacturers of hospital beds
and mattresses recommend cleaning the mattress first with soap and
water, disinfecting the surface, and then rinsing the surface. It is also
recommended to only use disinfectants with a pH of 5-9. Chemical
manufacturers have tested disinfectants on hard non-porous surfaces
and not on soft surfaces. Any claim of efficacy of disinfectants
against bacterial pathogens only applies to the use of the product on
hard, non-porous surfaces. Mattresses are soft surfaces, and the use
of quaternary ammonia compounds on these soft surfaces should
be considered “off-label.” The current study is intended to define
how top hospitals in the United States (U.S.) are cleaning hospital
mattresses. Methods: The top 113 hospitals for 2011-2012, as
listed in the US News & World Report, were contacted by phone and
asked about their cleaning procedures for hospital mattresses. Each
respondent from environmental services was asked five questions:
What chemical do you clean your beds and mattresses with? How do
you mix or dilute the chemical? How long do you leave the chemical
on the bed or do you just let it dry on the bed? Do you use anything
other than that chemical first, like soap and water? Do you rinse off
the cleaner after you clean the bed? Results: Of the top hospitals,
69 (61%; 95% CI, 52-70%) agreed to answer the survey questions.
Six (5%; 95% CI, 3-11%) refused to participate and 38 (34%; 95%
CI, 26-43%) could not be reached after multiple attempts. Chemicals
used to clean the beds included: quaternary ammonia compounds
(58/69; 84%; 95% CI 74-91%), bleach compounds (7/69; 10%;
95% CI 5-19%), phenolic cleaners (3/69; 4%; 95% CI 1-12%), and
hydrogen peroxide (1/69; 1%; 95%CI 0-8%). Only two hospitals
were using disinfectants with a pH between 5 and 9, as recommended
by the manufacturers. The pH of all of these compounds is not within
the recommended range of 5-9. Only 16 (23%; 95% CI, 15-34%)
of the hospitals reported cleaning the mattress prior to disinfection,
and only 6 (9%; 95% CI, 4-18%) reported rinsing off the disinfectant
after use. Conclusions: Most top adult hospitals in the U.S. do
not follow manufacturer’s recommendations on appropriate cleaning
and disinfection of hospital mattresses. This failure may result in
inadequate cleaning and may damage the surface of the mattresses.
The Influence of ABHR Product Format on In Vivo
Efficacy: A Meta-Analysis
Sarah Edmonds, MS in Biology - Clinical Scientist, GOJO
Industries, Inc.; David R. Macinga, PhD - Principal Microbiologist,
GOJO Industries, Inc.; Adjunct Professor, Northeast Ohio Medical
University; Daryl Paulson - CEO, BioScience Laboratories
Background/Objectives: Alcohol-based hand rubs
(ABHR) are the primary form of hand hygiene in healthcare settings.
ABHR are available in a number of different formats including
rinse, spray, gel, and foam. In U.S. healthcare facilities the most
common formats are gel and foam. Currently, there are conflicting
data regarding the relative efficacy of gel versus foam ABHR. The
objective of this study was to determine whether product format
25
influences ABHR efficacy through a meta-analysis of multiple
studies comparing both gel and foam products. Methods: The
test products were commercial ABHR formulations based on 70%
ethanol and differing only by the addition of “gelling” ingredients
(Gel A) or “foaming” ingredients (Foam B). Data from a total of 18
studies which were executed at different times of the year, by different
laboratories, where the efficacy of Gel A and Foam B were evaluated
were included in the analysis. Standard in vivo test methodologies
were used in each study and included the U.S. Food and Drug
Administration Health Care Personnel Handwash (HCPHW)
method, ASTM E1174-06, ASTM E2755-10, ASTM E2784-10,
and EN 1500. All methods measure test product efficacy after both
a single use and after 10 consecutive uses, except EN 1500 which
measures efficacy only after a single test product use. Two metaanalyses were conducted, one based on single use data and one based
on data after 10 consecutive product uses. The Hedges’ g value was
calculated based on the log reduction from baseline for each product
for each study. The model used was a complete random effects model
with subgroups (Gel A and Foam B) evaluated. Results:After
a single test product use mean log reductions ranged from 2.325.25 and 2.43-5.06, for Gel A and Foam B, respectively. After 10
product uses, log reductions ranged from 3.11-5.24 and 2.61-5.19,
for Gel A and Foam B, respectively. Based on the meta-analysis
both products were highly effective after a single use (Hedges’ g =
11.746 and 12.174 for Gel A and Foam B, respectively) and after ten
product uses (Hedges’ g = 11.164 and 10.844 for Gel A and Foam
B, respectively). Because the Hedges’ g 95% confidence intervals for
Gel A and Foam B overlapped, there was no difference in efficacy
between Gel A and Foam B after a single use or after ten consecutive
uses.Conclusions: This was the first example of applying metaanalysis to compare the in vivo efficacy of different ABHR products
or product formats (gel vs. foam). The results of this meta-analysis
indicate that ABHR format does not significantly influence efficacy.
Previously published results suggest that other attributes, including
product formulation and product application volume, are more
predictive of ABHR efficacy.
A Multi-Disciplinary Team Tackles Standardization
of Endoscope Practices in a
Tertiary Care Setting: Finding
Common Ground for Patient
Safety
care center has multiple specialties using a variety of scopes in many
patient care areas. During a review of a near miss event, we identified
disparate understanding of what “Is that scope clean?” means: some
healthcare provider (HCP) use cleaning for the point of use precleaning, others equate it with manual cleaning and finally some
believe it means that it is safe to use on the next patient. Project:
A multidisciplinary task force convened to review scope standards
and practices, assess training and competency testing, establish
common terminology, assure proper cleaning and disinfection /
sterilization, assure documentation and standard logs, develop an
inclusive scope inventory and foster collaboration. Stakeholders
included Anesthesia, Central Sterile Processing, Respiratory /
Pulmonary, 4 Surgical Services suites, OR Sterile Processing, Heart
Station, ICUs, Emergency Department, Supply Chain, Clinical
Engineering, Patient Safety, Infection Prevention & Control (IP&C)
and administration. Departmental and hospital wide policies
were reviewed using professional standards and current literature.
Products were also reviewed for opportunities for standardization.
Results: Critical elements for scope management were
identified: pre-cleaning, leak testing, manual cleaning, and high
level disinfection /sterilization based on the Spaulding Classification
system for critical, semi-critical, and non-critical devices. Policies
were updated using common terminology and practices (flushing
scope with enzymatic cleaner, flushing with alcohol after processing,
vertical hanging scopes during storage to promote drying , and new
standardized transport bags marked contaminated were selected).
Finally, a “READY TO USE” green tag adopted to indicate that a
device had been processed according to standards and was safe for
patient care. The new competency documents provided checklists
for critical steps plus an attestation of the individual’s training
and successful demonstration of competency. Each stakeholders
agreed to implement the six(6)new logs to ensure compliance
with scope processing standards and training. (These logs will be
shared during presentation. Note the company or product name
is excluded. ) The logs included : Daily Scope Processor Type 1
Log, OPA* Competencies, OPA Plus™ Solution Testing Log Sheet,
Processor 1 Biological Testing Log Sheet, Daily Processor #2 Run
Log and the Endoscope Reprocessing Competency. Manufacturer’s
recommendations for care and maintenance were incorporated.
Everyone was to be re-trained within 90 days and then yearly.
Scope practices and standards plus the new logs were placed on
Loretta Litz. Fauerbach, MS, CIC,
FSHEA - Director, Infection Prevention
& Control, Shands at the University of
Florida; Terry K. Wilson, RN, MSN,
CNOR - Nurse Manager Operating
Room, Shands Hospital at the University
of Florida; Marie W. Ayers, RN, CIC infection Preventionist, Shands Hospital at
the University of Florida
Issue: Flexible endoscope management
is complex and non-standard practices
may lead to patient exposure. Our tertiary
26
Poster Abstracts: Bioterrorism/Disaster/Emergency Preparedness
the IP&C website for easy access. A comprehensive scope
inventory included manufacturer and model number, scope’s
use and the manufacturer’s recommendations for processing.
See table. Lessons Learned: Standardization of scope
practices improved communication and patient safety, facilitated
compliance monitoring, and decreases inventory by selecting
common products for all areas which also improved pricing. Use
of common terms and new labeling also improved practice and
reduced risk of error.
Bioterrorism/Disaster/Emergency
Preparedness
U.S. School/Academic Institution Disaster and
Pandemic Preparedness and Seasonal Influenza
Vaccination Among School Nurses
Terri Rebmann, PhD RN CIC; Michael B. Elliott, PhD Assistant Professor, Saint Louis University, School of Public
Health; Dave Reddick, BS, CBCP - Executive Director,
PandemicPrep.Org; Zachary Swick, MS - PhD student, Institute
for Biosecurity, Saint Louis University
Background/Objectives: School pandemic
preparedness is essential, but has not been evaluated. The purpose
of this study was to evaluate U.S. schools’ current readiness to
respond to an infectious disease disaster, such as a pandemic.
Methods: An online survey was sent to school nurses (from
state school nurse associations and/or state departments of
education) in May – July, 2011. School pandemic preparedness
scores were calculated by assigning 1 point for each item in
school pandemic plans; maximum scores were 11. Influenza
vaccine uptake among school personnel was also assessed.
Linear regression was used to describe factors associated with
higher school pandemic preparedness scores. Fisher’s exact tests
were used to compare rates of mandating vaccine across school
employee groups (nurses, teachers, etc). Results: In all, 1,997
nurses from 26 states completed the survey. Three-quarters
(73.7%, n = 1,472) reported receiving the seasonal influenza
vaccine during the 2010/2011 season. Very few (2.2%, n = 43)
reported that their school/district had a mandatory influenza
vaccination policy. Nurses were more likely than all other school
employees (p < .001) to be mandated to receive the seasonal
influenza vaccine. Pandemic preparedness scores ranged from
0 - 10 points; the average score was 4.3. Schools designated to be
a point of dispensing (POD) had significantly higher pandemic
preparedness scores (t = 9.3, p < .001) compared with schools
that were not designated as PODs (5.1 vs. 4.1 respectively). Less
than half of participating schools have a pandemic plan (47.8%
, n = 955), only 40% (n = 814) reported that the school plan
was updated in response to the H1N1 pandemic, and almost
no schools (only 4%, n = 79) have used an infectious disease
scenario in a school disaster exercise. Most schools reported that
27
Poster Abstracts: Device-Related Infections and/or Site Specific Infections
they lack access to medications (98.5%, n = 1968) and personal
protective equipment (71.3%, n = 1404) needed to respond to a
biological event. A little more than half of all respondent schools
(56.3%, n = 873) are participating in a community syndromic
surveillance program, such as reporting numbers of students
experiencing influenza-like illness, gastro-intestinal illness, or
absenteeism rates. Determinants of school pandemic preparedness
were as follows: plan to be a point of dispensing (POD) during a
future pandemic (p < .001), having experienced multiple student or
employee hospitalizations and/or deaths related to H1N1 during
the pandemic (p = .01 or < .05 respectively), having a lead nurse
complete the survey (p < .001), or having the school nurse study
participant be a member of the school disaster planning committee
(p < .001). Conclusions: Despite the recent H1N1 pandemic
that disproportionately affected school-aged children, schools lack
adequate pandemic plans. It is critical that schools focus on becoming
better prepared for a biological event.
Device-Related Infections and/or
Site Specific Infections
Maintaining Isolation Precautions During a
Hurricaine Evacuation
Robin Haag, BC, RN, MA - Infection Control Director, Coney
Island Hospital; Joseph Marcellino, MPH - Director of Emergency
Management, Coney Island Hopsital
Issue: Issue: In late August 2011, New York City was under a
warning for Hurricane Irene. Two days prior to expected landfall, on
Thursday, August 25th a decision to evacuate our facility was made
by the Mayor’s Office, the Office of Emergency Management, and
New York City Health and Hospital’s Corporation because we are
located in a Zone A (Zone A faces the highest risk of flooding from a
hurricane’s storm surge). Project: The bed capacity for our acute
care facility is 371 and includes three intensive care units (medical,
surgical, coronary) as well as medical-surgical, obstetrical, pediatric,
behavioral health and rehabilitation units. We were at capacity at
the time this unprecedented decision to evacuate was made. Eightytwo patients were able to be discharged home prior to the hurricane.
Evacuation began on Friday, August 26th . A critical evacuation tracing
form was created to provide a “snapshot” of basic patient information.
Patients on isolation precautions were sent with the Isolation Sign that
was hung outside their room, ensuring a visual cue to the transport
team and receiving facility. Fortunately our facility uses electronic
medical records and a detailed discharge summary was printed and
accompanied each patient. Records were maintained in the Incident
Command Center concerning isolation precautions including
organism, site and the facility to which patients were transported. The
Director of Infection Control was assigned to work in the Incident
Command Center and accessed electronic medical records to provide
receiving facilities with detailed patient information as needed to
ensure the safe transition of appropriate patient care. Results:
242 patients were safely evacuated to13 health care facilities in 8
hours. Medical and Nursing staff from our facility accompanied our
patients and worked in the receiving facilities for the duration of the
evacuation. This provided continuity of care. All patient rooms were
terminally cleaned as patients were evacuated. When we re-opened
28
after the hurricane, the transfer process was reversed and we became
the receiving facility. Infection Control personnel were stationed on
each unit ensuring appropriate patient placement upon their return.
Lessons Learned: Emergency preparedness training is essential
for a full-scale evacuation. No training can cover all contingencies.
Communication, cooperation, team work and adaptability are
necessary intra and inter institutionally. Visual cues, such as isolation
signs provided all staff with immediate knowledge of the patient’s
isolation status. Although only one person can be in charge, the
ideas of all team members should be considered because new leaders
emerged during the Hurricane Irene evacuation. A national electronic
medical record would have been most helpful for both the sending
and receiving hospitals.
Reduction in Catheter-Associated Urinary
Tract Infections by Bundling Interventions in a
Community Hospital
Karen A. Clarke, MD, MS, MPH, FACP - Assistant Professor,
Division of Hospital Medicine, Emory University; Bonnie Norrick,
CLS, EdM, CIC - Director, Infection Control Department, West
Georgia Health
Background/Objectives: Urinary tract infections (UTIs)
are the most common type of hospital-acquired infection, and 80
percent are associated with indwelling urinary catheters. In the era
of accountable care, the relative frequency of catheter-associated
UTIs (CAUTIs) imparts greater cost implications to hospitals and
healthcare organizations. Strategies to actively reduce CAUTIs,
especially those that are inexpensive and can be readily implemented,
could be useful in many hospital settings. We examined the
feasibility and cost-effectiveness of a bundled intervention to reduce
CAUTIs in a community hospital. Methods: We retrospectively
examined the effect of a bundle of four evidence-based interventions,
introduced in staggered fashion, upon the incidence rate (IR) of
CAUTIs in a 276-bed community hospital over a 2 year period. Rates
of CAUTI per 1000 catheter-days were estimated and compared
using exact methods based on the Poisson distribution. The first
intervention was the exclusive use of silver alloy catheters in the acute
care areas of the hospital, the use of which had been sporadic in the
hospital over the previous 3 years. The second intervention was a
new securing device to limit movement of the indwelling catheter
after insertion. The third intervention consisted of repositioning
the catheter tubing if it was found to be touching the floor. A twomonth run-in period began when the first intervention was started
in January 2009, and ended when the second and third interventions
were introduced in February 2009. The fourth intervention,
implemented in October 2009, was the removal of indwelling urinary
catheters on postoperative day 1 or 2, for most surgical patients.
Results: During the 19-month study period, 33 of 2228 patients
were diagnosed with a CAUTI (10,978 catheter-days; IR = 3.0/1000
catheter-days; 95% confidence interval 2.1 to 4.2). The CAUTI IRs
for the 3 month baseline and subsequent 2-month run-in period were
5.2/1000 catheter-days and 6.5/1000 catheter-days, respectively.
For the 7 months following full implementation of the first three
interventions, the IR was 3.1/1000 catheter-days, a non-significant
reduction relative to the run-in period (p=0.09). However, for the
7 months following the implementation of the fourth intervention,
the IR was 1.5/1000 catheter days, a significant reduciton relative to
the run-in period (p=0.009). Conclusions: A bundle of four
evidence-based interventions, two of which were merely changes in
care processes, reduced the incidence of CAUTIs by 71 percent in
a community hospital. This relatively simple bundle appears to be
effective, feasible, and cost efficient, and it might be sustainable and
adaptable by other hospitals.
been developed based on the ICU environment, as well as focus on
the patient experience throughout the hospital stay. Observation and
evaluation of central line handling in the operating room, radiology
and cardiac catheter lab resulted in the establishment of standard
infection prevention practices outside the patient units. Regular
multi-disciplinary meetings and review of infections helped establish
personal interest and responsibility for infection events. Utilizing the
industrial model of Root Cause Analysis in review of each CLABSI
helped obtain information from all staff involved in patient care
and resulted in improved communication and problem-solving.
Because of identification of CLABSIs occurring within five days of a
procedure outside the ICU, our Anesthesia department undertook an
improvement process to evaluate and standardize practice related to
central lines in the OR. CLABSI prevention efforts in the ICU have
been applied to all patients with central lines in all inpatient units of
the hospital. Administration has made CLABSI reduction a hospital
goal for several years, raising awareness and importance of these
infections to all staff. CLABSI-reduction has become an important
component of the hospital’s focus on patient safety. RESULTS:
Over time, the many actions taken to reduce infections have resulted
in a decrease in the hospital-wide yearly CLABSI rate from 6.2 to
2.2 in six years. Efforts continue to maintain and improve on these
results. LESSONS LEARNED: Seattle Children’s did not follow
strict scientific methods in analysing effects of interventions focused
A Multi-interventional, Multi-disciplinary Effort to
Reduce Hospital-Acquired Central Line-Associated
Blood Stream Infections
Julie A. Smith, RN, MN, CIC - Infection Preventionist, Seattle
Children’s Hospital
Issue: Central lines are often necessary for effective care of
hospitalized patients. These lines may be needed for physiologic
monitoring, and delivery of medication and fluid in the Intensive
Care Unit, or for long term nutritional support or antibiotic
administration in less critically ill patients. These invasive devices
increase the risk of developing bacteremia. Many interventions to
reduce central line-associated blood stream infections (CLABSIs)
have been recommended based on scientific evidence. Other
interventions have been developed or trialed in an attempt to
further reduce infections. PROJECT: At our 250-bed pediatric
hospital, reduction of CLABSIs has been a focus for several years.
Participation in CLABSI-elimination collaboratives established
specific goals and increased internal communication of infection data.
Implementation of evidence-based “bundle” practices, focus on hand
hygiene compliance and other well-known interventions have been
added or elevated as standard care. Additional interventions have
29
on CLABSI reduction, so there is no specific cause and effect that
can be concluded from our data. The goal was to reduce infections,
specifically CLABSIs. Therefore, multiple efforts were undertaken
and interventions were implemented if they made sense and could be
achieved. The overall decrease in CLABSIs has been gratifying. The
reduction of the CLABSI rate motivates staff to continue to improve
on these numbers and know their actions can result in better patient
outcome.
A Multi-Disciplinary Performance Improvement
Project to Reduce Craniotomy Surgical Site
Infections
Molly Hale, MPH, CIC - Infection Preventionist, Oregon Health
& Science University; Nicholas Coppa, MD - Assistant Professor,
Oregon Health & Science University; Aclan Dogan, MD - Assistant
Professor, Oregon Health & Science University; John Townes, MD Associate Professor, Oregon Health & Science University
Issue: Craniotomy surgical site infections (SSI) often have
devastating effects on the patient, such as cranial bone defects,
brain abscess, meningitis, and may require hospital readmission,
repeat surgery and long courses of antibiotic therapy. In May 2010,
the Department of Infection Prevention and Control (DIPC)
was notified of a perceived increase in craniotomy infections.
Retrospective surveillance revealed an infection rate of 4.4% from
October-December 2009, which had increased from 0.6% in the
prior quarter. Medical record review of infection cases from July
2009-May 2010 showed 88.2% occurred among non-emergent
surgeries; 22% were Coagulase Negative Staphylococci, 22% were
S. aureus, 26% were P. acnes, and 30% were from organisms not
commonly associated with skin flora. We conducted a case-control
study and found a higher mean postoperative blood glucose among
cases compared with controls (194.3mg/dL vs.155.2mg/dL;p=0.03)
and an increased risk of infection associated with a single operating
room (OR=3.34, 95%CI: 0.73-14.52). An observational study
demonstrated that neither skin preparation nor postoperative
incision care orders were standardized, clippered hair was left on the
floor during procedures, OR traffic was not minimized, and antibiotic
ointment was used on more than one patient. Project: A multidisciplinary task force of staff from neurosurgery, perioperative
services, neurosciences intensive care unit (NSICU), neurosciences
acute care unit and DIPC met bi-weekly from September 2010 until
January 2011 to address these issues and to standardize practice. A
“Craniotomy Checklist” was implemented February-September 2011
to assist with standardization of perioperative practice, including
skin preparation with chlorhexidine gluconate (CHG)-alcohol,
postoperative incision care orders, and preoperative bathing with
CHG and hair shampoo. Antibiotic ointment was made singlepatient use only, common equipment stored in the OR was relocated
to a central location to decrease traffic, and a new glycemic control
protocol was instituted in NSICU. Results: Within 3 months of
checklist implementation, there was 100% compliance with patients
receiving bathing instructions if seen in pre-op clinic, standardized
skin prep with CHG-alcohol, and incision dressing protocol. There
30
was 87% compliance with collecting and discarding clippered hair
and 80% compliance with physicians writing post-op incision care
orders. Craniotomy SSI’s decreased from 4.4% in October-December
2009 to 1.16% in July-December 2011 (p=0.03). Lessons
Learned: The use of a standardized pre-operative checklist
and post-operative incision care instructions, together with minor
changes in OR room set-up was followed by a significant reduction in
craniotomy SSI. Interventions were most successful when they were
built into the existing workflow, such as adding bathing instructions
to preoperative patient instructions, adding incision care orders
to existing order sets, and adding a line for hair shampoo into the
preoperative checklist. A team approach to change practice with close
collaboration between neurosurgeons, preoperative, perioperative,
and postoperative unit staff was essential to success of the project.
Sedation Reduction Leads to Reduction in
Ventilator Associated Pneumonia
Janet Briggs, RN, BSN, CIC - Infection Preventionist, Hilton
Head Hospital; Kelly Arashin, RN, MSN, CCNS, ACNP, CEN
- Clinical Nurse Specialist, Hilton Head Hospital; Lori Ross, RN,
BS, MBA - Vice President of Clinical Quality Improvement, Hilton
Head Hospital; Robert Burnaugh, MD, FCCP - Past Chief of Staff;
Hospital Pulmonologist, Hilton Head Hospital
Issue: Hilton Head Hospital is a 93-bed community hospital that
provides a broad range of services, including cardiac surgery. Historically
Ventilator Associated Pneumonia (VAP) has been part of the hospital
surveillance program. The rates for VAP remained constant for the years
2007 at 5.84 and 2008 at 5.18 with a slight decline to 2.84 in 2009.
While standing physician orders and the IHI care bundle for VAP
prevention were in place for the ventilated patient, we continued to
experience VAP. As a result, a project was initiated, in collaboration with
the pulmonologist, in an attempt to identify improvement opportunities.
Project: A comprehensive retrospective patient chart review was
completed to assess compliance with the key VAP bundle components:
head of bed (HOB) at 30 degrees, daily sedation reduction, peptic ulcer
disease (PUD) prevention, and deep vein thrombosis (DVT) prevention.
To be included in the review, patients were to have been on the ventilator
for greater than 72 hours. After compiling and analyzing the data,
sedation vacation was the one component identified as being missed most
often. Sixty-four total observations of charts yielded only 47% positive
observation for sedation vacation whereas we achieved better than
90% in the other three key bundle components. This finding led to the
realization there was no standardized protocol in place to assess a patient’s
response to a decrease in sedation. Therefore, a multidisciplinary team
was convened to develop an improvement plan. Through its work, the
team determined a need to develop a formal sedation reduction protocol.
The protocol was subsequently developed, implemented, and staff was
educated on its use. The ultimate project objective was to eliminate
VAP occurrences by decreasing the number of days a patient required
ventilation thus reducing their exposure risk. Key project goals included:
l Standardization of the ordering of sedation agents and titration
parameters
l Appropriate sedation utilization and initiation of daily sedation holds
l Development of weaning parameters and initiation of breathing trials
l Daily assessment of sedation levels using the standardized Ramsay
Scale. Results: Through the development of a formal protocol,
we ensured sedation reduction was incorporated into the routine care
of the ventilated patient. Since implementation of the protocol, we
have not experienced a VAP. Lessons Learned: Everyone who
participated in this project learned something new and contributed
to the improvement effort. The following provides a summary of key
Lessons Learned:
l Increased clinician awareness about the need and benefit of formal
protocols for complex and critically ill patients
l Enabled the Quality and Infection Control Departments to partner
with the Medical and Clinical Staff in a successful quality improvement
effort
l Demonstrated that with interest and staff engagement, patient care
improvement is possible
l Identifying just one area for improvement can lead to important gains
Reducing Ventilator Associated Pneumonia – Goal – Zero
Renee M. Savage, RN, BSN, CIC - Infection Preventionist,
Lawrence & Memorial Hospital
Issue: Ventilator Associated Pneumonias (VAP’s) are the leading
cause of death among hospital-acquired infections (HAI) and the
second most common HAI in the United States. Literature shows
the cost of a VAP ranges from $15,000 up to $50,000 per patient.
The National Healthcare Safety Network (NHSN) states patients
with mechanically assisted ventilation have a high risk of developing
a healthcare associated pneumonia with the incidence in 2006-2007
that ranged between 2.1 – 11.0 per 1000 ventilator days. Project:
In July 2005 a VAP team was formed in our Medical Intensive Care
Unit. We reviewed the Institute for Healthcare Improvement (IHI)
Saving 100,000 Lives Campaign and the VAP bundle of elements.
Reaching back I completed chart reviews for the time period of
9/03 – 9/05 that were coded for both a vent and pneumonia. We
started education on the bundles and began trialing our forms in
October, updating and revising them over several months. After
the first year of trials we saw a large increase in VAP’s reported as
each vented patient was assessed during their ventilation and 48
hours beyond by the Infection Control Department following the
NHSN definition. We continued with modifications and education
instituting all six bundle elements. VAP’s decreased over the next two
years. In 2010 three VAP’s were identified within 5 months and the
committee reconvened. The committee found five changes had been
made including a bundle element no longer being done. Revisions
were put into place and over the course of several months three
new interventions were put into place. This again reduced VAP’s
to zero. Results: Assessment in January 2008 showed no VAP’s
since May 2007 with compliance of bundles at 100%. We moved to
quarterly meetings. By August 2009 we had no VAP’s for 17 months
so the committee became a subcommittee of Critical Care. When
we again saw VAP’s, we immediately reconvened and assessed what
had changed. This again resulted in no VAP’s for another 17 months,
June 2010 through October 2011. Following the fiscal year, our rates
from for 2006-2011 ranged from 3.9 to 0. Lessons Learned:
Every ventilated patient is at risk for a VAP. Be vigilant to do the
bundle check list every day and assess for weaning. Always be aware
of any change in the definition of a VAP or in the use of the bundle
elements as these may result in new cases. Engage all nurses and
all the physicians including the intensivists, pulmonologists and
hospitalists to understand and assist in the process elements. By
reducing ventilator associated pneumonias, we saved lives, reduced
length of stay and saved thousands of dollars.
A Multifaceted Approach Reduces Surgical Site
Infection Rates, Incidents, and Associated Costs
for Abdominal Hysterectomy and Caesarean
Section Patients
Sonya Mauzey, RN, BS, CIC - Infection Preventionist, The Women’s
Hospital
Issue: Surgical site infections (SSI) are one of the leading causes
of healthcare associated infections (HAI). They are associated with
increased morbidity/mortality as well as prolonged length of stay
and costs. R. Douglas Scott, II of the CDC reported in 2009 that
SSI may cost anywhere from $10,443 to $25,546 per infection.
As a specialty hospital for women, our largest surgery volumes are
hysterectomies and caesarean sections (c-sections). We estimate our
hospital’s SSI cost for these surgeries to be approximately $10,500
per infection (please see graphs). American College of Obstetricians
and Gynecologists (ACOG) identifies abdominal hysterectomies as
higher risk for SSI compared to vaginal approach. In spite of excellent
compliance with Surgical Care Improvement Project (SCIP)
measures, our SSI rates remained elevated. A multidisciplinary
approach was utilized to search for possible causes and preventive
measures. Project: SSI cases were reviewed for similarities,
opportunities for improvement, etc. It was recognized that most SSI
were superficial incisional and occurred in women with elevated body
mass indexes (BMI). When looking for improvement opportunities,
it was noted that during preadmission visits and phone interviews,
patients were instructed to bathe with 4% Chlorhexidine Gluconate
31
(CHG) soap prior to admission for scheduled surgery. Laboring
patients going for unscheduled c-sections were prepped with 4%
CHG soap and water prior to being transferred to the operating
room. However, it was not able to be determined if this practice
was done in a consistent manner, e.g., whether or not the product
was used and, if so, how much was used. Another improvement
opportunity recognized was ensuring adequate dosage of preoperative
antibiotics. All patients were routinely receiving 1 gram Cefazolin,
but the dose should have been 2 grams for patients with elevated
BMI (>30). To improve practices and outcomes, we implemented
two new interventions. First, after consulting our pharmacist, we
began administering 2 grams Cefazolin to all patients preoperatively
to avoid giving an insufficient amount to those with elevated BMI’s.
Second, we implemented the use of a 2% CHG impregnated cloth
as a preoperative preparation to be utilized prior to all c-section
patients to ensure consistency with technique; we later implemented
this product for hysterectomy patients. Results: Implementing
two interventions that provided improved and consistent practices
resulted in significant reductions in SSI rate, incidence, and
associated costs. Lessons Learned: SSI prevention is a
continual and multifaceted venture that requires persistence in
looking for improvement opportunities. In our efforts to reduce SSI,
we found that implementing consistent practices such as ensuring
adequate dosing of prophylactic antibiotics and utilizing 2% CHG
cloths had the greatest sustained impact on our patients undergoing
abdominal hysterectomy or c-section surgical procedures.
Reducing Peripherally Inserted Central Line
Associated Blood Stream Infections (CLABSI): Targeting 0 in Non-Critical Care Medical
Surgical Units
Eileen Yaney, MT(ASCP) MS, CIC - Director, Infection Prevention
and Control, Saint Barnabas Medical Center, Livingston, NJ; Anita
Arrunategui, RN,CIC - Infection Preventionist, Saint Barnabas
Medical Center; Cindy Basile, RN, MSN, CCRN - Education
Coordinator, Saint Barnabas Medical Center
Issue: In the third quarter of 2008, a cluster of PICC line
infections were noted during routine review of laboratory blood
culture results. We understood the urgency of this dilemma; first for
patient safety and then our hospital’s financial burden. Outcomes
include a.) increased length of stay and b.) increased cost per episode
can vary from $3700 to $29,000 per episode. and c.) event not
reimbursable by Medicare. In response to this cluster, we began
hospital wide surveillance on all PICC lines. In 2010, we expanded
our surveillance hospital wide for all central lines. Project:
Saint Barnabas Medical Center participated in the Institute for
Healthcare Initiative (IHI) implementing the “Bundle Approach”
32
for the care of central venous catheter lines in our critical care areas.
Central line associated blood stream infection (CLA-BSI) rates in
critical care have been reduced over the years to near zero. However,
in the fourth quarter of 2008, a cluster of PICC line infections
in our non-ICU was observed, therefore our investigation into
CLA-BSIs in the non critical care areas began. Whole house
surveillance began with input from each unit. The collection and
inputting of central line days at the same time each evening was
implemented on all ten nursing units that had patients with central
lines. Separating PICC device days was a challenge as only total
central line device days were able to be captured. Our target was
set to 0. The investigation included: a.) accessing potential causes
for our CLA-BSI in non critical areas, b.) plan the interventions
necessary to lower the rate and c.), implement the changes with the
unit managers and d.) evaluate improvement by monitoring our
rates. Results: PICC line infections decreased from an average
of 27 per year from 2008-2010 to 5 in the first 6 months of 2011.
Initiatives included: 1.) chlorhexidene/ alcohol preps were added
to the unit stock supply; 2.) the central line checklist for insertion
of CVC was monitored hospital wide for compliance; 3.) the
blood culture policy was updated to limit use of the central line
for blood draws, 4.) all non- ICU staff were educated regarding
“Scrub the Hub” 5.) the mechanical connector was changed to a
connector coated with an antimicrobial designed to help prevent
microbial contamination and growth of pathogens in the device;
6.) rounds were conducted and staff were reminded to cap off
unused lumens 7.) the use of chlorhexidene protective disk was
initiated on all PICC lines at insertion. 8.) we investigated any new
devices/procedures implemented during this time that may have
been linked to the cluster. Lessons Learned: Targeting 0 is a
monumental challenge. We are ready for the challenge but are aware
that all disciplines need to be involved in the process including
celebrating the successes and correcting the failures. It involves
much time and man power and ongoing observations to keep our
patients safe from infections during their hospital stay. We need to
keep this project at the fore front of our daily care and continually
look for ways to improve our patient safety and our facility’s
continued operation without undue financial burdens as we strive
for excellence in patient care.
Is Antimicrobial Closure Technology A Clinically
Effective Strategy For Reducing the Risk of
Surgical Site Infections – A Meta-Analysis?
Charles E. Edmiston, Jr, PhD - Professor of Surgery & Hospital
Epidemiologist, Medical College of Wisconsin Department of
Surgery; David Leaper, MD - Professor, Imperial College; Frederic
C. Daoud, MD, MSc - Epidemiologist, Medextens; Martin
Weisberg, MD - Medical Director, Ethicon, Inc
Background/Objectives: Surgical site infections
comprise 20% of all healthcare-associated infections, having a
significant impact on patient morbidity, mortality and healthcare
resources. The present systematic literature review (SLR) metaanalysis evaluates the current evidence-based literature in an attempt
to validate the clinical effectiveness of antimicrobial (triclosancoated) suture technology as a complementary adjunctive strategy
to reduce the risk of SSI in selected surgical patient populations.
Methods: A systematic literature review was conducted using 4
independent, comprehensive databases; PubMed, Embase/Medline,
Cochrane Database Group and www.clinicaltrials.gov in an effort to
identify all relevant clinical trials involving triclosan-coated braided
sutures that met the criteria for Evidence Level 1b. Selective eligibility
criteria were established so as to limit the potential of either analytical
or publication bias. The relevant publications were tested against
specific inclusion and exclusion criteria. Data extraction included
study design, surgical procedure, clinical indication, outcomes,
suture material, and patient number. The risk ratio (RR) was chosen
as the measure of effect for the meta-analysis. A fixed-effects model
was used to calculate the relative magnitude of the RR under the
assumption that all included RCT were drawn from the same
population with a common treatment. Homogeneity was tested
using the Cochran’s Q statistic and the percentage of heterogeneity
was measure with the I2 indicator. The random-effects pooled
RR was also calculated to draw qualitative conclusions about the
presence or absence of a significant treatment effect in favor of one
or the other arm under the assumption that the included RCTs were
drawn from different populations with treatment effects favoring
the same treatment but with different magnitudes. Publication bias
was assessed using the graphical funnel plot and Egger regression
intercept methods. Sensitivity analysis was conducted by rerunning
the analysis with 6 RCTs after iteratively removing each RCT and
comparing results. Results: A total of 20 relevant clinical trials
were identified from the peer-reviewed literature and following
filtering of inclusion and exclusion criteria 7 eligible RCTs were
chosen to be included in the meta-analysis. The seven RCTs were
determined to be homogeneous (Q = 6.26, NS). The random-effects
model demonstrated a RR of 0.482 (95% CI:0.31-0.75), indicating
a statistically significant reduction in the risk of SSI when triclosancoated sutures were compared with non-coated closure devices
(p=0.0012). No publication bias was detected (Egger Intercept test:
p = 0.974) and the results were robust to sensitivity analysis. The
results of the meta-analysis were defined as CEBM Evidence Level
1a. Conclusions: Triclosan-coated closure technology is
associated with a significant lower risk of postoperative SSI compared
to non-coated closure devices (p<0.001). In the current evidencebase healthcare environment adoption of an antimicrobial suture
33
technology is warranted as an appropriate adjunctive component of
a thoughtful risk reduction strategy to improve clinical outcomes in
surgical patient populations.
Pediatric Ventilator Associated Pneumonia (VAP)
Prevention Bundle: 5 Years Later
Andrea Kiernan, MLT (ASCP) CIC - Infection Preventionist,
St. Christopher’s Hospital for Children; Patricia Hennessey, RN,
BSN, MSN, CIC - Manager, Infection Prevention, St. Christopher’s
Hospital for Children
Issue: In 2005, VAP rate in our pediatric Critical Care (CC)
Units was below the 50th percentile of performance as compared
with the CDC’s NHSN Pediatric CC VAP data. Adult VAP
prevention had evolved but pediatric evidence was limited. All CC
Units are ECMO centers. Project: A multidisciplinary team
convened with the goal of developing a Pediatric VAP Prevention
Bundle (VPB). Objectives included: 1) identify opportunities for
improvement; review internal policies and practices at the bedside;
2) review evidence based literature; 3) network with other pediatric
institutions to determine best practices; 4) evaluate adult evidence to
determine applicability to pediatrics; 5) evaluate improvement on an
ongoing basis. The VPB was implemented in our ICU, SCU (Special
Care Unit/Burn Center), CCU (Cardiac Care Unit), and our Level
III NICU in May 2006. (Figure 1) Results: Using the VPB, the
ICU, CCU & SCU Units maintained zero VAPs from October 07October 2011 (Figure 2). Because our NICU VAP rate continued
to exceed NHSN NICU benchmarks, we modified the VPB in
September 2008 to include neonates. Major revisions of the VPB
are shown in Figure 1. Following implementation of the modified
VPB, NICU VAP rates decreased 62% from 3.9 to 1.5 infections
per 1000 ventilator days, and have been sustained at 0.46 per 1000
ventilator days (n=5) from 2008-2011.(Figure 2) VAP HAIs and
Bundle Compliance are targeted at zero and 100 % respectively.
VAP rates have been zero (maintaining the NHSN 90th percentile
of performance) for 56 months, 48 months, 46 months in the ICU,
SCU, CCU respectively. NICU VAP rates decreased 62% from 3.9
to 1.5 infections per 1000 ventilator days in the first year post Bundle
implementation. NICU VAP rates have been sustained at 0.46 per
1000 ventilator days from 2008-2011 (n=5) (Figure 2). The NHSN
rate is zero for the 75th and 90th percentile of performance in Level
III NICUs. Lessons Learned: • A multidisciplinary team
approach was critical to VPB development • Annual mandatory
staff VPB education is vital to sustaining low VAP rates • NICU is
a special needs population for VAP prevention • Zero VAP rate is
attainable and sustainable
When a central line bundle is not enough:
Sustaining gains and striving for zero
Kathy Ware, RN, BSN, CIC - Infection Control Coordinator, Texas
Children’s Hospital; Carol Turnage. Carrier, MSN, RN, CNS,
CPHQ - Clinical Nurse Specialist, Texas Children’s Hospital; Yvette
R. Johnson, MD, MPH - Assistant Professor of Pediatrics, Baylor
College of Medicine and Texas Children’s Hospital
Background/Objectives: In 2008, it was identified that a
substantial number of central line associated blood stream infections
(CLABSI) were occurring at a higher rate in very low birthweight
infants in a 76 bed, Quanternary Care, Level 3 Neonatal Intensive
Care Unit (NICU). After implementing a central line bundle, the
CLABSI rate was lowered in 2009. Various interventions included
a bundle consisting of a neutral displacement valve, scrub the hub
technique, closed medication system, hand hygiene, maximum
barrier precautions, standardized dressing change kit, and dedicated
Vascular Access Team (VAT). In 2010, five of eleven (45 percent)
CLABSIs were attributed to umbilical line infections alone. The
Gaps in Practice (GIP) Team collaborated with various consultants
to identify problems with current umbilical line security, migration,
and dislodgement of catheters not addressed by the current central
34
line bundle. A literature review by the team provided no evidence for
best practice in securing umbilical lines. The objective of this initiative
was to improve the security of umbilical arterial and umbilical venous
catheters using commercially available skin barrier and a clear dressing
over the coiled umbilical line to reduce migration and subsequent
neonatal umbilical line-related infections in the NICU by 40% within
6 months to 1 year. Methods: The GIP team benchmarked with
the top ten children’s hospitals to compare different methods against
their outcomes of catheter migration and infections. Four of the ten
hospitals used the skin barrier and clear dressing over the coiled catheter
and reported no associated adverse events. The GIP team collaborated
with the VAT and Infection Control Nurse to use the Plan-Do-StudyAct (PDSA) improvement method to test the most commonly used
dressing and securement device. In January 2011, the VAT conducted
the PDSA testing of the new dressing on 4 infants in the NICU.
Specific criteria were used for eligibility to include preterm and term
neonates with 50% of the neonates being in humidified environments.
Results of the PDSA testing showed no complications of catheter
migration and no infections associated with umbilical lines in the four
patients. Nurses were educated on the procedure and the securement
device was implemented in the NICU. Weekly monitoring of infection
frequency by line type was continued. Results: Umbilical line
infections were decreased by 40 percent following full implementation
of the dressing change intervention throughout the NICU, as evidenced
by the following graphs and tables. Conclusions: Using quality
improvement tools and teamwork further reduced umbilical and central
line related infections in the NICU.
Multifaceted Interventions to Prevent Central
Line Associated Blood Stream Infections in a
New York City, Neonatal Intensive Care Unit
Larry T. Colbert, MA, CIC - Associate Director of Infection
Control, Bellevue Hospital Center
Marianne Pavia, MT(ASCP), CLS, CIC - 2011 PresidentElect, APIC Greater New York Chapter 13; Associate Director
Infection Control, Bellevue Hospital Center; Susan Marchione
- Sr. Associate Director Infection Control, Bellevue Hospital
Center; Harold Horowitz - Hospital Epidemiologist, Bellevue
Hospital Center; Yang Kim - Assistant Professor Pediatrics,
Neonatologist, NYU, Bellevue Hospital Center; Roslyn
Mayers - Assistant Director Nursing, Bellevue Hospital Center
Issue: Central line associated blood stream (CLABSI)
Infections are a serious issue in a Neonatal Intensive Care Unit
(NICU). They have been associated with increased morbidity,
mortality, and length of stay in the NICU. Bellevue Hospital
RPC NICU is a 25-bed, level 3 unit where an increased
incidence of central line infections occurred from 2007 to 2009.
These rates were higher than national standards. Project:
35
A multidisciplinary and multifaceted infection prevention program
was developed and in place March 2009 in order to reduce the
CLABSI rate in the NICU. Our program includes: 1. participation
in statewide CLABSI prevention Collaborative which included
use of central line check lists (insertion and maintenance) and the
central line bundle. 2. Implementation of “Bug Stop Here” campaign
which included: staff education, hand hygiene measures, aseptic
technique practices, revamping of cleaning policy of all equipment/
NICU environment, “Leave Your White Coats at the Door” Policy,
Instituting “personal” plastic bags for visitors belongings. Parents were
also given a written NNICU infection control parent agreement.
The agreement addressed hand washing, separation of clean and dirty
items on the unit, not visiting when ill. Free bottles of hand sanitizer
were also distributed to the parents.3. Infection Control participation
in daily patient rounds to enforce central line protocol. Results:
Prior to the interventions the CLABSI rates were 4.4 and 8.3 in 2007
and 2008 respectively. After the interventions rates were 8.3, 1.5 and
1.6 in 2009, 2010 and 2011 respectively. Lessons Learned:
A multidisciplinary intervention that included CLABSI bundle
components as interventions, & “Bug Stop Here” Program helped
decrease our CLABSI rate.Reduced NICU central line associated
blood infection rates may lower hospital costs, length of stay,
morbidity and mortality.Parent and staff education with continued
active surveillance can be important tools in reduction of CLABSI
rate. Collaborative groups and sharing of information can help
facilitate implementation of prevention aims.
with the mean (SD) LOS was 24.7 (13.4) days and the mean (SD)
LOS in ICU was 17.2 (15.8) days. All 51 patients were infected
by multi-resistant methylase producing Acinetobacter Baumanii.
89.2% of isolates was resistant with imipenem. These Acinetobacter
Baumanii are grouped as 3 clusters with the similarity 70% in each
cluster. The severity of diseases is different significantly among the
cluster (p<0.01). The patients in each cluster were found to be related
with location, sharing the suction machine, oxygen humidifiers
and same staff. Twenty eight (54.9%) isolates have gene 16S rRNA
armA, and these gen were transmitted among the clusters. (Figure
1). Conclusions: There is an endemic of VAP due to multidrug resistant Acinetobacter Baumanii in the hospital, sporadic
cases as well as outbreaks of VAP due to Acinetobacter Baumanii is
occurring. 16S rRNA methylase gene armA was widely distributed
in these isolates. This suggested that the spread of clones played an
important role in the outbreak of multi drug resistant A. baumannii
in Vietnam. Although the source of outbreak is unknown, the cases
showed having close contact and sharing equipments. Contaminated
environment or instruments with inappropriate reprocessed may
contribute an important role in transmission of this pathogen. Strict
contact precaution should be enhanced in this setting. More studies
should be done to invest the source and the spread of these clones of
Acinetobacter baumani in the ICU.
Ventilation Associated Pneumonia caused by
Acinetobacter Baumanii at a Tertiary Hospital in
Vietnam: Clinical and Molecular Patterns
Anh Thu T , LE - Chief of Infection Control department, Cho Ray
Hospital, Vietnam
Background/Objectives: The pathogen causing
ventilation associated pneumonia (VAP) in Vietnam mainly due
to multi drug resistant Acinetobacter Baumanii, which cause a high
impact for patients who required ventilators. The aim of the study
is to evaluate clinical and molecular epidemiological characteristics
of VAP caused by Acinetobacter Baumanii and their antimicrobial
susceptibility. Methods: Study design: Cohort prospective
study Setting: 30 bed medical-surgical ICU of Cho Ray Hospital, a
tertiary hospital of Southern Viet Nam. Subjects: Patients defined
as Acinetobacter Baumanii VAP admitted to the ICU from 1st
June to 1st September 2011. CDC definition 2003 was used to
diagnose VAP. The genotypic-resistance characteristics of all isolates
of Acinetobacter Baumanii were investigated by pulsed field gel
electrophoresis (PFGE). Results: During the studied period,
there were 51 patients with Acinetobacter Baumanii VAP. Thirty
six (70.6%) was male with the mean (SD) age of patients was 50.8
(17.7). Thirty eight (74.5%) had underline diseases, mostly diabetes
(N=12; 23.5%). Forty (78.3%) patients were coma with mean
(SD) Glasgow scale of 6 (3.2). Twenty-five (49.0%) patients were
undergone operation, mostly abdominal operation (N=20; 39.1%).
The mortality was 52.2%. Forty seven (92.2%) patients had SIRS,
36
Patient Education as a Means to Reduce
Methicillin-Resistant Staph Aureus Surgical Site
Infections in Patients with Known Colonization
Kathy M. Bailey, RN, CIC - Director, Infection Prevention, Centra
Health
Issue: Methicillin-Resistant Staph aureus (MRSA) is a frequently
recognized pathogen causing surgical site infections (SSIs). Patients
with MRSA colonization are known to have an increased risk of
MRSA infection. Evidence based preventive measures were in place
in 2009 to include chlorhexidine cloth applications pre-operatively,
appropriate antibiotic selection and timing, clipping versus shaving,
Staphylococcus aureus nasal screens for implant patients and, intranasal
Mupirocin for patients with positive nasal screens. MRSA SSIs rates
continued to be higher than desired as evidenced by surveillance
of nine targeted surgical procedures. National Healthcare Safety
Network (NHSN) SSI definitions were utilized to identify infections.
Project: In May 2010 a process was developed to provide face
to face patient education by an Infection Preventionist (IP) for
individuals known to be colonized with MRSA at the time of surgery.
A multidrug resistant organism (MDRO) alert in our computerized
patient medical record provided information regarding prior
colonization with MRSA. Each day patient records carrying this alert
were matched with operating room schedules to create a listing of
candidates for the education. An IP visited these patients on the first
or second post-operative day to provide education and answer any
questions of the patient or family. A one page educational tool on SSI
prevention along with a complementary alcohol based hand sanitizer
was left with the patient. Results: Our MRSA SSI rate decreased
by 75% when 2010 rates were compared to 2011 rates of infection.
The MRSA SSI rate in patients receiving the education was 0.3%
(N=331). Because we addressed our MRSA SSI rate with a sense of
urgency several preventive measures were established simultaneously.
As a result, we were unable to determine the specific impact of the
education towards the reduction. We did however recognize that
patients better understood their MRSA status and risk of infection.
Additionally, this effort was a patient satisfier as evidenced by positive
patient and family comments. Finally, we believe that this process will
enhance our efforts towards The Joint Commission’s national patient
safety goal of patient education on surgical site infection reduction.
Lessons Learned: All patients meeting the criteria were not
educated. Outpatient surgery patients were discharged before the IP
could see them. Some patients were medicated for pain while others
suffered from dementia with no family member available to receive the
information. This was a labor intensive commitment for the IPs but
one that provided valuable patient education on surgical site infection
prevention, improved patient satisfaction and is one of several
interventions that led to a significant reduction in MRSA SSIs.
An Interdisciplinary Approach Toward Reducing
the Incidence of Catheter-Associated Urinary Tract
Infections in a Post-Acute Facility
Peter Kolonoski, RN, MSN, CIC - Infection Control Coordinator,
California Pacific Medical Center; Kim Stanley, MPH, CIC Infection Control Coordinator, California Pacific Medical Center;
Karen Anderson - Infection Control Manager, California Pacific
Medical Center
Issue: Catheter-associated urinary tract infections (CAUTI)
are the most prevalent healthcare associated infection (HAI),
accounting for more than 30% of all HAIs in the United States.
CAUTI has been associated with increased morbidity, mortality,
length of stay, cost, and antibiotic use. Indwelling urinary drainage
systems can also be a reservoir for multidrug resistant organisms.
Project: This quality-improvement project was implemented
in three post-acute units in a large tertiary teaching hospital.
Physicians and nurses were interviewed to gather opinions about
catheterization practices. A point prevalence survey of Foley catheter
use was then done, in order to determine prevalence and reason for
the use of indwelling catheters, by comparison to a list of criteria
of indications from published literature. A multidisciplinary team
consisting of physicians from urology, orthopedics, critical care and
hospitalist services, Nursing, and Infection Prevention formulated
new protocols for catheter management. Key components were
indications for catheterization and bladder training in order to
reduce long-term use. Infection Prevention would continue to
monitor device utilization and CAUTI incidence. Results: Staff
interviews demonstrated that staff felt that catheters were overutilized, alternatives were seldom considered, and that physicians
were often not aware that patients had an indwelling catheter. Some
physicians also felt that poor collection of urine output data led
to prolonging the use of catheters. Nurses felt that the decision to
maintain an indwelling catheter was up to the physician, and did not
consider it within their scope of practice. Prevalence studies showed
that approximately 25% of indwelling catheterizations did not meet
the selected criteria. Nurses were often unaware of why the patient
had a catheter, but did not usually advocate for its removal. These
data were used by the multidisciplinary team in formulating new
protocols. The catheter management protocol contained elements
relating to catheter insertion procedure, care, alternatives, and
37
indications, with the stipulation that catheters not meeting criteria
should be removed. There was general agreement among the team
that catheter insertion and removal should require a physician’s order.
A bladder training protocol with a baseline assessment on admission
was also instituted with the goal of regaining normal bladder
function as soon as possible. The three nursing units had a decrease
in CAUTI rate from 19.1 CAUTI/1000 catheter-days in 2008 to
14.29 in 2011. Device utilization declined from .142 to .099 . While
patient census remained relatively constant over the study period,
the number of CAUTIs decreased from 74 in 2008 to 30 in 2011.
Lessons Learned: Quality improvement initiatives require
multidisciplinary input and buy-in. A definitive baseline assessment is
necessary to gauge progress. Having nurses aware of indications led to
greater advocacy for catheter removal.
Incidence of Hypothermia under Perioperative
Standard Thermal Management in Patients with
Abdominal Surgery and Its Effect on Surgical Site
Infections
Toshie Tsuchida, RN, PhD - Associate Professor, Hyogo University
of Health Sciences; Kaoru Ichiki - Infection Control Professional
Head Nurse, Division of Infection Conrol and Prevention Hyogo
College of Medicine; Yoshio Takesue - Chief Professor, Hyogo
College of Medicine; Yoko Fujimoto - Head Nurse, Hyogo college of
Medicine Hospital
Background/Objectives: Perioperative thermal
management has been routinely performed to prevent hypothermia
induced adverse events including surgical site infections (SSIs). This
study aimed to examine the incidence of hypothermia in abdominal
surgeries under perioperative standard thermal management and
its effect on SSI. Methods: A retrospective cohort study was
conducted involving patients who underwent liver (BILI-H),
pancreatic (BILI-P), esophageal (ESOP), gastric (GAST), colon
(COLN) and rectal (REC) surgery within the period from January to
December 2010. Perioperative thermal management was performed
using a forced-air warming system in all cases. The following data were
collected: the lowest perioperative rectal temperature (pharyngeal
temperature in patients undergoing colorectal surgery); 5 patientrelated characteristics; 5 surgical procedure-related characteristics;
and 5 SSI-related items. Analysis was performed by calculating: 1)
the incidence of each stratified level of hypothermia (mild; 36.0-35.6
degrees C; moderate; 35.5-35.1; and severe; 35.0 or lower) and odds
ratios (OR) for risk factors of hypothermia. 2) risk ratios (RR) for
SSI risk factors, including hypothermia (36.0 degrees C or lower,
35.5 or lower). SSI was diagnosed based on the criteria defined by
the National Healthcare Safety Network. Results: A total of 632
patients (BILI-H: 81; BILI-P: 46; ESOP: 24; GAST: 133; COLN:
134; and REC: 196) were studied. The incidence of each level of
hypothermia was as follows: mild 151 patients (24%); moderate 54
patients (9%); and severe 9 patients (1%). The RR for each cause of
hypothermia with a body temperature of 36.0 degrees C or lower
was as follows: thoracolaparotomy 1.84 (95% Confidence Intervals:
1.22-2.76); lithotomy position: 1.28 (1.14-1.44); males: 1.55(1.20-
38
1.99); a Body Mass Index (BMI) lower than 18.5: 1.42(1.19-1.70);
stoma:1.20 (1.03-1.39, P=0.01) and anemia: 1.13 (1.01-1.26,
p=0.038). In multivariate analysis, thoracolaparotomy (OR 4.27,
95%CI 2.01-9.07), lithotomy position (1.97, 1.37-2.83). BMI lower
than 18.5 (2.52,1.67-3.84), males (1.98, 1.35-2.91) were selected
as risk factors for hypothermia with a body temperature of 36.0 or
lower. The perioperative body temperature was not correlated with
the bleeding volume, duration of surgery, and transfusion volume.
The incidence of SSIs was 21% (BILI-H: 16%; BILI-P: 37%; ESOP:
37%; GAST: 14%: COLN: 15%; and REC: 25%). Significant risk
factors for SSIs were as follows: contaminated wounds (1.60, 1.052.43); emergency surgery (1.27, 0.98-1.64); and stoma construction
(1.16, 1.05-1.29). Hypothermia (36.0 or lower, 35.5 or lower) was
not selected as a significant risk factor for SSIs [1.02 (0.94-1.12), and
0.99 (0.87-1.13), respectively]. Conclusions: The incidence of
hypothermia in abdominal surgeries was 34%, and was influenced by
combined thoracotomy, the sex, surgical position, and body weight;
however, the occurrence of severe hypothermia was rare, and most of
patients were included mild to moderate hypothermia. Hypothermia
in such a condition did not appear to be a risk factor for SSI.
Vascular Access Associated Blood Stream
Infections in Patients Undergoing Plasmapheresis
Compared with those in Patients with Hemodialysis
Kaoru Ichiki - Head Nurse, Division of Infection Conrol and
Prevention Hyogo College of Medicine; Toshie Tsuchida, RN, PhD
- Associate Professor, Hyogo University of Health Sciences; Yoshio
Takesue - Chief Professor, Hyogo College of Medicine; Nakajima
Kazuhiko - Lecturer, Hyogo College of Medicine; Ueda Takashi
- Pharmacist, Division of Infection Control and Prevention Hyogo
College of Medicine
Background/Objectives: Vascular access associated blood
stream infections (VABSI) underwent hemopurification have been
mainly studied on hemodialysis (HD). Hemopurification therapy
is, also applied to patients with plasmapheresis (PP). This study
aimed to examine the incidence of VABSI on PPand investigated
risk factors affecting it. Methods: Patients who underwent PP
and HD with vascular access catheters between January 2007 and
September 2011 were eligible for the study. Blood stream infections
were diagnosed based on the criteria defined by the National
Nosocomial Infections Surveillance (including clinical sepsis) and
National Healthcare Safety Network. Analysis was performed
by calculating the incidence of VABSI on HD and PP. The risk
factors affecting VABSI on PP were specified using univariate and
multivariate analysis among 20 factors including nine host factors, six
catheter related factors and 5 other factors (activity on daily living,
incontinence, sanitary conditions, capacity to understand, skin lesion
at the insertion site).Results: Two hundred seventeen patients
with HD and 62 patients with PP were observed. Mean number of
hemopurification therapy were 5.6±4.2 on HD and 4.8±2.4 on PP.
Primary diseases underwent PP were as follows: Multiple sclerosis
32 patients, Myasthenia gravis 9 patients, Chronic inflammatory
demyelinating polyradiculoneuropathy 8 patients, Lambert-Eaton
myasthenic symdrome and bullous pemphigoid 4 patients. The
incidence of VABSI was 8.8% (6.29/1,000 device-day) on HD,
14.5% (9.2/1,000 device-day) on PP (P=0.18 and P=0.10). The
Odds ratio of PP for cause of VABSI was 0.82( 95%CI; 0.58-1.15,
P=0.24) PP was not an independent risk factor of VABSI in patients
with hemopurification. Variables that achieved statistical significance
in the univariate analysis for cause of VABSI in patients with PP were
follows: emergent insertion of vascular access, steroid pulse therapy
and patients with poor hygiene. In multivariate analysis, emergency
insertion was identified as the only independent risk factor of VABSI
on PP. Conclusions: There was no significant difference in
the incidence of VABSI in patients with HD and PP. Further study
is required to conclude the difference among the patients with
hemopurification therapy. Emergency insertion was the risk factor
affecting VABSI on PP.
Total Burden Assessment Of Surgical Site
Infections In Initial Admissions And Readmissions
Using National Administrative Claims Data
Anuprita Patkar - Asso. Director, Health Economics &
Reimbursement, Ethicon, J&J; Somesh Nigam - VP, Healthcare,
Johnson and Johnson Corporate; Mehmet Daskiran - Statistical
Analyst, Johnson and Johnson Corporate; Ronald Levine Statistician Level III, Johnson and Johnson Corporate; Scott Wolven
- Asso. Director Reimbursement, Ethicon, J&J; Sashi Yadalam Statistical Analyst, Johnson and Johnson Corporate
Background/Objectives: Surgical site infections (SSIs)
have a significant negative impact on hospital reimbursement and
clinical outcomes. This study quantifies the incidence and economic
burden of SSIs in 6 selected surgical categories as an aggregate.
Uniquely, this investigation focuses on the impact of patients having
SSI in their initial admission with downstream outcomes, including
readmission counts, payments and total length of stay (LOS) to
assess the complete consequences of SSI, not just a single episode of
care. Methods: Patients were drawn from the Thomson Medstat
Marketscan® Database, a national administrative database that
longitudinally tracks commercial claims data from nearly 150 million
patients since 1995. The economic impact of SSI was evaluated in
selected 6 high-volume surgery specialties specified by ICD9-CM
procedure code (cardiac, general, orthopedic, neurological, plastic
and ob-gyn) during the period January 2007 to December 2009.
Patients qualified if they had no prior surgeries in a 90-day look back
period. Subsequently, each patient was observed for readmissions in
a 90-day look forward period. Patients developing infections during
their index admission were defined by ICD-9-CM codes 998.5x,
998.66 and 998.67 as their secondary diagnosis; patients developing
one or more SSI’s during their readmissions were defined by the
same codes identified as their primary readmission diagnoses. The
total burden of SSI was assessed by evaluating differences in LOS
and provider payments relative to patients with no SSI: 1) during
the initial admission for patients experiencing SSI; (2) during the
90-day post surgery for patients who had developed SSI in their
initial admission; and 3) in patients developing SSI in their 90-day
post-operative period. Generalized Linear Models adjusting for
patient age, gender, region and diabetes were used to compute mean
differences and 95% confidence intervals. A constant sample based
on the index procedure census was used for all three analyses to
maintain a consistent denominator. Results: Patients developing
SSI as a complication of index surgery incur an additional LOS of
6.86 days (95%CI: 6.71-7.02 days) and $20,288 (95%CI: $19,369$21,206) of extra payments. Patients during the 90-day post surgery
period who had developed SSI in their initial admission are likely
to have 0.21 more downstream readmissions (95%CI: 0.19-0.21),
1.94 days additional LOS (95%CI: 1.81-2.08) and $5,549 additional
payments (95%CI: $5,106-$5,993). Patients developing SSI at
any time during their 90-day post-operative period are at risk of
1.3 additional readmissions, and incur an average additional LOS
of 8.37 days (95%CI: 8.26-8.47) and $25,436 (95%CI: $25,094$25,779) in additional payments. Conclusions: SSI increases
current and downstream burdens by a factor of 3 to 10 times in terms
of readmission rates, and additional length of stay and payments.
Appreciation of its impact emphasizes the importance of control and
prevention of this surgical complication.
Challenges In Adherence With National Healthcare
Safety Network Definitions: A Central LineAssociated Bloodstream Infection Conundrum
Teresa Chou, MPH, CIC - Manager, Infection Control and
Epidemiology, Advocate Illinois Masonic Medical Center; James
Kerridge, MA, RN, CIC - Infection Preventionist, Advocate Illinois
Masonic Medical Center; Katie Wickman, MS, RN - Infection
Preventionist, Advocate Illinois Masonic Medical Center; Mandavi
Kulkarni, MD - Infectious Disease Attending, Advocate Illinois
Masonic Medical Center; James Malow, MD, FIDSA - Chairman
Internal Medicine, Chairman Infection Prevention Committee,
Medical Director Advocate Healthcare Infection Prevention Team,
Advocate Illinois Masonic Medical Center
Issue: The Centers for Disease Control and Prevention’s National
Healthcare Safety Network (NHSN) has standardized definitions
for healthcare-associated infections including central line associatedbloodstream infections (CLABSI) and pneumonia (PNU). In
conjunction with the Center for Medicare and Medicaid Services
(CMS), the State of Illinois requires hospitals to report CLABSIs
using NHSN. Last year, Illinois began conducting audits of CLABSI
data to validate adherence with NHSN definitions. Adherence with
these definitions may not always concur with clinical diagnoses. The
following case demonstrates the conundrum. Project: A 67
year old male patient with multiple co-morbidities was admitted
on October 14, 2011, with dyspnea, fever, and peritoneal dialysis
catheter malfunction. On admission, laboratory tests showed
leukocytosis and computer tomography of the lungs revealed
bilateral infiltrates and multiple nodules. A bronchoalveolar lavage
(BAL) culture on October 19 grew few Klebsiella pneumoniae
and many yeast, not Cryptococcus. The patient did not respond
to antibiotics or high dose steroids. Initial blood cultures were
negative. Blood cultures obtained on October 28 from a peripheral
site and a central line grew C. neoformans. At the time, he had
2 central lines (dialysis, peripherally inserted) and an arterial
39
line. He expired on October 29; no autopsy was performed.
To determine if the patient had a CLABSI, NHSN definitions
were reviewed, pulmonologists and infectious disease physicians
evaluated the patient, a literature search for CLABSIs associated
with Cryptococcus was conducted, and NHSN was consulted.
Results: Although the patient exhibited signs and symptoms
of pneumonia, it did not appear that the PNU2 definition was
met; Cryptococcus was isolated from blood 15 days after admission.
The case met the CLABSI criteria 1 definition: the patient had
central lines, no Cryptococcus was isolated from the BAL culture,
admission blood cultures were negative and the pathogen was
isolated from blood during hospitalization. A NHSN nurse
consultant advised adherence with definitions but did not specify
the infected site. Since imaging revealed infiltrates and lung
nodules, 2 pulmonologists and 3 infectious disease physicians
stated that the bacteremia was secondary to the pneumonia, not
a CLABSI. Cryptococcus is not easily isolated from a BAL, and
the nodules were not biopsied (preferred method). Furthermore,
the BAL was obtained many days before the patient developed
bacteremia. Only 1 cryptococcal CLABSI case has been reported
in the literature; the patient was on chronic hemodialysis and had
no other sites of infection. Lessons Learned: The CLABSI
definitions leave no room for clinical interpretation. Hospitals are
left in a quandary as whether to adhere to the clinical diagnosis
or NHSN definitions. If the CLABSI definition is met and not
reported, the hospital risks being cited. We support Sexton, Chen
and Anderson’s recommendation to revise the definitions and create
an indeterminate category.
Shared Successes For Surgical Site Infection
Reduction: Utilization of CHG-impregnated Cloths
as an Adjunct to the Pre-op Shower
Linda K. Miller, RN, CIC - Manager, Infection Prevention &
Control, Methodist Charlton Medical Center; Mary A. Fulton,
RN, BSN, CIC - Infection Prevention Practitioner, Methodist
Charlton Medical Center; Zakir Hussain A. Shaikh, MD, MPH,
FIDSA, FSHEA, CPE, CMSL - Medical Director and Hospital
Epidemiologist, Methodist Heath System of Dallas
Issue: Surgical site infections (SSI) increase hospital costs
and length of stay as well as adversely impact patient mortality.
Reduction efforts have focused on implementation of a set of
measures as part of the Surgical Care Improvement Project (SCIP),
evidence-based practices that are well documented as a successful
reduction strategy. Our facility is a 305-bed, acute care, non-teaching
community hospital serving an inner-city population. After intensive
implementation of the SCIP measures and compliance monitoring,
it was determined that SSI reduction efforts for laminectomy cases
could be further enhanced. Project: In early October 2009 the
effectiveness of the pre-op CHG shower program was assessed. The
existing process, in place for five years, included supplying patients
with a CHG product and written/verbal instructions for showering
the night before and the morning of surgery, paying special attention
to the surgical area. As part of the SSI reduction strategy, Infection
40
Prevention recommended implementation of a concentrated pre-op
wash of the back using the CHG-impregnated cloths in pre-operative
holding. All SCIP measures continued as previously implemented
and no other variables were changed during the next 12 months.
Given consistent success of the new process for laminectomy
procedures over a one-year period, the program was expanded to
include orthopedic surgeries. Beginning October 2010, the use
of the CHG-impregnated cloths in the pre-op holding area was
implemented for knee and hip total joint replacement procedures.
Results: During FY 2007-09, the combined mean SSI rate
for laminectomy procedures was 3.5/100 procedures. Following
implementation of the CHG impregnated cloth pre-op wash in
October 2009, no additional laminectomy SSI have been identified.
The 100% reduction in SSI rate as compared to the previous three
years is statistically significant [p value=0.017]. During FY 2007-10,
the combined mean SSI rate for knee and hip total joint replacement
SSI was 1.7/100 procedures. Following implementation of the CHG
cloth pre-op wash in this population, the decrease in SSI rate for
these procedures was noted to be statistically significant [p-value
= 0.013]. Lessons Learned: Implementation of CHGimpregnated cloths as a pre-op wash applied directly to the operative
site as an adjunct to the traditional pre-op CHG shower has been
successful in eliminating laminectomy SSI. Expansion of this process
to include orthopedic procedures resulted in a significant decrease
in knee and hip total joint SSIs. Our sustained success with SSI
reduction supports the practice of a pre-op wash utilizing CHGimpregnated cloths as an adjunct to the traditional pre-op surgical
shower, and demonstrates the value of sharing our learning and
success beyond the initial implementation group.
Micro-Patterned Surfaces for Reducing Platelet
Adhesion and Bacterial Attachment Associated
with Catheter-Associated Blood Stream Infections
Rhea M. May - Microbial Research Associate, Sharklet Technologies
Inc.; Matthew G. Hoffman - Microbial Research Associate, Sharklet
Technologies Inc.; Shravanthi T. Reddy - Director of Research,
Sharklet Technologies Inc.
Background/Objectives: Central venous catheters
(CVCs) are responsible for approximately 90% of all catheter-related
bloodstream infections (CRBSIs). The resulting 300,000 infections,
commonly caused by Staphylococcus aureus and Staphylococcus
epidermidis, are associated with as many as 28,000 deaths per year
in America alone. CRBSIs prolong hospital stays, induce human
suffering, and magnify healthcare costs (up to $2.68 billion).
Infection is four times more likely to occur in patients with catheterrelated thrombosis (CRT), and up to 67% of patients with CVC
develop CRT. A common strategy used to prevent CRBSIs has been
to impregnate CVCs with antimicrobial agents to control microbial
colonization, and heparin coatings to prevent CRT. These strategies
can be limited by the short duration of efficacy and the potential for
contributing to antimicrobial resistance and heparin induced safety
concerns. A novel micro-topography (Figure 1, bottom panels)
may provide an alternative strategy as it has been shown to reduce
bacterial attachment and biofilm formation without the use of
antimicrobial agents. This biomimetic micro-pattern also inhibits
bacterial migration, offering the possibility of reducing bacterial
access into the bloodstream via the CVC. The objectives of this
study were to determine the performance of the micro-pattern in
reducing S. aureus attachment after whole blood pre-conditioning
and to evaluate the innate anti-fouling properties the pattern may
have in reducing platelet attachment and aggregation, precursors to
thrombosis that can lead to CRT related CRBSIs. Methods:
Patterned and un-patterned (control) silicone samples (n=3) were
immersed statically in whole blood for either 10 minutes or 2 hours
at 25°C, followed by a saline rinse, and inoculation with ~10^7
CFU/mL S. aureus (ATCC6538) suspended in saline. The samples
were incubated statically for 1 hour at 25°C before rinsing with
saline and enumerating the attached cells after ultrasonication and
dilution plating. Platelet adhesion was evaluated on patterned and
un-patterned silicone surfaces (n=2) through exposure to platelet
rich plasma (150x10^4 platelets/μl) under shear laminar flow
conditions (100 rpm) for two hours at 37°C before osmium tetroxide
fixation and imaging with scanning electron microscopy in six predetermined locations. Platelet area coverage was analyzed through
ImageJ software. Results: After preconditioning surfaces with
blood for 10 minutes and 2 hours, the micro-pattern reduced S.
aureus attachment by 68% (p≤0.05) and 82% (p≤0.15), respectively,
when compared to preconditioned un-patterned surfaces. The
patterned surfaces also reduced platelet area coverage by 90%
(p<0.00001) when compared to an un-patterned surface (Figure 1).
Conclusions: The physical surface modification afforded by
the micro-patterned texture inhibits the adhesion of platelets, and
attachment of S. aureus after blood preconditioning. Introduction of
this micro-pattern on a central venous catheter surface may be useful
for controlling CRBSIs and CRT.
Our Journey to Eliminate Central Line Associated
Blood Stream Infections in our NICU
Anne Reeths, RN, MS - Infection Preventionist, Aurora BayCare
Medical Center
Issue: Our 22 bed level III NICU opened in 2003. Our first two
years of data show an increase in central line associated blood stream
infections (CLABSI) rates in the <1000 gram infant population.
Our root cause analysis identified several challenges. First, we
reviewed each central line and discovered the longer the central line
was in place the more likely the patient would develop an infection.
This review also showed the most common organism causing the
infections were coagulase-negative Staphylococcus species. Secondly,
we noted inconsistent central line practices that included insertion
techniques and line maintenance. Finally, we wanted to determine
if our team was employing current evidenced based best practice in
this unique population. Our primary goal was to be current with
recommended practice models and target zero CLABSIs in our unit.
Project: In 2005, a multidisciplinary team, including Physician
Champions, Nursing, Infection Prevention, and Nursing Education
introduced the collaborative concepts to nursing staff and set short
and long term goals. The initial meeting focused on practice changes
and implementation. An education curriculum was created focusing
on hand hygiene, central line access, central line maintenance and
aseptic technique. Data, including hand hygiene compliance, line
days and infections are reviewed monthly and shared with the unit.
Results: Practice changes include updating unit based policies,
transformation of the line care, and implementation of Vancomycin
locks to any patient with a central line. The NICU celebrated 613
days without a CLABSI, see figure 1. Although we acknowledge
our success, we have opportunities for improvement. Lessons
Learned: Since focusing on this initiative, we have strived to
implement evidence based practices at the neonatal bedside. With
administrative support and staff involvement, the multiple changes
that occurred with the unit have been embraced. The culture of
the unit evolved into one of accountability and safety. Milestones
are celebrated and suspected infections analyzed. The NICU team
understands the importance of making quality improvement at the
bedside a part of everyday practice.
41
Activity of Dynamic Concentrations of Silver
and Chlorhexidine Against Common Bacterial
Pathogens
Ben Luchsinger - Senior Scientist, Bacterin International
Background/Objectives: Silver and chlorhexidine are
incorporated into medical devices to prevent device associated
infections. While minimum inhibitory concentrations (MICs) and
standard kill curves have been measured for fixed concentrations
of each antimicrobial, the effect of the concentration of the
antimicrobial increasing over time by eluting from a medical
device is not widely understood. Performing this type of analysis
would not only determine the relative sensitivity and killing
kinetics between various bacteria but also provide insight into the
specific pharmacokinetic of kill. Using a silver and chlorhexidine
containing needleless IV connector (NC), we examine the effect of
a dynamically increasing antimicrobial concentration against eight
common pathogens. Methods: The septum of a NC [InVisionPlus® CS™ (RyMed Technologies Franklin, TN)] that is incorporated
with silver and chlorhexidine using a proprietary method [Bacterin
International Inc. (Belgrade, Montana)] was used to evaluate the
relative sensitivity of eight bacterial pathogens. A 10 μL solution
containing approximately 10^6 colony forming units (CFU) was
placed on the surface of the septum. Killing kinetics were determined
at 10, 20, and 30 minutes by vortexing the septa in saline and plating
appropriate dilutions on permissive media. Log reduction was
calculated for each time point. Results: S. epidermidis was the
most sensitive to the silver chlorhexidine co-treatment demonstrating
a four-log reduction in 10 minutes. K. pneumoniae and E. coli were
second most sensitive showing a four-log reduction in 20 minutes. A.
baumannii, S. aureus, and MRSA each showed a four-log reduction
and P. aeruginosa showed a two-log reduction in 30 minutes. The
least sensitive was E. faecalis showing a one-log reduction in 30
minutes. Interestingly, comparing the killing kinetics demonstrated
that some bacteria (K. pneumoniae, E. coli, A. baumannii, and S.
epidermidis) displayed a large kill at a discrete time point while
other bacteria (A. baumannii, S. aureus, MRSA, and E. faecalis)
displayed more smooth time-dependent killing over the course of the
experiment. Conclusions: This study not only determines the
relative sensitivity and killing kinetics of eight different pathogens
by dynamic concentrations of silver and chlorhexidine but also gives
valuable insights into the pharmacokinetics of kill. This data should
be considered to aid future design efforts of antimicrobial containing
medical devices and provides insights into bacterial physiology.
Comparison of Antimicrobial Needleless I.V.
Connectors in a Septum Contamination Assay
Helena M. Lovick, PhD - Research Scientist, Bacterin International,
Inc.; Mark Schallenberger - Scientist/Project Manager, Bacterin
International Inc.; Ben Luchsinger - Senior Scientist, Bacterin
International; Todd R. Meyer - Director of Research and
Development, Bacterin International, Inc.
42
Background/Objectives: To counteract the increase
in CABSIs that accompanied the introduction of needleless IV
connectors (NCs) in the 1990s, several companies have begun to
incorporate an antimicrobial agent into the NC. We have recently
reported a highly relevant in vitro assay for determining the
effectiveness of antimicrobial NCs in reducing contamination on the
NC’s environmentally exposed septum. Herein we report the in vitro
activity of five antimicrobial NCs against eight relevant pathogens.
Methods: Five commercially available antimicrobial NCs were
examined in the present study along with their corresponding nonantimicrobial twin [InVision-Plus® CS™ (RyMed Technologies Inc.,
Franklin, TN), V-link® (Baxter Healthcare Corporation, Deerfield,
IL) Max Guard ™ (Medegen, Ontario, CA), Antimicrobial Clave®
(ICU Medical, San Clemente, CA) and Ultrasite® Ag (B. Braun
Medical, Bethlehem, PA)]. Contact contamination was simulated
by pipetting a 10 μL solution on top of the NC’s septum containing
approximately 106 colony forming units (CFU) of the following
clinically relevant organisms: A. baumannii, E. coli, K. pneumoniae,
MRSA, P. aeruginosa, S. aureus, and S. epidermidis. After one hour,
CFU were determined by vortexing each NC in saline and plating
appropriate dilutions on permissive agar media. Log reduction was
calculated by comparing CFU counts to the NC’s respective nonantimicrobial twin. Results: Of the five NCs examined, only one
displayed measurable antimicrobial activity under the conditions
employed (P<0.05). It reduced contamination on the exposed surface
by at least three logs for all bacteria tested compared to its nonantimicrobial twin. The other four NCs provided a complete recovery
of the total surface contamination and showed no measureable
reduction in the CFU compared to their non-antimicrobial twin.
Conclusions: As septum contamination has been implicated
as a source of CABSI associated with NCs, we sought to compare the
antimicrobial NCs an in vitro assay to replicate the contamination
they may face in the health care environment. While the in vitro
reduction in contamination of one antimicrobial NC is clearly
demonstrated herein, the clinical efficacy of this treatment strategy
has not been established and future work is needed to relate this, or
other, in vitro assays with clinical data.
Micro-Patterned Surfaces for Reducing Biofilm
Formation in an Endotracheal-Tube-Like
Environment
Matthew G. Hoffman - Microbial Research Associate, Sharklet
Technologies Inc.; Rhea M. May - Microbial Research Associate,
Sharklet Technologies Inc.; Shravanthi T. Reddy - Director of
Research, Sharklet Technologies Inc.
Background/Objectives: Pneumonia is the second most
common Hospital-Acquired Infection (HAI) in the U.S. and is a
leading cause of death due to HAI. Ventilator-associated pneumonia
(VAP) is one of the leading HAIs in Intensive Care Units (ICUs)
and accounts for 86% of nosocomial pneumonia cases in hospitals.
A particularly troublesome aspect of VAP is the rise in antibiotic
resistant strains of bacteria causing late-onset VAP infections. There
are currently no definitive methods to prevent late-onset VAP,
which will likely involve combining several approaches that can
work synergistically. This study presents a unique non-kill, physical
surface modification for inhibiting biofilm growth without the
use of antimicrobial agents. This biomimetic micro-pattern has
previously demonstrated reduced colonization for several species of
microorganisms in vitro. The objective of this study is to evaluate
in vitro the ability of a micro-patterned silicone surface to inhibit
Staphylococcus aureus (ATCC 29213) biofilm formation after four
days of biofilm growth. Methods: Silicone coupons with the
micro-pattern (Figure 1), with smooth silicone coupons as controls,
were sterilized and then inoculated with S. aureus (ATCC 29213)
for four days in nutrient rich growth media with and without
2g/L mucin at 37˚C to allow for biofilm formation under static
conditions. Samples were then rinsed with diH2O to remove
planktonic organisms, and the remaining attached cells were fixed
with glutaraldehyde. Biofilm formation was assessed by confocal
microscopy (Zeiss LSM 510 microscope) using propidium iodide
stain, followed by analysis for biofilm area and volume coverage.
Results: The micro pattern demonstrated an 84% reduction
(n = 4, p = 0.06) in S. aureus biofilm formation over four days of
growth on 16mm silicone coupons in TSB (Figure 2), and an 89.5%
reduction (n = 3, p = 0.27) in the presence of 2g/L mucin (Figure
3). Conclusions: The physical surface modification afforded
by the micro-pattern texture inhibits biofilm formation of S. aureus
(ATCC 29213) in standard microbial growth conditions and in the
presence of mucin. The results of this study suggest that the use of
this micro-pattern on an endotracheal tube surface could be useful
for controlling ventilator-associated pneumonia.
A Novel Chlorhexidine Hydrogel Coating for
Peripheral Venous Catheters
Todd R. Meyer - Director of Research and Development, Bacterin
International, Inc.; Mark Schallenberger - Scientist/Project
Manager, Bacterin International Inc.
Background/Objectives: Peripheral intravascular
access devices are the most commonly used medical device in
with 150 million used annually in North America alone. With an
infection rate of 0.5% these devices contribute to approximately
750,000 infections each year creating a sizable health and economic
burden. To potentially mitigate this public health concern, we
present preliminary results for a novel biocompatible, lubricious,
chlorhexidine containing hydrogel coating for peripheral venous
catheters (PVCs). Methods: The chlorhexidine hydrogel
coating is applied to PVCs using a proprietary process developed
by Bacterin International Inc. The coated PVCs were tested
for antimicrobial activity using an in vitro infection model.
Additionally, repeat zones of inhibition were monitored by
transferring the devices from plate to plate for three days. The
lubricating properties of the coating were measured using a
validated assay. Lastly, biocompatibility was evaluated through
cytotoxicity and hemolysis testing. Results: The hydrogelcoated PVCs generated a greater than 4 log reduction of colony
forming units in the in vitro infection model against all clinically
relevant pathogens examined. The coating also continued to
produce sizable zones of inhibition (> 5 mm) for at least three
days. The coated PVCs required significantly (P > 0.05) less force
to insert though an elastomeric membrane than the non-coated
device demonstrating the lubricating properties of the coating.
Additionally, preliminary results suggest that the coating is
biocompatible by producing negative results in cytotoxicity and
hemolysis testing. Conclusions: As peripheral venous access
devices contribute to an estimated 750,000 device related infections
annually in North America, we sought to test a novel chlorhexidine
containing hydrogel coating for PVCs. Here in we report the
promising antimicrobial, lubricative, and biocompatibility results
of coated PVCs. While the in vitro antimicrobial activity is clearly
demonstrated, the clinical efficacy of this treatment strategy has not
been established and future work is needed to relate these in vitro
assays with clinical data.
43
Our Journey to Zero: Preventing Central Line
Associated Bloodstream Infections in the Pediatric
Intensive Care Unit
Prevention of Central Line Associated Bloodstream
Infections by Implementation of Central Line Bundle
Beth Rhoton, RN, MS, CIC - Infection Preventionist, MUSC
Medical Center; Linda Formby, RN, BSN, CIC - Manager,
Infection Prevention and Control, MUSC Medical Center
Issue: The mean rate of central line associated bloodstream
infections (CLABSI) in our PICU from November 2007 through
October 2009 was 6.4/1000 central line (CL) days, even after
putting IHI’s central line placement bundle into practice. In 2009
we recognized this was a serious problem. Project: Our pediatric
intensive care unit (PICU) is an 11-bed medical/surgical critical care
unit in a university hospital setting that admits infants, children and
adolescents who require concentrated and continuous medical care
not available on general inpatient units. For treatment and supportive
care these patients require a variety of intravascular (IV) lines,
frequently placed in femoral sites for extended periods of time. We
recognized the need to address more than line placement to prevent
BSI. We looked at NACHRI’s multicenter PICU project progress
in BSI prevention through standardizing line care and maintenance
(LCM). When our Medical Center’s Infection Prevention and
Control (IPC) Department organized a team to customize an
intravascular (IV) LCM bundle, key PICU nursing personnel joined
the effort. A customized IV LCM bundle based on CDC and INS
bloodstream infection (BSI) prevention guidellines was developed by
the hospital’s Zero BSI team. Mandating education of CL insertion
and LCM bundles in the PICU was not enough. When the hospital
committed to participating in the national Stop BSI project, the
PICU volunteered and a multidisciplinary unit-based team was
organized to eliminate CLABSI. Patient safety became part of the
unit culture. Unit champions were identified and empowered. Medical
and nursing staff were engaged. A daily patient goal sheet was put into
practice. Line care audits were started. Days and then months since the
unit’s last CLABSI were counted. Results: This multidisciplinary
project resulted in nearly 97% reduction in CLABSI with a mean
rate of 0.2/1000 CL days from November 2009 to November 2011
while decreasing the number of CL days. Using SHEA’s published
estimates that each CLABSI has an 18% fatality rate, costs $36,000 to
treat, and increases length of stay an average of 13 days, we calculated
an expected number of CLABSI. Based on our baseline rate, the
PICU’s CLABSI prevention program has saved an estimated 3 or
4 lives, $756,000 in patient charges, and 273 days of unnecessary
hospitalization. Lessons Learned: We learned that CLABSI
prevention requires a standardized continuous multidisciplinary
effort. It involves creating a culture of safety. Frequent monitoring and
regular reports of bundle audits and infection rates to maintain staff
interest and engagement are needed. Active participation and visible
involvement of the IPC Department in the process is important.
Administrative support is essential. All of these have helped our PICU
change what is possible in CLABSI prevention.
44
Muhammad Yaseen, RN, BSN, MS, CIC - Infection Control
Coordinator, King Abdulaziz Medical City Jeddah Saudi Arabia;
Abdulhakeem Al Thaqafi - Associate Executive Director Infection
Prevention and Control, National Guard Health Affairs; Fahad
Hameed - Deputy Chairman Critical Care Unit, King Abdulaziz
Medical City Jeddah; Medhat Lamfon - Infection Control
Coordinator, King Abdulaziz Medical City Jeddah; Areej Qudsi Infection Control Practitioner, King Abdulaziz Medical City Jeddah
Issue: The prevention of central line infections is of paramount
importance due to its impact on patients as well as the hospitals
resources. The IHI (Institute of Healthcare Improvement) bundles
have already been proven to reduce healthcare associated infections
and team work to ensure its compliance helps even more to prevent
healthcare associated infections. This project was carried out in
ICU patients with one or more central lines in place. Project:
In January 2008, a multidisciplinary team was convened to work
together and come up with prevention strategies to reduce the rate
of Central Lines Associated Bloodstream Infections (CLABSI) in
a 22 bed Medical and Surgical ICU. The team adopted “Central
line Bundles” by the IHI (Institute for Healthcare Improvement)
to review the practices that can have an impact on the CLABSI
rate. These practices included: 1. Hand hygiene prior to insertion
2.Maximal barrier precautions, 3. Chlorhexidine skin antisepsis, 4.
Optimal catheter site selection, with subclavian vein as the preferred
site for insertion. 5. Daily review of line necessity with prompt
removal of unnecessary lines. The surveillance for the rate of CLABSI
also continued simultaneously. The assigned Infection Control
Practitioner, who also acted as the coordinator for the CLABSI
Prevention team, monitored the whole process of surveillance
activity including “Central Line Bundle”. The data was collected
on a daily basis by the Infection Control Practitioner with the
help of other team members e.g. Nurses, Physicians. The data was
analyzed quarterly and presented to the concerned areas and in the
Infection Control Committee meetings. The CLABSI prevention
team meetings were held regularly to discuss the overall progress.
Results: The rate of CLABSI in the first quarter of 2008 was
2.8/1000 central lines days. The overall rate of CLABSI in the year
2008 and 2009 was 2.0 and 2.8/1000 device days respectively. The
overall rate of compliance to Central line Bundle in 2008 and 2009
was 37% and 83% respectively. The real reduction in the rate of
CLABSI was achieved in 2010 and 2011 when the CLABSI rate
dropped to 0.7 in 2010 and 1.2/1000 device days in 2011. The
compliance rate to Central Line Bundle increased to 98% in both
2010 and 2011 which is clearly reflected in the decreased in the rate
of CLABSI from 2.0/1000 device days in 2008 to 1.2/1000 device
days in the year 2011. Lessons Learned: The major lesson to
be learnt was that consistency pays at the end. The team had quite a
few challenges in implementation and compliance to the bundles in
the beginning but with the dedication of the whole team, desirable
results were achieved. Although this is a significant achievement
but more hard work is required to bring the rate down to zero for a
prolonged period.
Targeting Zero Central Line Associated Blood
Stream Infection: Innovative Prevention Initiatives
Toward Desired Outcomes
Debi A. Hopfner, RN, BSN, CIC - Infection Preventionist, St.
John Hospital and Medical Center; Janice Rey, MT (ASCP), CIC
- Manager Infection Prevention, St. John Hospital and Medical
Center; Mohamed Fakih, MD, MPH - Medical Director Infection
Control Department, St. John Hospital and Medical Center
Issue: The risk of developing a central line-associated bloodstream
infection (CLA-BSI) depends on a variety of factors such as insertion
technique, length of catheterization, location of catheter, and line
management. Comparing our present rate of CLA-BSI to 2004, we
successfully lowered our rates, but have yet to reach our goal of zero
infections. Intensive review of the infected cases revealed that the
majority developed after one week of placement—indicating a line
management issue, rather than insertion technique. Project:
Our infection prevention team implemented a bundle of strategies
to improve central line management in our 60-bed adult teaching
intensive care units (ICU). We educated ICU staff on central line
placement, management, and proper “scrub the hub” technique. We
administered identical tests both before and after the educational
sessions to assess immediate knowledge gain. Results were shared with
the staff. We conducted monthly central line maintenance audits,
and fed back results to the ICU nurses. The infection prevention
team performed a critical care event analysis on each CLA-BSI,
describing all pertinent details, and forwarded a comprehensive
report to ICU management, staff, and program directors. Upon
identifying a CLA-BSI, we also mailed an informational letter to
the line-inserting physician and the corresponding medical director.
To optimize the educational experience, we implemented a handson, mobile “Training on Wheels” unit. The education focused on
early assessment of central line necessity and prompt removal of
unnecessary lines. The in-service also promoted lower- risk catheters,
such as peripherally-inserted central venous catheters (PICC). We
implemented the National Kidney Foundation’s guidelines for
best practices to address femoral dialysis catheters. All short-term,
uncuffed catheters (especially from the femoral site) were to be either
discontinued or changed to long-term, cuffed catheters within one
week of use. We developed an algorithm to assist nurses in femoral
catheter removal decision making. For every identified infection, we
held ICU team debriefings to assess opportunities for improvement.
Results: Incidence of cases of CLA-BSI was used as an outcome
measure of improvement. Since our initiatives 2006 (n=23) - 2011
(n=8) we have sustained a continuous reduction in our CLA-BSI,
providing an average rate of one CLA-BSI/1000 central line days for
our combined ICU’s. The total number of CLA-BSI did not reach
our target of zero: however lower risk catheters (PICC’s) account
for the majority of our CLA-BSI cases. Hands-on education did
improve central line maintenance and knowledge. A collaborative,
ongoing educational process (e.g., team debriefings), however, is
required to maintain this knowledge and the success of the initiatives.
Lessons Learned: The Infection Prevention and ICU
teams must collaborate completely to reduce risk and reach a goal
of zero infections. A multidisciplinary team approach with 100%
accountability for all participants provides an opportunity to address
CLA-BSIs outside of a standardized surveillance approach.
Reduction In Duration Of Post-Operative Catheter
Use Following Imiplementation Of An Electronic
Reminder System
Patricia Emmett, MS, RN, CIC - Infection Prevention Coordinator,
Issue: The risk of catheter-associated urinary tract infection
(CAUTI) increases each day that the indwelling urinary catheter
remains in place. Reduced duration of indwelling urinary catheter
use is an important strategy to reduce CAUTI. Through process
measurement, we determined that we had poor compliance with
prompt removal of indwelling urinary catheters from surgical
inpatients. Project: Our private non-profit community nonteaching 166 bed acute care California hospital serves medicalsurgical, oncology, family birthing, level II nursery, and critical care
including open heart surgery patients. 799 Surgical Care Improvement
Project (SCIP) procedure cases were studied for this project and
included total hip and knee replacements, abdominal hysterectomy,
vascular cases, colon cases, coronary artery bypass graft cases, and other
cardiac surgery cases, e.g. valvular surgery. Our project aim was to
measure and improve compliance with removal of indwelling urinary
catheters from the selected population on post-operative dayone
or two. Data collection began in quarter 4, 2009 and continues to
date. Education was provided to physicians in an online physician
newsletter, Bruits and Murmurs. Education was provided to nurses
in to online venues, The Nursing Newsletter and NetLearning
Infection Prevention, at the start of quarter 1, 2010. An electronic
reminder to orthopedic and general surgeons was implemented in
the patient’s computerized medical record at the start of quarter 2,
2011. Compliance was determined prior to intervention (data quarter
4, 2009), after education the following quarter (data quarter 1-4,
2010; and quarter 1, 2011), and again after an electronic reminder
system was implemented in quarter 2, 2011 (data quarter 2-3, 2011).
45
Results: 1) Compliance with removal of indwelling urinary
catheters from the selected population on post-operative day one or
two, without any intervention, was 47.1% (104 surgical procedures).
2) Compliance after education rose from 47.1% to 64.3%, and fell to
approximately 50.0% for a sustained period (486 surgical procedures).
3) Compliance after use of the electronic reminder reached 81.0%
after two quarters (209 surgical procedures). Lessons Learned:
1) An electronic reminder displayed to the orthopedic and general
surgeons when opening the patient’s electronic chart provided the
greatest improvement from 47% baseline compliance to 81% postintervention compliance. 2) Expanded use of this method beyond the
SCIP cases may further reduce the risk of CAUTI. 3) Continue to
integrate education to involve nurses in best practices during catheter
insertion, maintenance, and working in an advocate role for patient
safety from infection.
units, with no unit having more than 2 cases. No other commonly
identified sources of CDI transmission were identified. PFGE
testing of all 7 isolates revealed only two of the cases were considered
related: one CO-HA and a subsequent hospital acquired, hospital
onset case on the same unit. The working hypothesis was that
low-level contamination of the environment affected only the most
susceptible population: the severely immunosuppressed oncology
patients. The increased incidence was resolved by implementing
control measures commonly used during any increased incidence
of CDI on all GCH areas, inpatient and outpatient: scrupulous
attention to environmental cleaning including use of UV irradiation
of rooms, and enhanced infection prevention measures. The month
after the increased incidence was identified, the hospital-acquired
CDI rate fell to 0 identified cases, and the median rate for CDI
for the GCH from August-December 2011 was 5.7/1000 pt days.
Conclusions: Clusters of CDI in the pediatric population
have not been well described in the literature. Increased incidence of
CDI among hospitalized pediatric patients is only beginning to be
reported. This case report mirrors reported experiences with CDI in
pediatric population, and provides new information to guide further
research into the pediatric experience with CDI. Conclusions: 1.
Immunosuppressed pediatric patients are at increased risk for CDI. 2.
CDI may affect a population, not necessarily a geographic location.
Surveillance data collection should consider adding service to data
points (not currently required for NHSN surveillance). 3. Pediatric
populations are not immune to CDI, and more research is needed for
this patient population.
Canaries in a Coal Mine: A Case Report of Increased Incidence of
Clostridium Difficile in a Pediatric Oncology Patient Population
Melissa Z. Bronstein, RN, MPA, CIC - Infection Preventionist,
Strong Memorial Hospital, University of Rochester Medical Center
Background/Objectives: The Golisano Children’s
Hospital (GCH) at Strong Memorial Hospital at the University
of Rochester in Rochester NY provides tertiary care to over 3000
patients each year, including 165 pediatric oncology patients each
year. In July 2011, the incidence of C. difficile infection (CDI) in the
GCH rose from an average 9.3/1000 pt days (n=3) to 25.7/1000
pt days (n=9). Methods: Cases were reviewed for previous
admissions, date of current admissions, onset of CDI, and category of
CDI using standard National Healthcare Safety Network (NHSN)
criteria. Chi square analysis was used to compare CDI rates between
oncology and non-oncology patient populations. PCR and PFGE
testing was done at New York State Dept of Health laboratories.
Results: Investigation of the cluster revealed that of the 9 cases
of CDI identified during the time period, 7 were on the oncology
service. Attack rate for the oncology service was 4.2% versus 0.63%
for the non-oncology pediatric population (Chi square=89.03, p<
0.001). Of the 7 oncology CDI cases identified, 6 were community
onset, hospital acquired (CO-HA), as described by NHSN criteria.
Atypical of most CDI investigations, location appeared not to be a
factor in this outbreak, as cases were attributed to 3 of 5 pediatric
46
Differentiating Infection from Inflammation after
Total Knee Arthroplasty
Crystal R. Heishman, RN - Surveillance, University of Louisville
Hospital
Issue: Each year, approximately 15% of Healthcare Associated
Infections (HAI) are reported as Surgical Site Infections (SSI).
SSI, according to The Center for Disease Control and Prevention
(CDC), is the third most reported HAI. SSI is reportable up to 30
days after a non-implant procedure. This is increased to one year
in surgeries such as Total Knee Arthroplasty (TKA) secondary
to the implant. Criteria used in determining SSI include: pain,
erythema, fever, tenderness, edema, purulent drainage, deliberate
reopening by the surgeon, non-cultured or culture positive,
or SSI diagnosis by the surgeon. A complication that may go
unrecognized is pseudogout. Pseudogout is a condition in which
calcium pyrophosphate crystals that form in the cartilage migrate
to the synovium of a joint, thus causing inflammation. Symptoms
of pseudogout include: pain, stiffness, tenderness, erythema, heat,
fever, edema, and fatigue. The knee is most often affected, with a
higher incidence noted in men greater than age 50. Manipulation of
the cartilage during TKA allows crystals to break free and migrate
into the synovium. The inflammatory response mimics SSI, with
the exception of purulent drainage, and misidentification can result
in non-therapeutic treatment. Project: A literature review was
conducted utilizing multiple search methods to determine whether
TKA post surgical issues, such as infection and inflammation, could
Poster Abstracts: Emerging and Reemerging Infectious Diseases
be differentiated utilizing criteria in a way that eliminates unnecessary
surgical interventions, procedures, and inappropriate antibiotic
use. Results: Extensive literature reviews revealed limited topic
information. Differentiation of infection versus pseudogout is
currently determined through physical assessment, medical history,
risk factors for gout and pseudogout, and the inflammatory markers
C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate
(ESR). Additional diagnostics include procalcitonin levels and
joint aspiration for gram stain and crystals. Procalcitonin usage for
infection identification, while demonstrating success, is currently
in its infancy stages. In addition, early research suggests utilizing
Neutrophil CD64 to aid in earlier identification of pseudogout.
Empiric antibiotic therapy and irrigation of the wound and/or
joint prior to microbial confirmation are still common practices
among Orthopedists. Lesson Learned: Purulent drainage
is a physical marker for infection. CRP and ESR are not reliable
confirmatory markers as they tend to be elevated in both infection
and inflammation. Procalcitonin may have a better predictive value
in ruling out infection. The gold standard among orthopedists for
ruling out infection after TKA is aspiration of the joint for gram
stain and crystals. Further research is needed in order to identify and
incorporate new and/or current differential diagnostic methods prior
to surgical intervention and empiric antibiotic therapy.
Emerging And Reemerging
Infectious Diseases
The Effect of Chlorhexidine Gluconate Bathing
on MRSA/VRE Acquisition Rates in Medical ICU
Patients
with a washout period. SETTING: Medical intensive care units at
a 500 bed community teaching hospital. PATIENT SELECTION:
Phase I: Pts admitted to the medical ICUs received routine daily
soap and water baths. After a washout period, Phase II began: Pts
were bathed using 2% CHG impregnated no-rinse cloths following
a standardized protocol. Pt inclusion for analysis required a medical
ICU length of stay > 72 hours and obtaining admission and
discharge (A/D) MRSA nasal and rectal VRE surveillance cultures
(SC). Pts with a previous history of either organism or positive
admission cultures were excluded. LABORATORY TECHNIQUE:
MRSA AND VRE SURVEILLANCE CULTURES – Nasal swabs
for MRSA and rectal swabs for VRE were collected using culturettes
and plated on selective media. BATH BASIN CULTURES: 12 bath
basins use for 72 hours on patients in Phase 1 were cultured using
standard methods. DATABASE DEVELOPMENT and PATIENT
VARIABLES COLLECTED: An Access database that included pt
demographics, A/D information from the medical ICUs, MRSA and
VRE A/D SC results with corresponding dates, number of CHG
baths completed, body mass index (BMI) and Acute Physiology and
Chronic Health Evaluation (APACHE) IV scores, length of stay
(LOS), history of diabetes, hemodialysis, and use of a fecal collection
system was created. STATISTICAL ANALYSIS: Fisher’s exact two
tailed test was used for analysis of categorical data. Mann Whitney U
test was used for continuous data. RESULTS: 667 pts were enrolled
in Phase I, 549 were excluded with LOS < 72 hours or incomplete
A/D SC. Of the remaining 118, 76 pts were naive for MRSA and
79 were naive for VRE on admission. For Phase II, 421 pts were
enrolled, 299 were excluded with LOS < 72 hours or incomplete
A/D SC. Out of the remaining 122, 71 pts were naive for MRSA and
72 were naive for VRE on admission. Only 3 pts in Phase I and 2 pts
in Phase II acquired MRSA in the ICU (p = 1.0), further analysis
of MRSA was not done. VRE was isolated from 50% of bath basins
cultured. 17 pts in Phase I and 11 pts in Phase II acquired VRE in
the ICU (p = 0.4). Data for Phase II VRE cohort are described in
Table I. CONCLUSIONS: Our data did not support using CHG
towellettes in our medical ICU population to reduce acquisition of
MRSA or VRE.
Carla V. Hannon, RN, MS, APRN, CCRN - Clinical Nurse
Specialist, Critical Care, Hospital of Saint Raphael; Diane G.
Dumigan, RN, BSN, CIC - Infection Preventionist, Hospital
of Saint Raphael; Cynthia A. Kohan, MT, MS, CIC - Infection
Preventionist, Hospital of Saint Raphael; JoAnn Sica, BS - Six
Sigma Black Belt and Senior Decision Support Analyst, Hospital
of Saint Raphael; Jacqueline F. Nadeau, M(ASCP) - Manager
of the Microbiology, Serology and Molecular sections of the
Clinical Laboratory, Hospital of Saint Raphael; John M. Boyce,
MD - Hospital Epidemiologist, Hospital of Saint Raphael; Clinical
Professor of Medicine, Yale University School of Medicine
Background/Objectives: Chlorhexidine gluconate
(CHG) towellettes have been reported to prevent colonization
and infection when used for daily patient (pt) bathing in Medical
Intensive Care Units (ICUs). We compared soap and water bathing
to CHG towellette bathing in our medical ICU pts and measured
acquisition of methicillin-resistant Staphylococcus aureus (MRSA)
and/or vancomycin-resistant Enterococcus (VRE). Methods:
STUDY DESIGN: Prospective, multi-phase interventional study
47
Developing an Emergency Department
Tuberculosis Triage Screening
ED TB screening is now mandatory. Documentation of the TB
screening must be completed for every ED patient. Lessons
Learned: A team approach is very beneficial when creating and
implementing a new process.
Erica L. Disharoon, MS, RN, CIC - Infection Preventionist, Shore
Health System
Issue: Our acute care hospital had 199 staff exposures to a patient
that had Mycobacterium tuberculosis. This resulted in two staff PPD
conversions that required treatment. The patient presented with an
asthma exacerbation and was admitted to our hospital. He presented
with shortness of breath, fever, cough and decreased appetite. During
his admission his cough was becoming more productive, increasing
shortness of breath and he required oxygen. On the last day of the
patient’s admission, day 12, a bronchoscopy was performed. Routine
cultures were obtained which included an acid-fast bacilli culture
that grew Mycobacterium tuberculosis. Infection Prevention and
Control (IPC) had an Emergency Room TB triage screening built
into the electronic medical record/documentation system. IPC
did not understand why the patient was not suspected for TB on
admission. When reviewing this case IPC discovered that the ED
staff did not do the TB screening for this patient. It was discovered
that they were rarely completing the TB screening when indicated.
At that time, IPC was requiring patients that present with a cough
be screened for TB. IPC discovered that the ED triage assessment
was very long and the TB screen was one of the last sections on the
assessment. It was also discovered that the screening needed to be
updated and provide more information about TB. Project: The
TB exposure and findings were reported to the Infection Control
Committee (ICC). The ICC wanted a better ED TB screening tool
created. The screening would need to accurately capture suspected
TB patients without causing too many false alarms. A team was
formed that included the Director of Emergency Services, three
Emergency Department (ED) Managers, the ED Clinical Educator,
an Application System Analyst and an Infection Preventionist.
The project was to revise the TB screening in the ED triage
assessment that had already been created in Meditech (an electronic
documentation/medical record software). Results: The TB
screening was revised. The screening was moved to the top portion
of the ED assessment. The risk factors (RF) were listed as primary
and secondary. Primary RF-blood in sputum, cough, fever, night
sweats, unexplained weight loss were given a score of two points
each. Secondary RF-foreign born/foreign travel, HIV, homeless,
immunocompromised and incarceration were given a score of one
each. If the patient’s TB screen total was 5 or more the nurse needs
to initiate airborne precautions. The type of isolation was also moved
up and added to the bottom of the TB screening. When airborne
precautions are documented IPC is alerted electronically. The new
48
Incidence of Klebsiella pneumoniae
Carbapenemase (KPC)-Producing MultidrugResistant Bacterial Infections in a Teaching
Hospital in SouthEast
Farah Bahrani-Mougeot, PhD - Associate Professor, Carolinas
Medical Center; Wendy Strader - Infection Preventionist, Carolinas
Medical Center; Jean-Luc Mougeot - Senior Research Scientist /
Chair Institutional Biosafety Committee, Carolinas Medical Center;
Roger Lovell - Chairman, Infection Control Committee, Clinical
Professor, Carolinas Medical Center
Background/Objectives: Over 1.4 million people worldwide suffer from health-associated infections (HAIs) at any given
time, and over 270 people die each day from these complications.
Compounding the problem is an increase in the emergence of HAIs
caused by multidrug-resistant microorganisms, most commonly by
K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae.
The objective of this study was to assess and compare the rate of
infections with carbapenem-resistant K. pneumoniae at Carolinas
Medical Center (CMC) Main Hospital, an 874-bed teaching
hospital, in 3 recent years. Methods: Data were collected
for 2009 to 2011 in the following adult divisions: Critical Care,
Cardiac, Medical, Surgical, Hematology/Oncology, and Women.
Data were collected from different sources including CMC’s
Infection Control Surveillance database (Theradoc®), CMC’s
Medical Records (Cerner PowerChart®), and CMC’s pharmacy
(Trendstar® software). Data were collected in regard to demographic
characteristics, hospital units, procedure codes, and laboratory
results. A list detailing total doses of all major classes of antibiotics
given over the three years time period were obtained from the CMC
Main Pharmacy Department using The Trendstar® software system.
A list of total admissions, discharges and patient-days for each year
was obtained from our billing records database to calculate total
patient days. The rate of KPC-producing K. pneumoniae infections
were expressed as the number of positive cases per 10,000 patient
days. For study purposes, we defined nosocomial multidrug-resistant
KPC-producing K. pneumoniae infection only if these organisms
were isolated at least 48 hours after admission to the hospital. The
KPC-producing pathogens were identified by the Modified Hodge
Test (MHT), as recommended by Center for Disease Control and
Prevention (CDC). CMC-IRB approval was obtained for data
collection. Results: Our data show an increase in the average
rate of nosocomial KPC-producing K. pneumoniae isolates at CMC
in 2010 and 2011 compared to 2009 (i.e. 1.2 and 1.3, respectively,
vs. 0.3 per 10,000 patient days). This was also the case for the rates
for total isolates (i.e. nosocomial plus non-nosocomial isolates),
which were 0.8, 3.4, and 5.8 per 10,000 patient days for 2009,
2010 and 2011, respectively. On average, approximately 28% of
the multidrug-resistant KPC-producing K. pneumoniae isolates
for were nosocomial (i.e., 0.96 vs. 3.4). Critical Care division had
the highest rate of these isolates. Conclusions: The CDC
requires robust efforts at detection of carbapenemase production
and non-susceptibility in Enterobacteriaceae, especially Klebsiella
spp., in critical care units, with immediate reporting to epidemiology
and infection control departments if identified. Not surprisingly,
we detected a higher rate in the Critical Care division, as patients in
this division receive multiple courses of antibiotics and often have
prolonged hospital stay. Our data show an increase in the rate of
KPC-producing K. pneumoniae isolates from 2009 to 2011.
University; Satya Datla, MBBS - Research assistant, Division of
Infectious Diseases, Wayne State University; Vamsi Kuchipudi,
MBBS - Research assistant, Division of Infectious Diseases, Wayne
State University; Swetha Reddy, MBBS - Research assistant,
Division of Infectious Diseases, Wayne State University; Shobha
Shahani, MBBS - Research assistant, Division of Infectious Diseases,
Wayne State University; Vijaya Upputuri, MBBS - Research
assistant, Division of Infectious Diseases, Wayne State University;
Judy A. Moshos, MT - Epidemiology Practitioner, Detroit Medical
Center; Paul R. Lephart, PhD - Associate Technical Director of
Microbiology, Detroit Medical Center University Laboratories;
Emily Toth Martin, MPH, PhD - Assistant Professor, Department
of Pharmacy Practice, Wayne State University College of Pharmacy
and Health Sciences; Elaine Flanagan, BSN, MSA, CIC - Director
Epidemiology, Detroit Medical Center; Jason Pogue, PharmD Infectious Diseases Pharmacist, Detroit Medical Center; Keith Kaye,
MD, MPH - Corporate Director of Infection Prevention, Hospital
Epidemiology and Antimicrobial Stewardship, Detroit Medical
Center/Wayne State University
Background/Objectives: Extended-spectrum-βlactamase (ESBLs)-producing organisms are increasingly prevalent
worldwide, and pose a serious public threat. Recently, increasing
Current Epidemiology and Clinical Impact of
Extended-Spectrum β-Lactamase-Producing
Escherichia Coli At A Tertiary Medical Center
Kayoko Hayakawa, MD, PhD - Fellow, Wayne State University,
Detroit Medical Center; Dror Marchaim, MD - Post Doctoral
Fellow Infection Control and Epidemiology, Detroit Medical
Center/Wayne State University; Ashish Bhargava, MD - Fellow,
Wayne State University, Detroit Medical Center; Mohan B. Palla,
Medical Center; Khaled Alshabani, MD - Research Assistant,
Wayne State University, Detroit Medical Center; Uma Mahesh,
Center; Harish Pulluru, MBBS - Research Assistant, Wayne State
University, Detroit Medical Center; Pradeep Bathina, MBBS
- Research Assistant, Wayne State University, Detroit Medical
Center; Pranathi Rao Sundaragiri, MBBS - Research assistant,
Division of Infectious Diseases, Wayne State University; Moumita
Sarkar, MD - Research assistant, Division of Infectious Diseases,
Wayne State University; Hari Kakarlapudi, MBBS - Research
Assistant, Wayne State University, Detroit Medical Center; Balaji
Ramasamy, MBBS - Research Assistant, Wayne State University,
Detroit Medical Center ; Priyanka Nanjireddy , MBBS - Research
assistant, Division of Infectious Diseases, Wayne State University;
Shah Mohin, MBBS - Research assistant, Division of Infectious
Diseases, Wayne State University; Meenakshi Dasagi, BDS Research assistant, Division of Infectious Diseases, Wayne State
49
numbers of reports have suggested a change in the epidemiological
characteristics of infections due to ESBL-producing E. coli
(ESBLEC). ESBLEC have increased greatly in frequency and have
been reported more frequently from the community, and have been
associated with high rates of mortality. These clinical observations
might relate to a shift in the dominant type of ESBLs from TEM and
SHV types to CTX-M. Recent reports from North America focused
on ESBLEC are still limited. We aimed to conduct a retrospective
cohort study to describe the epidemiological characters of patients
with recent ESBLEC isolation at a large tertiary medical center.
Methods: All unique cases (inpatients or cases who visited
emergency department) with ESBLEC isolation during the study
period (February, 2010-July, 2010) were included. Positive ESBL
phenotypic tests per the automated broth microdilution system
(MicroScan) were confirmed with disc diffusion tests in accordance
with 2009 CLSI criteria (M100-S19). Modified Hodge Test positive
isolates were excluded. Results: Three-hundred eighty-two cases
with ESBLEC were identified during the study period. The mean
age of the study cohort was 67.6±17.5 years, 159 (42.1%) were male,
249 (66%) were African American. Forty-two (11.2%) patients had
ESBLEC isolation in the emergency department. One-hundred
ninety-three subjects (50.5%) resided in institutions (nursing homes
or hospitals) prior to admission. Epidemiological characteristics
of patients with ESBLEC are summarized in the Table. The most
common anatomic sources from which ESBLEC was isolated
were urine (n=286, 75.1%), wounds (n=37, 9.7%), blood (n=29,
7.6%), and sputum 27 (7.1%). Two hundred ninety-three (77.5%)
of the patients with ESBLEC had pathogens that were present
on admission (isolated from a culture obtained within 2 days of
hospitalization). Antimicrobial exposure occurred in 170 (47.4%)
of subjects and ESBLEC isolates were resistant to multiple classes
of antibiotics in addition to beta-lactam antibiotics (Table). Twenty
patients (5.4%) died in hospital, 41 (13.3%) died within 3 months
after ESBLEC isolation. Three (10.3%) patients with bacteremia due
to ESBLEC died during hospitalization. Conclusions: These
results are consistent with findings from other parts of the world,
which suggest ESBLEC has frequently been present on admission. A
high proportion of study subjects had dependent functional status,
recent exposure to healthcare and indwelling devices. ESBLEC
was frequently resistant multiple classes of antimicrobials. Further
studies focusing on the epidemiological and molecular characteristics
of ESBLEC in the US are needed so that appropriate infection
prevention and antimicrobial strategies can be optimally utilized.
Issue: Measles cases are increasing in the United States. The
incidence of measles cases in 2011 was the highest since 1996.
Two measles outbreaks occurred in Minnesota in 2011, both
linked to index cases who acquired infection in Kenya. A spring
outbreak included 21 cases, and an August outbreak included 3
cases. Children’s Hospitals and Clinics of Minnesota cared for
13 of the 24 cases. Not all cases were recognized as measles at the
time of presentation, resulting in lack of immediate rooming into
Airborne Infection Isolation (AII), thus exposing patients who
required follow-up. Project: Patient exposure follow-up was
conducted upon notification of confirmed measles cases. Exposed
Patient Identification Process: 1) Exposure definition established
based on: • Contagion period (4 days prior/4 days post rash onset)
• Timeframe not in AII • Department(s) exposed • Exposure
timeframe (time of arrival to departure plus 2 hours) 2) Created
exposed patient list 3) Assessed measles, mumps, and rubella
(MMR) immunization status using the state immunization registry
Minnesota Immunization Information Connection (MIIC).
4) Prioritized exposed patient follow-up based on MMR status
(patients who received 0, 1 or 2 doses of MMR) Exposed Patient
Follow-up Process: First Priority (Zero doses MMR): Notified
by phone to return within 6 days of exposure for intramuscular
immune globulin (IMIG). If <72 hrs or > 6 days post-exposure
and patient was > 12 months, provided MMR. Consulted with the
Minnesota Department of Health (MDH) for social distancing
guidance. Second Priority (One dose MMR): Notified by phone
to receive 2nd MMR from primary provider if minimum interval
of 4 weeks from 1st MMR was met. Third Priority (Two doses
MMR): Informed of exposure by phone or letter. All Exposed:
Verified immune status, gave appropriate guidance for persons who
accompanied exposed patient to healthcare facility, and provided
measles education. Results: The majority of exposed patients
(n=788) had some level of protection to measles (32% 2 MMR,
38% 1 MMR). IMIG was administered to 18% (n=38) of the
exposed patients who had zero MMR. 2 of the exposed patients
who were unvaccinated due to parental vaccine refusal and did
not receive IMIG subsequently developed measles. Lessons
Learned: Many pediatric viral illnesses cause symptoms similar
to measles such as fever, cough, conjunctivitis, and rash so it is not
necessarily obvious at initial presentation who is a suspect case.
Achieving immediate isolation in AII is difficult and exposures are
likely to occur. It is essential for cases to be identified and confirmed
as quickly as possible. An established process in place allows
efficient post-exposure follow-up. The limited amount of disease
Measles Outbreak Management at
a Minnesota Children’s Hospital in
2011
Julie LeBlanc, MPH, CIC - Healthcare
Epidemiologist, Children’s Hospitals and
Clinics of Minnesota; Patricia Stinchfield, MS,
RN, CPNP - Director of Infectious Disease/
Immunoloy and Infection Prevention and
Control, Children’s Hospitals and Clinics of MN
50
Poster Abstracts: Environment of Care/Construction/Remediation
transmission at our hospital can likely be attributed to existing
immune protection in the exposed, hospital air handling systems,
and prompt response by Infection Prevention and Control to
contact exposed patients.
Learned: The Ontario provincial guidelines leave significant
room for interpretation within the Infection Control community
contributing to a lack of standardization for facilities implementing
an ESBL program.
Environment Of Care/Construction/
Remediation
Developing An ESBL Program
Safiyya Nazarali, BScN, RN - Infection Control Practitioner,
Woodstock Hospital; Natalie J. Goertz, BScN, CIC - Manager of
Infection Prevention and Control, Woodstock Hospital; Kishori
Naik, BSc. - Infection Control Coordinator, Woodstcok Hospital
Issue: Ontario guidelines recommend that patients found to be
colonized or infected with an extended spectrum beta lactamase
(ESBL) organism should be placed on contact precautions, have
their records flagged and re-screened on re-admission. However,
the duration of precautions depends on each facilities program,
leaving the province varied between facility practice. In our
provincial region, ESBL programs are underdeveloped and many
facilities were resistant to implementing a program. We found
this to be especially challenging because in sharing an Electronic
Patient Record (EPR) system, it becomes difficult to adjust features
specifically for our hospital, coupled with a lack of support for
developing a program outlined in our provincial best practice
standards. Project: Our aim was to develop a program for
our hospital that would be standardized to most programs in
the province. We began by polling hospitals in different regions
compiling practice standards for patients with ESBLs. Of the 10
hospitals polled, 8 initiated contact precautions and had patients
flagged. Although the polled hospitals use contact precautions
not all hospitals are consistent on the length of time a patient is
required to stay in precautions. Additional challenges included
implementation of a patient flag within our regional group,
developing educational material for staff, patients and visitors
and attempting to standardize our hospital policy to provincial
standards. Results: The most significant implementation was a
flag created in the patients electronic records. Consensus with the
regional group took a year and half, created with the provision that
only WGH would be using it. This initiative was significant as it
would keep track of previously positive patients and alert staff to
use contact precautions on re-admission to the hospital. There were
a number of implementations that differed within the province
making standardization difficult; these were screening and duration
of isolation. Majority of hospital programs identified ESBLs
through clinical isolates and did not screen based on risk, both of
which our facility adopted. Finally the duration for precautions
with most facilities was one year. Our program settled on the
de-flagging criteria of after a year of being positive, if patients are
re-admitted to the hospital 3 rectal swabs will be taken one week
apart. If all results are negative, patients will be discontinued from
contact precautions and de-flagged on the EPR. Education played
an important role in implementing the ESBL protocol. Teaching
occurred on the units regarding ESBLs and the new protocol.
Written material was also created as a reference for staff. Lessons
Impact of Equipment with Fans in the Operating
Room
Rosemarie Erlichman, RN, BSN, CIC - Infection Preventionist,
UMassMemorial Medical Center; Richard T. Ellison III. - Hospital
Epidemiologist, UMassMemorial Medical Center; James Sigler
- Vice President, Business Operations, Air Systems Technologies,
Inc.; Lars Erickson - Vice President, Field Operations, Air Systems
Technologies, Inc.
Issue: Proper airflow in health-care facilities can protect susceptible
patients from acquiring disease-causing organisms. In an operating
room (OR), it is even more imperative that airflow patterns be smooth
and non-turbulent. With increasing technology requiring more
equipment in the OR, the question has arisen as to whether fan-less
technology may be beneficial in this setting. To address this issue we
undertook an investigation to determine if there were airflow issues
associated with the use of OR equipment that had built-in fans when
used in the vicinity of an OR table. Project: One OR with a
non-turbulent flow (perforated) supply air diffuser panel system was
surveyed using smoke visualization testing, utilizing theatrical smoke.
A stack of blankets was used to simulate a patient on the OR table.
Testing was performed with cameras capturing airflow patterns located
in thirteen predetermined locations. All smoke visualization testing
was recorded using digital recording equipment. Equipment tested in
this study included: Anesthesia Station, including personal computer
a forced air-patient warming unit (Bair Hugger™) Electrosurgical
Unit Arthroscopic Machine Pyxis™ Anesthesia System High intensity
Light Source Two additional personal computers – One at the
Picture Archiving and Communication System Station and one at the
charting station. Results: The baseline room airflow from a ceiling
diffuser was fairly uniform over the simulated patient, although there
was minor air turbulence in the zone between the inner and outer
sets of supply air diffusers. The operation of one piece of equipment,
the high intensity light source, was found to cause turbulence in the
airflow, but only when the back of the machine, normally positioned
away from the OR table, was re-oriented to face the OR table. The
use of all other pieces of equipment running simultaneously had no
observable effect on the non-turbulent airflow over the OR table.
Lessons Learned: During normal use, the fans within small
computer stations, forced-air warming blankets, electrosurgical units,
and arthroscopic equipment have no impact on non-turbulent/
unidirectional airflow. In general there does not appear to be a need
for the use of fan-less electrical equipment in a well-designed OR
environment.
51
Environmental Hygiene Sustainability - Is It
Possible?
Navigating through the Construction Zone
Sherry R. Reid, RN - Infection Prevention and Control Coordinator,
VA North Texas Health Care System
Issue: Infection Prevention and Control (IPC) Coordinators
understand the importance of environmental hygiene for prevention
of infections, but most will attest to the fact that it is very difficult
to maintain and enforce environmental hygiene. Sustaining
environmental hygiene requires the right cleaning, consistency,
and commitment. Periodic environmental inspections have been
shown to have little effect on the sustainability of environmental
hygiene, and most available checklists fall short at determining the
right surfaces that need cleaning and the right timing for cleaning
to occur. Project: At a large Veteran’s Affairs Medical Center, a
multi-disciplinary team under the direction of an IPC Coordinator
developed a system that has proven effective for sustaining
environmental hygiene. The system included a unique checklist, an
education package, and a mechanism for garnering administrative
support. Items on the checklist are scored based on the frequency of
touch (1-low, 2-medium or 3-high). The checklist also defines the
frequency of cleaning expected and the types of staff responsible for
cleaning. IPC Coordinators conducted on-going training covering
environmental hygiene clinical practice guidelines. Administrators,
managers and staff accompanied the IPC Coordinator semi-annually
in each clinical area to complete environmental hygiene inspections
and record observations on the checklist. The semi-annual inspections
were conducted weekly for a month, and the team reviewed findings
to determine corrective actions for any infractions in environmental
hygiene. Scores were computed from the checklist, and data graphs
were shared with the clinical area staff, IPC Committee, and
administrators. Team inspections and educational classes continued
beyond the scheduled inspection month when scores from any unit
exceeded the expected level. Administrators were held accountable for
providing necessary resources and encouragement for staff to properly
maintain environmental hygiene. Time-series scores analyzed using
statistical process control graphs and Pareto charts were used to isolate
most common areas where environmental hygiene improvements
were needed. Comparisons were made between clinical area scores
and the rate of identified infections. Results: Environmental
hygiene scores improved substantially for all clinical areas but one
during the monthly inspection periods. Ninety percent (90%) of
the clinical areas continued to maintain scores below the cutoff level
between inspection periods. An association was found between the
environmental hygiene scores and the numbers of blood stream and
urinary tract infections. The most common areas where environmental
hygiene failed to be sustained were in non-direct patient care areas.
Scores from each clinical unit were inserted into a risk assessment
grid for determining the amount of IPC involvement with the
clinical area. Lessons Learned: Environmental hygiene is best
sustained when administrative support is apparent. Administrative
decision making is best supported by reliable and valid data. Ongoing
education is essential to ensure commitment on the part of providers
for environmental hygiene.
52
Michelle D. Moseley-Ladell, RN, BSN - Infection Prevention and
Control Coordinator, Veterans Affairs North Texas Health Care System
Issue: Construction can have a profound impact on patient care and
ultimately affect everyone throughout a medical center. The role of the
Infection Prevention Coordinator (IPC) is critical on the construction
safety teams, yet often the functions of the IPC have been limited.
In large facilities where many new and renovation construction
projects are likely to be constantly occurring, it is necessary for IPCs
to become more involved with construction. Project: A project
was initiated at a large Veteran’s Affairs Medical Center to explore
functions for the IPC as an effective consultant on the construction
safety team. A strategic planning approach was used to formulate
the IPC’s consultant role with careful attention given to the annual
construction risk assessment. Goals, outcomes, and activities were
defined in a strategic planning logical framework to direct the IPC
functions. Since the IPC has responsibilities other than management
of construction projects, the amount of time projected for completing
each activity was also carefully considered in formulating the logical
framework. As a consultant the IPC worked closely with the team
and construction safety officer to initiate several improvements such
as weekly rounds of construction sites, checklists for data collection,
and a construction flow chart illustrating the project completion
progress. The IPC conducted ongoing surveillance of organisms
commonly transmitted due to construction. The initial IPC needs
assessment as part of strategic planning indicated a general lack of
knowledge among construction workers and clinical staff regarding
necessary infection prevention measures in construction sites. A
share point site was created so all members of the team could have
real-time access to project management plans, Infection Control Risk
Assessment (ICRA), and check lists. The IPC developed curriculum
plans and began presenting instructional classes for clinical staff
and construction workers to improve compliance with infection
prevention measures. Results: The visibility of the IPC as a
member of the construction team has caused healthcare workers
throughout the facility to quickly share information regarding
infection risks. Numerous deficiencies were identified during weekly
rounds, and the IPC was able to affect project improvements before
problems occurred. No construction related healthcare associated
infections have been identified since the project began. Stakeholder
and credentialing surveyors have reported high satisfaction with the
role of the IPC on the construction team. Lessons Learned:
The IPC role as a consultant with the construction team is important,
but clear delineation must be understood between infection
prevention and safety. When team members and healthcare workers
blend safety issues with the IPC role functions, the time demands
on the IPC can distract from other responsibilities. IPCs involved
with construction must become knowledgeable about a vast amount
of equipment, filtration, and materials specifications. Infection
prevention is greatly enhanced when healthcare workers are better
educated about construction projects.
Infection Prevention and Control Planning for
Development of a New Bone Marrow Transplant
Unit is NOT a Lone Star Production
Elizabeth (Libby) Singhoffer, MPH, BSN, RN, CIC - Infection
Preventionist, UCHealth University Hospital; Catherine Tierney,
RN, BSN - Transplant Coordinator, UC Health University
Hospital; Gregory Braswell, MBA - Division Director-Facilities
Management, UC Health University Hospital; Bradley Beckham Manager Plants and Operations, Electrical/Mechanical, UCHealth
University Hospital; Mark Slye - Director Plant and Operations,
UCHealth University Hospital
Issue: The decision to open a new bone marrow transplant program
in a large tertiary care medical center prompted an extensive risk
assessment by the Infection Prevention and Control Professional.
The risk assessment encompasses guidelines form both subject
matter experts and regulatory oversight agencies such as the Centers
for Disease Control and Prevention (CDC), Association for
Professionals in Infection Control and Epidemiology (APIC) , the
Center for International Blood and Marrow Transplant Research
(CIBMTR), and the American Society of Blood and Marrow
Transplant (ASBMT). The purpose of these guidelines and the
resultant risk assessment is to prevent infection in a high-risk patient
population by decreasing environmental sources of infection through
rigorous planning. Project: A multiphase renovation project in
three separate areas of the hospital, one of which was built initially
in the late 1960’s. The project began with the renovation of two
rooms on an existing hematology/oncology unit. The project also
included renovation of three rooms in the medical intensive care
unit, an area in the emergency department as well as the outpatient
clinic. Another phase included plans for a permanent unit starting
with 6 beds with expansion to 14. Results: A multidisciplinary
team was developed, including representatives from Nursing,
Environmental Services, and Facilities Maintenance. The addition
of these members to the team helped streamline processes as the
project continued and decreased the amount of time spent rewriting
policies and procedures. Mock up rooms were created which allowed
for evaluation of room layout and requirements for air handling, etc.
before the construction plans were finalized. The Infection Prevention
and Control Professional was the key team member providing
communication between departments and monitoring all phases of
the project for compliance. With the involvement of these department
representatives, we were able to instill preventive and functional plans
from the beginning. Early involvement also allowed for continual
input and oversight by each department in the construction stage
and provided open communication between the contractors, heating,
ventilation and air-conditioning (HVAC), maintenance, and
nursing representatives. Lessons Learned: Although there
are guidelines available, there is no published standard operating
procedure for the development of a new bone marrow transplant unit.
The Infection Prevention and Control professional was given the task
of coordinating all aspects of infection prevention for this project. The
development of a multidisciplinary team early in the project consisting
of representatives from design and construction, heating, ventilation
and air conditioning (HVAC), maintenance, environmental services,
nursing and administration contributed to the success of the project.
This process allowed for better design and understanding of the care
and maintenance required after the project completion. Clearly,
Infection Prevention and Control planning for a bone marrow
transplant project is NOT a lone star production.
Construction and Renovations using a Checklist
Tool for Safety: Laborers and Patients
Ruby V. Boychuk, RN, CHN - Infection Control Specialist, Saad
Specialist Hospital, Al Khobar, Kingdom of Saudi Arabia
Issue: Modern technology today is pushing the construction
industry to provide better and safer facilities for the purpose of
diagnosis and treatment of patients either short term or long
term. Safety is the key feature in the construction or renovation of
healthcare facilities. In Saudi Arabia there is a need to expand existing
hospitals to admit and sustain long term care patients as there are
no other facilities available. Project: During the last few years
were were involved in the construction of an oncology center and
now with extensive hospital renovations for Long term Care patients
in an Acute Center. Both construction and renovation have similar
considerations for Interm Life Safety Meaures, and with the use of a
modified OSHA checklist, were are now able to set some standards
that may be considered mundane, howver, has proven necessary as
a tool for safety within our facility. The geography of Saudi Arabia
has been a major challenge for infection prevention and control as
we encountered issues that required us to “go back to basics” and dig
into the literature of science and experience to meet the challenges
with a positive outcome and lessons learned documented to assist in
future projects. Sharing this knowledge and experience with experts
in the field has been a rewarding experience. In this presentation
we will show how the IC Checklist became a major tool for our
inspections. This included temporary construction barriers, air
handling and dust control, removal of debris, traffic control, dress
code, fire safety equipment and interm life safety- personal protective
equipment, hazard communication, utilities interruptions, smoking
policy, asbestos survey, work permits, security surveillance, fire walls,
ceiling closure, and emergency communication. Results: Often
we integrated our findings with Risk Management through the
Occurence Variance System. Identifying the issues corrected many
processing through a root cause analysis was extremely helful in
problem sloving. These issue became part of our IC Risk Assessment
Tool. Lessons Learned: With the use of this tool, we were able
to establish a safer working environment for the laborers. Recognizing
the gaps in the system of closure, the checklist assisted us to be more
aware of wall penetrations, dust, and breaching of barriers. With new
knowledge and application of safety meaures, we have added these to a
revised checklist.
53
Preliminary Assessment: Efficacy of Room
Sanitizing with Controlled Exposure to UVC Light
Stephen Streed, MS, CIC - System Director, Epidemiology and
Infection Prevention, Lee Memorial Health System; System Director,
Epidemiology and Infection Prevention, Lee Memorial Health
System, Ft. Myers, FL; B. Joann Andrews, RN, MS, CIC - Senior
Infection Preventionist, Lee Memorial Health System; Alexis Price,
RN, BSN - Infection Preventionist, Lee Memorial Hospital; Cynthia
Knoke, MT, BS, CIC - Infection Preventionist, HealthPark Medical
Center; Elizabeth Houser - Manager, Environmental Services, Lee
Memorial Hospital
Background/Objectives: Background: The study locale
is a 355-bed acute care hospital located in Southwest Florida. Major
service lines include medical and surgical/trauma intensive care units
as well as extensive orthopedics, neurosurgical, oncology, general
surgery and internal medicine services. Because of the seasonal nature
of the service demographic, demand for rapid room turnover often
results in compressed discharge to admission-ready intervals. Using
methods similar to those described below, our previous work has
demonstrated incomplete bioburden reduction resultant from the
standard cleaning protocols as performed by Environmental Services
(ES). This study was designed to evaluate the affects of post-cleaning
ultraviolet light C (UVC) exposure on total bioburden reduction.
Methods: Study Methods: Study rooms were selected based on
their availability as determined by ES, with rooms excluded only if
they had been treated with UVC at any time within the previous 7
days. Once selected, 6 standardized “touch points” were quantitatively
cultured by an Infection Preventionist using standard RODAC plates
and ES was then allowed to proceed with room cleaning. Following
cleaning, 6 more samples were collected in the same manner at sites
immediately proximal to the original 6 sample sites. The room was
then treated with exposure to a UVC light source (V-360º, UVDI)
with UVC exposure times standardized at 10 minutes in the bathroom
and 30 minutes in the main portion of the room. For control purposes,
a small portion of one of the touch points was screened from the
UVC source in order to evaluate the time-effect of residual germicide
left on the surface. Following treatment, 6 additional samples plus
the control were collected, again in areas immediately proximal to
previous collection sites. Results: Results: Samples were
obtained from 13 rooms as described above and quantitatively read
by a laboratory technologist unaware of the source or sequence of
the samples. Average CFU’s per plate were as follows: Pre-cleaning =
29.4, post cleaning = 8.8, post-UVC treatment = 1.7 and controls =
2.8. Paired t-tests indicated significant reductions from pre-to post
cleaning (p < 0.0001), post cleaning to post UVC treatment (p =
0.0009) and of course pre-cleaning to post-treatment (p < 0.0001).
There was no statistical difference between post-UVC treatment
counts and control counts. Conclusions: Conclusions: These
data indicate a persistent and statistically significant downward trend
in average CFU’s per plate as cleaning progressed from before ES
cleaning through final treatment with UVC exposure. Because of the
similarity of post-treatment versus control results, it is unclear if the
CFU reductions observed post-treatment were the result of the UVC
exposure, the residual effect of the germicide left on the surfaces, or a
combination of the two processes. While the average CFU’s post-
54
treatment was slightly lower (1.7/plate versus 2.8/plate for controls)
this comparison is underpowered since relatively few control samples
were collected. Further research and a modification of the sampling
plan to discriminate between the germicidal effects of the liquid
cleaning compounds and UVC light exposure is needed to fully
demonstrate the efficacy of this re-emerging technology.
Microbial Load of Reusable Cleaning Towels used
in Hospitals
Laura Y. Sifuentes, MPH - PhD Candidate, University; Peter K.
Raisanen III., Bachelor of Science - research fellow, University of
Arizona
Issue: Hospital cleaning practices play a critical role in the
prevention of nosocomial infection transmission. To this end,
reusable towels soaked in disinfectants are commonly used to clean
and disinfect hospital surfaces. There are reports linking reusable
cleaning towels to the outbreak of Bacillus cereus. Furthermore, it is
known that reusable towels can interfere with the action commonly
used quaternary ammonium (QAC) disinfectants. It is therefore
important to understand if reusable towels can increase the risk for
the transmission of pathogens in the hospital. The objective of this
study was to investigate the prevalence bacteria and fungi in reusable
cleaning towels. Project: The microbial load in reusable hospital
towels was determined and the findings correlated with hospital
cleaning practices. Ten hospitals were surveyed regarding their
cleaning practices after terminal discharge and the use of disinfectants.
Laundered reusable cleaning towels were collected in triplicate
and evaluated for both the ability of the towel to harbor possible
infectious agents and the effectiveness of laundering procedures. The
buckets used to soak the towels in disinfectants were also sampled.
The towels and buckets were evaluated, using quantitative plate count
methods, for the presence of heterotrophic bacteria, total coliforms,
aerobic spore formers, fungi, Staphylococcus aureus, MethicillinResistant (MRSA) S. aureus, Escherichia coli, and Clostridium difficile.
Results: A majority of towels (93%) sampled were positive for
bacteria. Furthermore, 37.5% of the buckets sampled were positive for
bacteria. The mean number of heterotrophic bacteria found in towels
was 1.7 X 104 colony forming unit (CFU) per towel, while the mean
number of total bacteria found on buckets was 67.2 CFU per bucket.
MRSA and C. difficile were not isolated from any of the sampled
towels or buckets, but interestingly total coliforms were found in both
the towels and buckets. E. coli was found in 23.3% of clean towels.
Lessons Learned: Reusable towels used for cleaning hospital
rooms contain high numbers of microbial contaminants. Hospital
laundering practices in this study appear to be either insufficient to
remove microbial contaminants or even add contaminants to the
towels. Furthermore, towels are known to interfere with the action of
common hospital grade disinfectants, such as QACs. Independently
and together these two factors may increase the risk for transmission
of pathogens in the hospital. Importantly, these observations point
to the need to critically revaluate current hospital cleaning practices
associated use of reusable towels.
The Safety Dance: Establishing a Comprehensive
Safety Program to Ensure Contractor Compliance
James Kerridge, MA, RN, CIC - Infection Preventionist, Advocate
Illinois Masonic Medical Center; Teresa Chou, MPH, CIC Manager - Infection Prevention & Epidemiology, Advocate Illinois
Masonic Medical Center; Katie Wickman, MS, RN - Infection
Preventionist, Advocate Illinois Masonic Medical Center; Steven
Verzi, CHSP - Environment of Care Safety Officer, Advocate Illinois
Masonic Medical Center; Mandavi Kulkarni, MD - Infectious
Disease Attending, Advocate Illinois Masonic Medical Center; James
Malow, MD, FIDSA - Chairman Internal Medicine, Chairman
Infection Prevention Committee, Medical Director Advocate
Healthcare Infection Prevention Team, Advocate Illinois Masonic
Medical Center
Issue: Multiple studies have identified infections due to
construction activities. In the past two years the number of
construction projects, ranging from small aesthetic improvements
to major demolition, have increased sharply at this facility. Infection
Prevention (IP) noted several instances of contractors not following
infection control risk assessment (ICRA) guidelines. Due to these
concerns, IP sought to establish a more comprehensive construction
safety program. Previous research has examined partnerships between
IP and contractors; however, less attention has been paid to expanding
these partnerships to other hospital safety personnel. Project:
The facility is a 408 licensed-bed urban community-teaching hospital
with a Level 1 trauma center and a Level 3 perinatal center. IP began
by establishing a partnership with the hospital safety officer (HSO),
who conducts the interim life safety measures (ILSM) program. A
comprehensive “construction safety” education session was established
for contractors. The educational sessions covered regulatory
requirements, basic safety protocols, and infection prevention
guidelines. The IP and HSO began attending Planning, Design
& Construction’s (PD&C) biweekly meetings to stay current on
construction projects and to identify concerns. Weekly construction
safety inspections were conducted on all projects; violations were
noted on the ICRA and ILSM checklists, and PD&C staff and
contractors were notified immediately. Minor violations consisted
of small breaks in barriers or documentation lapses, major violations
consisted of large breaks in barriers, absence of proper barriers, lack of
high-efficiency particulate air (HEPA) filtration and/or increases in air
particulate measurement readings. Results: Since the beginning of
the program, inspections revealed a decrease in the rate of violations
identified. Out of 11 projects in 2010 there were 4 minor and 1 major
violations for a rate of 0.45. In 2011 there were 34 projects with 11
minor and 1 major violations for a rate of 0.35. Major violations
identified included: complete absence of proper barrier for diagnostic
imaging department renovation and lack of HEPA filtration unit on
inpatient nursing unit renovation project. Recurrent minor violations
included breaks in barrier seals and lack of adequate environmental
cleaning near construction work area. Lessons Learned:
When multiple PD&C projects occur simultaneously, strict oversight
and guidance are needed to ensure a safe hospital environment. The
joint efforts of IP and the HSO were more effective at reducing safety
violations and improving compliance with construction policies
than the individual efforts of the IP and HSO. In addition, this new
program was instrumental at improving communication and team
work between IP, the HSO, PD&C, and contract staff.
Measuring the Effect of Hospital Cleaning
Intervention to Prevent Health Care Assocaiated
Infections
Yoko J. Tsukamoto, PhD, FNP, CIC - Professor, Health Sciences
University of Hokkaido; Kaori Yamada, RN, Certified in Infection
Control Nurse - Graduate Student, Health Sciences University of
Hokkaido
Background/Objectives: As evidence becomes more
available, the importance of hospital environmental hygiene is now
emphasized to prevent health care associated infections. In this
study, we implemented an educational intervention and measured
an adenosin triphosphate (ATP) level of patient environmental
surfaces to evaluate hospital cleanliness. A relationship between
ATP level and incident rate of S.aureus, Methods: This study
was a prospective study and conducted in three wards of a 553
bed community hospital from July to September 2012. One of
the three wards was assigned as an interventional group and other
two were assigned as an observational group. A self-administered
questionnaire was conducted before and after the intervention to
all the nursing staffs that actually cleaned the patient environmental
surfaces. The questionnaire was asking about current cleaning
practice and recognition of the importance of environmental
hygiene to prevent infections. ATP levels at patient environmental
surfaces were also measured before intervention. Educational
program, a daily cleaning check list, and ATP levels feedback were
provided to the interventional group. After the intervention, ATP
levels were measured again to compare between the interventional
and observational group. Results: Among 96 samples, the
questionnaire was collected from 57 samples (59.0%). There was no
difference of years of experience between two groups, but there was
a difference of bed occupancy rate and the interventional group’s
rate was significantly higher than the observational group’s one
(p=.021). Cleaning of isolation room was significantly better after
the intervention compared to observational group (p=.05). Thirty
four area of ATP level were measured before and after intervention
and total of 488 ATP levels were collected. ATP levels of door knobs
at multiple bed room and bed rails, over table, TV remote controller,
and Nurse Call button at isolation rooms were significantly lower
after intervention. The reduction rate of infection rates per 1000
patient-days were compared between before and after intervention
of two groups, however, there was no difference between two groups.
Conclusions: In this study, there was no significant difference
of ATP levels between before and after intervention of interventional
group. However, there was a significant reduction rate between the
interventional and the observational group, therefore, we concluded
there was some effectiveness of the intervention. One of the reasons
is that there was a question about cleanliness of the cleaning wipes.
The container of the cleaning wipes were ovserved dirty several
times. The intervention needs to be continued longer to examine
associated between ATP levels and infections rate.
55
Poster Abstracts: Healthcare Worker Safety/Occupational Health
Children’s Hospital, Orange, CA.
The Development of an Environmental Audit
Program
Issue: Efforts to improve levels of immunization of healthcare
workers have been widely published. We have offered Tdap
vaccine to staff since February 2006. The acceptance rate has been
poor. Tdap vaccination is recommended by CDC, the Advisory
Committee on Immunization Practices and California Department
of Public Health for HCW and for contacts of children < 12
months, both relevant to HCW at childrens’ hospitals. Tdap is
strongly encouraged upon hire, at annual TB screening, and with
the annual Influenza vaccine program. All vaccines are offered free
to staff and physicians. Project: We include all individuals
in our program; bedside staff, indirect patient care, non-patient
care including our offsite business office, and human resources
department. Despite efforts, compliance was poor and in 2008 we
implemented a declination form for those who refused Tdap. On
June 17, 2010 the California Department of Public Health declared
a pertussis epidemic. There were 9,146 cases and 10 deaths in
California. We had 133 cases and one death at our facility. Further
revisions to the policy included mandatory Tdap for new volunteers,
students, fellows, registry, travelers and for contractors with patient
care contact. We set our goal at 95% protected. Results: Prior
to the statewide Pertussis epidemic we had 67% of staff and 50%
of attending physicians protected. We markedly improved our
level of Tdap participation achieving overall 92% staff protected
and 82% attending physicians protected. Our medical residents
and environmental services department are at 100% protected
followed by OICU 97.6% and PICU and emergency transport
personnel both at 95.6%. Lessons Learned: We have had
vaccine available for over 5 years with small improvements in staff
coverage from year to year. The statewide Pertussis Epidemic lead
to heightened awareness within our medical center due to infection
prevention update communications, patient and family education
about the importance of Tdap vaccine and also local media coverage
both newsprint and television. Our staff and physicians were
receiving re-education on “Get your Tdap” at work and at home.
Accountability is at all levels; staff, physicians, supervisors, managers,
directors, vice presidents and the CEO. It is imperative that all levels
of the organization are in alignment for success. In FY 2011, some
clinical managers and at least one medical director chose improving
Tdap coverage as an individual performance goal. Currently,
infection prevention is communicating directly with department
managers who are below the 95% protected level. Although we had
achieved much success with a masking requirement for staff not
protected with the Influenza vaccine, this method is not feasible for
Tdap. We believe that Tdap should be a condition of employment in
the childrens’ hospital setting.
Kishori Naik, BSc. - Infection Control Coordinator, Woodstcok
Hospital; Safiyya Nazarali, BScN, RN - Infection Control
Practitioner, Woodstock Hospital; Natalie J. Goertz, BScN, CIC Manager of Infection Prevention and Control, Woodstock Hospital
Issue: Health care environments significantly influence the
occurrence of infection in hospitals. Frequently touched surfaces pose
a greater risk to patients than public areas. The role of environmental
services is vital in reducing the risk of transmission of hospitalacquired infections. The lack of an auditing program at our facility
allowed for gaps in knowledge leading to inconsistencies within the
environmental services department. Project: Our aim was to
create a monthly auditing program through the use of fluorescent
dye illumination. Results: On a monthly basis IPAC performs
audits in three rooms on seven different units. Seven spots in each
room are marked with a fluorescent dye. After 24 hours IPAC returns
to the rooms with a black light assessing whether the spots have been
cleaned. Using this auditing method we were able to identify gaps
in knowledge and workload issues. Various techniques were used
to educate and train the environmental staff including on-the-spot
feedback, which was provided once the presence/absence of the glow
dots was evaluated. IPAC also provided education at environmental
service meetings in order to address questions in a large group setting,
allowing a review of high touch surface areas. Those resistant to accept
change were identified and were provided with extra feedback and
support. IPAC stars were implemented for proactive staff that took
initiative. These staff members were recognized and highlighted
in the hospital newsletter as well as on posters throughout the
hospital. IPAC’s consistent presence allowed for an open and positive
relationship with the housekeeping staff. Lessons Learned:
Auditing environmental practice is an important part of Infection
Prevention and Control. Audits helped to identify gaps in knowledge
and forge an open relationship where on-the-spot education and
feedback is acceptable.
Healthcare Worker Safety/
Occupational Health
Healthcare Worker (HCW) Pertussis (Tdap)
Vaccine Compliance Improves During a Statewide
Pertussis Epidemic
Wendi Gornick, MS, CIC - Infection Prevention & Epidemiology
Manager, CHOC Children’s Hospital, Orange, CA; Nimfa Santos,
RN, BSN, COHN - Associate Health Manager, CHOC Children’s
Hospital, Orange, CA; Bijal Patel, BS, MHA - Infection Prevention
Analyst, CHOC Children’s Hospital, Orange, CA; Jasjit Singh,
MD - Medical Director of Infection Prevention & Epidemiology,
Department of Pediatrics, Division of Infectious Disease, CHOC
56
Development of Point of use Sharps Disposal Unita Simple Solution to a Difficult Problem
Carolyn Louise Moore, Graduate Certificate in Nursing Science,
Infection Control - Infection Control Nurse, St Vincents & Mercy
Private
Issue: Healthcare workers face the risk of injury from needles
and other sharp instruments. Injuries most often occur after use and
before disposal of a sharp device. Australia is the only country with
well-developed systems of infection prevention and control and
occupational health and safety that has not yet mandated the use of
safety devices. Such mandates currently exist in the USA, Canada
and the United Kingdom (Australian Infection Control Guidelines,
2010). The safe management of clinical and related waste is essential
for occupational, community and environmental health. Health
services are legally and ethically responsible for the disposal of clinical
and related waste. Ideally, sharps should be disposed of at point of
use to minimise risk of injury, however, Australian Standards and
the geographical layout of our patient rooms do not allow this to
occur. Healthcare workers are required to transport the sharp to a
designated sharp disposal unit in a separate area of the clinical unit.
Needle stick injury rates in clinical units (excluding perioperative
services) reported in 2010 via incident reports were at a rate of
1.25 per month across 3 campuses (450 beds, 100,093 bed days).
Project: The development of an alternative means of sharps
disposal at the point of care was necessary to reduce the risk of sharps
injuries. A search of current products available to meet our needs
whilst ensuring Australian Standards were met identified a need for
the Infection Control team to develop a product that could fulfil our
requirements. What began as a small project that had us looking at
how we could adapt plastic baskets purchased from a storage retailer,
saw us being introduced to a design engineer who was interested in
expanding his field of manufacturing into the area of healthcare. Over
several meetings, together we designed a product that allowed a) safe
transport of injectable medication, b) point of use sharps disposal
and c) hand hygiene compliance. Cardboard mock-ups and several
minor design adjustments led to the final version of the Sharps Caddy,
an ergonomically designed, infection control friendly and safe sharp
disposal compliant product. Results: The point of use sharps
disposal unit has been rolled out across the three campuses of our
hospital over the past month. Data collection to demonstrate the
effectiveness of this product is ongoing. Lessons Learned:
Working with external experts from a field unrelated to health care
enabled us to address a situation for which we had long sought a
solution. By working together, we were able to develop a product that
was practical to the wider market at a reasonable cost. We recognise
that reducing sharps injuries needs to be a multi-faceted approach, and
this is one aspect of the overall goal.
Linda G. Harris, BS, MT-ASCP - Senior Research Scientist,
Kimberly-Clark Corporation; F. S. Kilinc-Balci, PhD - Senior
Service Fellow, National Personal Protective Technology Laboratory
(NPPTL), National Institute of Occupational Safety and Health
(NIOSH), Centers for Disease Control and Prevention (CDC); Janet
A. Lewis, RN, MA, CNOR - Administrative Director Perioperative
Services, Regional West Medical Center, Scottsbluff, NE
Background/Objectives: Isolation gowns are widely used
in infection control, but little has been reported regarding their wear
performance and issues that may affect compliance. Infection control
professionals (ICPs) were surveyed to determine use and wear issues
with these products. Methods: Members of the Association
for Professionals in Infection Control and Epidemiology (APIC)
were requested to participate in an on-line survey regarding isolation
gowns. Respondents provided descriptive information regarding
their use of isolation gowns and answered questions regarding risk
perceptions, protection levels, compliance issues, mobility restriction
and garment failures. Descriptive statistics were used to analyze
the data. Results: A total of 1498 ICPs replied to the request
with 1354 (90%) indicating that they wore isolation gowns in their
typical work activities. The following results are based on these 1354
ICPs. Respondents were well distributed in years of experience in
infection prevention and control. Most (83%) indicated primary
employment in a hospital. Disposable gowns (76%) were the most
common type used. Frequency and duration of wear by ICPs was
low with the majority wearing gowns once a month or less and for 10
or less minutes. Perceptions of risk were low with most ICPs (82%)
believing that their isolation gowns kept them at low or very low risk.
However, 45% indicated they had encountered punctures or tears
in isolation gowns. Although 77% are involved in educating others
about isolation gowns, less than half of the ICPs indicated they were
aware of the ANSI/AAMI standard PB 70:2003(R) which describes
liquid barrier testing that may be done on gowns and performance
levels based on the results. ICPs reported high degree of compliance
with isolation gowns by clinical staff, but they had less favorable
compliance perceptions for guests and visitors. The majority (74%)
Isolation Gown Use, Performance and Potential
Compliance Issues Identified by Infection Control
Professionals
Rinn M. Cloud, PhD - MGJ Endowed Chair in Textiles, Baylor
University; Uncas B. Favret, BS - President and CEO, Vestagen
Technical Textile, LLC; Terrell Cunningham, BS, RN - Senior
Reviewer/Team Leader, FDA Center for Devices and Radiological
Health, Office of Device Evaluation, Infection Control Branch;
Jacqueline Daley, HBSC, MLT, CIC, CSPDS - Director Infection
Prevention and Control, Sinai Hospital of Baltimore
57
Diane G. Dumigan, RN, BSN, CIC - Infection Preventionist,
Hospital of Saint Raphael; Lisa Tyler - Executive Assistant,
Department of Patient Services, Hospital of Saint Raphael;
Lizette Cortes - Executive Assistant, Human Resources, Hospital
of Saint Raphael; Elizabeth Conrad, MS - Vice President of
Human Resources, Hospital of Saint Raphael; Richard Meskill Information Systems Customer Service and Application Delivery
Specialist, Hospital of Saint Raphael; Andrea Santerre, RN, MS
- Manager of Critical Support, Occupational Health, Hospital of
Saint Raphael; Michelle N. Whitbread, MT, MPH - Infection
Prevention, Hospital of Saint Raphael; John M. Boyce, MD Hospital Epidemiologist, Hospital of Saint Raphael; Clinical
reported that type of garment (disposable or reusable) had little or no
impact on their compliance, but 48% indicated that gown features
could have moderate to very high impact on their compliance.
The features believed most likely to discourage compliance were:
restricts movement, time to use/remove, ease of donning/doffing,
thermal comfort and gown fit. Although most ICPs reported no fit
or mobility restriction issues with isolation gowns, 22% reported
problems with tight fit in the shoulder area. Content analysis of open
ended questions revealed issues related to large sized clients, neck
designs, tie closures and breathability. Conclusions: This study
measured usage patterns for isolation gowns among ICPs and their
perceptions of performance and compliance issues. Results indicated
that: (1) ICPs expect and believe they achieve good protection with
isolation gowns; (2) fit, comfort and time to don/doff are important
compliance issues to be addressed; and (3) ICP education is needed
regarding the current requirements for protective performance of
isolation gowns (to be included in presentation).
Implementing a Mandatory Influenza Vaccination
Program in a University-Affiliated Teaching Hospital
58
BACKGROUND/OBJECTIVES: Seasonal influenza
(flu) vaccination for health care personnel (HCP) has been
recommended by over 20 professional organizations. By 2011 flu
vaccination was mandated as a condition of employment in over
40 hospitals in the United States as reported to the Immunization
Action Coalition. During the 2010-2011 influenza season we
created a mandatory participation program that required HCP
to be vaccinated or sign a declination form and wear a mask if not
vaccinated during flu season. Objective: Convert our mandatory
influenza prevention program into a mandatory influenza
vaccination program for all our hospital-employed HCP by
Dec 1, 2011 in preparation for the 2011-2012 influenza season.
METHODS: Policy development: With the backing of senior
administration our multidisciplinary committee developed human
resource policies mandating all our HCP without a legitimate
medical exemption be vaccinated against seasonal flu by 12/1/11.
HCP with a legitimate medical contraindication to the vaccine
had between 9/1/11 and 10/15/11 to obtain a certificate of
medical exemption from their primary care provider, which
was then sent to Occupational Health for final approval. HCP
without an exemption who were not vaccinated by 12/1/11 were
not allowed to work, using unpaid leave, until their participation
requirement was met. After 2 weeks of non-compliance HCP
would be terminated. Vaccination documentation: We utilized
a hand-held programmable scanner to scan HCP badges and
store employee work demographics, consent form and signature.
Confidential vaccination information was uploaded to a secure
password protected database that each manager could access
to see their unit’s vaccination status. Vaccination clinics, rolling
carts and champions: Several vaccination clinics were scheduled
in our cafeteria. Additional rolling carts were provided to large
departments. Nursing employees volunteered to be flu champions
and provided vaccinations to any HCP that came to their unit on
any shift: day, night or weekend. RESULTS: Out of a total of 3995
hospital-employed HCP, 24 (0.6%) were excluded due to noninfluenza seasonal work schedules; 121 (3.0%) received a certificate
of medical exemption; 2 were suspended without pay but later
accepted vaccination; no HCP were terminated; 3850 (96.4%) were
vaccinated against flu. Conclusions: Mandating influenza
vaccination of all hospital-employed HCP (excluding those with
a medical exemption) can go smoothly especially if it is preceded
by a year of a mandatory participation program which allows
both administrators and employees to develop, and adjust to the
demands of a mandatory vaccination program.
Poster Abstracts: Infection Prevention and Control Programs
A Comparison of Anti-Microbial Scrubs and Cotton
Scrubs in a Hospital
Peter K. Raisanen III., Bachelor of Science - research fellow,
University of Arizona; Laura Y. Sifuentes, MPH - PhD Candidate,
University of Arizona
Issue: Health care personnel come in contact with a vast array of
these infectious agents every day. It is possible that hospital personnel
may be part of this transmission process by exposing patients and
other personnel to microorganisms in their uniforms. In this study,
scrubs containing an antimicrobial were compared to widely used
cotton scrub uniforms in order to assess the effectiveness of silver in
preventing infectious agents from becoming impregnated on fabric.
Project: Emergency personnel wore the treated scrubs for one
day and the hospital provided scrubs on a separate day .The personnel
wearing the scrubs worked a 12 hour shift in a full service emergency
room providing patient care for the entire shift. A total of 18 scrubs (9
treated and 9 regular cotton) were then evaluated using quantitative
plate count methods for the presence of heterotrophic bacteria, total
coliforms, Staphylococcus aureus, Methicillin-Resistant (MRSA) S.
aureus, and Escherichia coli. Results: All scrubs sampled treated
and untreated were positive for heterotrophic bacteria. The mean
number of total bacteria found in treated scrubs was 1.65 X 105
colony forming unit (CFU) per scrub item, while the mean number
of total bacteria for the untreated scrubs were 8.13 X 105. There was
a significant difference between treated and untreated scrubs (p =
0.02) for total bacteria. MRSA was not isolated from any of the scrubs
treated or untreated, but interestingly total coliforms were found in
both the treated and untreated scrubs. E. coli was found in 22% of
untreated scrubs and 16% of treated scrubs. Lessons Learned:
Scrubs containing an anti-microbial where shown to contain statically
significant fewer total bacteria, and less occurrence of E. coli and
coliform bacteria
Infection Prevention and Control
Programs
Success in Preventing Catheter Associated Urinary
Tract Infections – What Works?
(CAUTIs) in 2008 and 2009 combined, a rate of 1.79. Following the
North Carolina Hospital Association (NCHA) NC Quality Center
Prevent CAUTI Collaborative kickoff meeting in March 2010, a
multidisciplinary team was formed to reduce CAUTIs. Project:
Due to the medical unit’s high incidence of CAUTIs, efforts were
first focused on this patient population. This organization is a
258-bed, not-for-profit, Magnet hospital located in the foothills
of NC that offers a full range of medical services and specialties
to a 5-county region. The CAUTI Prevention Team, comprised
of representatives from administration, infection prevention, risk
management, clinical resource management, medical and other
inpatient units as well as the emergency department and operating
room, accepted a mandate to develop and implement interventions
to reduce CAUTIs. NCHA’s Prevent CAUTI Collaborative
routine order tool was adapted and approved for implementation
within one week. Next a daily line review process was created,
which included a shared spreadsheet for utilization reviewers (UR),
who both review and advocate for removal at the earliest point
appropriate in the patient’s catheterization. The CAUTI Prevention
Team determined that heightened awareness and a multifaceted
approach to staff education would increase the probability of
success in reducing CAUTIs. We accomplished this by involving
direct caregivers and management throughout the organization
in the educational efforts. Frontline staff shift huddles, bathroom
blitz flyers, face-to-face physician education, a “Back to Basics”
Foley care campaign, interdisciplinary bedside team rounding and
discussion of Foley necessity in bedside shift report are examples
of the education provided. Results: An initial goal of reducing
medical patient CAUTIs by 25% in its first year was set. In addition,
a stretch goal of achieving zero infections was established. Efforts
proved successful as the medical unit experienced only a 0.9 CAUTI
rate (N=2) in 2010. Furthermore, the stretch goal was obtained
as no CAUTIs occurred in 2011 among medical inpatients. The
routine order for Foley insertion is now utilized in every department
throughout the organization. Lessons Learned: The initial
plan for implementation was too aggressive requiring postponement
and reevaluation of timeline, and we learned the importance of
establishing a realistic timeline. Early in the process, agree upon
inter-departmental expectations to eliminate confusion. The CAUTI
Prevention Team established a goal of 100% compliance with daily
Foley review, without a complete understanding of the UR staffing
barriers. Staff buy-in is key. A physician champion can positively
influence the practice of his/her peers. Taken together these lessons
learned reinforce that it is critical to ensure all stakeholders are
involved from the beginning of a project. In summary, success can be
achieved through an interdisciplinary, comprehensive approach.
Michelle P. Mace, MSN, RN, CIC - Administrator, Infection
Prevention, Catawba Valley Medical Center; Starr-Nell Bowman, BS,
MBA - Risk Management Analyst, Catawba Valley Medical Center;
Joelle Calloway - Resource Coordinator, Catawba Valley Medical
Center; Carla Macijewski - Clinical Development Coordinator,
Catawba Valley Medical Center
Issue: The general medical unit at a community Magnet hospital
had a total of 10 Catheter Associated Urinary Tract Infections
59
[OR], 10.3 [95% confidence interval {CI}, 2.4 - 44.4]), perceived
importance of vaccination [OR 8.3 (CI: 2.3 - 30.3)], perception that
influenza vaccine has few side effects [OR 6.0 (CI: 1.8 - 19.7)], and
past vaccine-seeking behavior [OR 4.1 (CI: 1.5 - 11)]. In logistic
regression controlling for demographics, determinants of intent
to be vaccinated included having the vaccine available on-site and
free [OR 21.1 (CI: 4.7 - 92.7)], and belief that EMTs should be
vaccinated every year [OR 6.8 (CI: 1.6 - 28.1)]. EMTs’ attitudes
and beliefs towards influenza vaccines differed significantly when
comparing vaccinated to non-vaccinated EMTs. Vaccinated EMTs
were significantly more likely than non-vaccinated EMTs to agree
that seasonal influenza (Χ = 7.0, p < .01) and H1N1 (Χ = 8.4, p
< .01) are serious diseases, that vaccination is important to them
(Χ = 93.2, p < .001), that non-immunized EMTs play a role in
influenza transmission (Χ = 21.8, p < .001), and that public health
officials can be trusted regarding vaccine safe (Χ = 9.2, p < .01).
Conclusions: Targeted interventions should be aimed at
EMTs to increase their vaccine compliance, including implementing
a mandatory vaccination policy and addressing EMTs’ beliefs and
attitudes about vaccine in an education campaign.
Seasonal and H1N1 Influenza Vaccine Compliance
and Intent to be Vaccinated Among Emergency
Medical Services Personnel
Terri Rebmann, PhD RN CIC; Kate Wright, EDD - Director,
Heartland Center for Public Health Preparedness, Saint Louis
University, School of Public Health; John Anthony - Emergency
Preparedness Manager, St Louis County Health Department;
Richard Knaup - Manager, Communicable Disease Control Services,
St Louis County Health Department; Eleanor Peters - Epidemiology
Specialist, St. Louis County Department of Health
Background/Objectives: Influenza vaccination among
emergency medical technicians (EMT) is imperative, but only
limited data is available on factors affecting their compliance. The
objective of this study was to examine factors influencing EMTs’
seasonal influenza and pandemic H1N1 vaccine compliance.
Methods: A vaccine compliance questionnaire in the form of
online and paper surveys was administered to EMTs working in
St Louis, MO in March - June, 2011. McNemar tests were used
to compare compliance rates across the three types of vaccine;
a non-parametric test was chosen because the outcome variable
is dichotomous and it is a matched sample (same EMTs over
different time periods). Hierarchical logistic regressions were used
to determine predictive models for 2010/2011 seasonal influenza
vaccination compliance and intent to be vaccinated in the future.
Good model fit, indicated by a nonsignificant chi square value,
was calculated with the Hosmer and Lemeshow goodness-of-fit
test. Results: In all, 265 EMTs completed the survey. EMTs’
attitudes and beliefs towards influenza vaccines differed significantly
when comparing vaccinated to non-vaccinated EMTs. EMTs whose
employer had a mandatory vaccination policy were significantly
more likely to receive the seasonal influenza vaccine (100% versus
75.6%) or the H1N1 vaccine (100% versus 66.8%) compared to
those without such a policy (Χ = 8.8, p < .001 and Χ = 6.7, p < .01
respectively). In logistic regression controlling for demographics,
the determinants of 2010/2011 seasonal influenza vaccination
included belief that EMTs should be vaccinated every year (odds ratio
60
Unleashing the Positive Deviants at the Frontline: More than just Sparking Change
Melissa Crump - Infection Control Practitioner, Vancouver Coastal
Health: VGH; Elizabeth Bryce, MD - Regional Medical Director
of Infection Control, Vancouver Coastal Health; Suk Ko - Patient
Services Manager, Medical and Subacute Medical Units, Vancouver
Coastal Health:VGH; Gail Busto - Infection Control Practitioner,
Vancouver Coastal Health: Richmond
Background/Objectives: Hospital acquired infections
(HAI) continues to be a growing challenge and financial burden on
Canadian hospitals. HAI accounts for 8,500 to 12,000 deaths per
year, making it the fourth leading cause of death for Canadians. A
patient that acquires a HAI incurs a longer hospital stay, increase risk
of morbidity and mortality, and emotional and physical isolation. The
financial strain cannot be ignored as the estimated cost of treating a
patient with C. difficile is an extra $18,000 with an average increase in
hospital length of stay of 13.6 days. A patient infected with MRSA
costs a hospital between $12,000 and $35,000 to manage their
care. This huge burden and growing challenge sparked a Canadian
subacute medical unit to take a multidisciplinary team approach to
developing unit-based solutions in October 2009. Methods: All
unit staff was invited to participate in multidisciplinary bimonthly
dialogues around change initiatives that they can lead and support.
Positive Deviance (PD) and Liberating Structures (LS) methodology
was used to extrapolate ideas, thoughts and solutions to the identified
problem of eradicating HAIs. Through facilitated dialogue, the team
was able to identify that the areas of hand hygiene, environmental
cleaning and current infection control practices needed to be
addressed. The team developed infection control unit protocols
and strategies to reduce the spread of HAI and to aid in their goal
of reducing HAI to the point of eradication. Educational resources
for patients, families, students and new hires were developed by
staff. New signage was created, and equipment cleaning and de
cluttering protocols were developed. Emphasis on single use items
was encouraged on the unit and multi use items were eliminated and
replaced with single use items when available. Removal of wash basins
was also initiated and basin bathing was replaced with prepackaged
cleansing bath clothes, due to questions regarding streamline
cleansing of basins. Transparency of HAI and hand hygiene rates
was promoted on the unit to increase awareness and encourage
dialogue. Results: Since the beginning of this project in October
2009 hand hygiene compliance has increased by over 30%, MRSA
rates have decreased by 64% and CDI has decreased by 41%.
Conclusions: The utilization of PD and LS methodologies on
this subacute medical unit has not only resulted in a decrease of HAI,
but increased nurse work satisfaction and positively influenced the
culture. Sustainable changes have been demonstrated as the frontline
worker’s ideas and solutions were the catalyst for this change. The
creation of a medical community where infection control practices
are at the forefront of everyday care has not only enhanced quality of
care, but reduced transmission of HAI.
approved cleaning product followed by sodium hypochlorite (bleach)
to sanitize all high touch surfaces. In 2009 our hospital expanded
this bundle to include a patient HH intervention that provided
opportunities for handwashing prior to meals and throughout the
day. Incidence of CD infection was followed for FY10 ( July 2009 to
June 2010) after full implementation of the patient HH intervention.
Results: The CD infection rate during the intervention period
was 6.95 per 10,000 patient days (116 cases/ 166,838 patient days)
in comparison to the FY09 rate of 10.45 (164 cases /156,956 patient
days). Application of a Chi-square test was significant at p=0.0009.
The expanded bundle resulted in a statistically significant decrease in
the CD infection rate. Lessons Learned: Applying the CD
bundle and expanding the interventions to include patient HH can
contribute to the reduction of CD infection in hospitalized patients.
Patients confined to bed do not often have the opportunity to wash
their hands in the hospital. Patients need assistance, education, and
verbal reminders, along with the encouragement of the nurse to
perform HH and help to prevent transmission of CD spores in the
hospital environment. It is difficult to ascribe success of a CD control
program to any one intervention; however the expanded bundle
that included patient HH significantly contributed to the decreased
incidence of CD infection in our hospital.
Expanding the Clostridium difficile Infection
Prevention Bundle to Include Patient Hand
Hygiene
Jody Feigel - Infection Control Coordinator, UPMC Health
System - Shadyside Hospital; Marian Pokrywka - Infection
Preventionist, UPMC Health System Children’s Hospital; Barbara
Douglas - Infection Preventionist, UPMC Health System Shadyside Hospital; Amelia Hensler - Infection Preventionist,
UPMC Health System Shadyside Hospital; Susan Grossberger Infection Preventionist, UPMC Health System Mercy Hospital
Issue: Clostridium difficile (CD) is one of the most prevalent,
virulent and costly pathogens of the last decade. CD infections have
contributed to increased length of stay, adverse outcomes including
colectomy and ICU transfer, an attributable mortality rate of 6.9%
at 30 days after diagnosis (16.7% at 1 year) as well as an estimated
healthcare cost of 3.2 billion dollars per year. Prevention strategies
for Clostridium difficile (CD) infection prevention in hospitals
have addressed barrier precautions, environmental disinfection, and
healthcare worker hand hygiene (HH). When applied as a “bundle”
this approach is a widely utilized, evidenced-based strategy to prevent
CD infection. Despite utilization of the bundle, infection rates for
CD remain high in many institutions. Project: The University
of Pittsburgh Medical Center (UPMC) Shadyside Hospital is a 520
bed tertiary care and teaching facility with a specialty in oncology
and stem cell transplant and a history of proactive initiatives to
prevent hospital acquired infections. Strategies to control CD began
in 2007 with interventions grouped into an “evidence-based bundle”.
Interventions included early detection of CD cases by toxin testing
of any patient with onset of unexplained diarrhea, electronic alerts
on positive toxin results to initiate barrier precautions with glove
and gown use, staff HH with soap and water as opposed to alcohol
sanitizer, extended duration of isolation for entire hospital stay, staff
and patient education and cleaning of all patient rooms with an
Hand Hygiene Opportunities in Pediatric Extended
Care Facilities
Amanda E. Buet, MPH - Research Assistant, Columbia University
School of Nursing; Bevin Cohen, MPH - Project Coordinator,
Columbia University School of Nursing; Melissa Marine, BS - Project
Coordinator, Columbia University School of Nursing; Fiona Scully Summer Research Assistant, Columbia University School of Nursing;
Paul Alper, BA - Vice President, Strategy and Business Development,
Deb Worldwide Healthcare Inc.; Edwin Simpser, MD - Executive
Vice President, Chief Operating Officer, and Chief Medical Officer
of St. Mary’s Healthcare System for Children, St. Mary’s Healthcare
System for Children; Lisa Saiman, MD, MPH - Professor of Clinical
Pediatrics and Hospital Epidemiologist of Morgan Stanley Children’s
Hospital, Columbia University Department of Pediatrics; Elaine L.
Larson, RN, PhD, CIC - Associate Dean for Research, Columbia
University School of Nursing
Background/Objectives: Children and adolescents
in extended care facilities (ECFs) are at high risk of healthcareassociated infections. Bacterial pathogens, including multidrugresistant strains,(1) as well as viral pathogens can cause endemic and
epidemic infections in this unique population.(2-5) To date, infection
prevention and control research, particularly pertaining to hand
hygiene (HH), has focused on acute care settings and adult long-term
care facilities. Such studies are unlikely to be applicable in pediatric
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ECFs given the different care patterns and distribution of devices in
these different healthcare settings. Pediatric ECFs provide medical
care as well as on-site social, academic, and therapeutic activities,
which require frequent and close contact between the children and
a wide variety of clinical and non-clinical care givers. The goals of
this study were to determine the frequency of various types of HH
opportunities and HH adherence in pediatric ECFs. Methods:
From June-August 2011, we conducted an observational study at
four pediatric ECFs providing subacute, long-term and residential
care, rehabilitation, chronic disease management, and/or specialty
care. Two children at each facility, aged 3 to 9 years, were each
observed by a trained observer for 16 hours. We used the World
Health Organization ‘5 Moments for HH’(6) to characterize
the types and frequency of HH opportunities and to monitor
adherence to HH by various care givers. Clinical care givers
were defined as physicians, nurses, nurse aides and respiratory,
physical or occupational therapists and non-clinical care givers
were defined as teachers, teachers’ aides, recreational support
staff, environmental service workers, social workers, volunteers
and adult visitors. Data analyses were descriptive. Comparisons of
categorical data were performed using Pearson’s χ2 test. Results:
We observed 865 HH opportunities of which a mean of 108 HH
opportunities (range, 60 - 196) occurred per child during the 16
hours of observation. ‘Prior to patient contact’ (39%) and ‘prior
to aseptic technique’ (1%) were the most and least common HH
opportunities, respectively. Nurses and nurse aides had the highest
number of HH opportunities (50%), while visitors; therapists;
school staff; other staff and physicians were associated with 22%,
9%, 9%, 8% and 1% of HH opportunities, respectively. Overall
HH adherence was 43% (27-65% per facility) and was significantly
higher among clinical care providers than among non-clinical
individuals (61% and 14%, respectively, P < 0.01). Adherence
was highest ‘after exposure to body fluids’ (66%) and lowest
‘before patient contact’ (36%). Conclusions: Overall HH
adherence was less than 50%, suggesting multiple opportunities
for transmission of infectious agents and highlighting the need
to improve HH practice in pediatric ECFs. Future studies should
investigate strategies to improve HH adherence among the wide
variety of care providers in this healthcare setting and assess their
impact on healthcare-acquired infections.
A CAUTI Bundle with a Twist
Frances P. Abraham, DrPH, RN, CIC - Infection Control
Coordinator, Michael E. DeBakey VA Medical Center, Houston
Texas; Frances P. Abraham - Infection Control Coordinator,
Michael E.DeBakey VA Medical Center
Issue: For many years we struggled with high incidence rates of
Catheter-Associated Urinary Tract Infections (CAUTI) in patients
on the Long Term Care units at our facility. Project: We
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implemented a comprehensive, but modified bundle of practices to
reduce the incidence of Catheter-Associated Urinary Tract Infections
in patients on the Long Term care units at our facility. This bundle
consisted of increasing staff knowledge by education and competency
training for all staff involved with the insertion of urinary catheters,
appropriate catheter insertion and maintenance techniques, and hand
hygiene. These conventional strategies were complemented with
improved patient hygiene by requiring a bed bath or shower at least
three times a week for all patients. We monitored the incidence rate
of infections on a monthly basis, from August 2010 to October 2011.
Results: In August 2010 the rate of CAUTI in our Long Term
Care units was 10.1 per 1000 Foley catheter days. By August 2011
the rate was reduced to 0.0 and sustained in September and October
2011. Lessons Learned: Implementation of a modified
CAUTI Bundle which involved the improvement in patient personal
hygiene appeared to have a positive impact on the incidence of
catheter-associated urinary tract infections in our Long Term Care
patient population. The attempt to control CAUTI, like most other
hospital-acquired infections, must be done from different fronts.
services, safety, quality improvement and nursing. The team evaluated
our current process of caring for C. difficile patients and developed
new initiatives to improve our current processes by implementing
aspects from the state Department of Public Health Collaborative
on Clostridium difficile. The initiatives included: preemptive contact
precautions, hand hygiene, environmental cleaning, laboratory alerts
and education. Our hypothesis was if patients with C. difficile were
identified promptly then prevention measures could be instituted
to prevent the acquisition and transmission of further C. difficile
infection. Results: From October 2010 to November 2011, we
were able to reduce the number of healthcare facility onset infections
of C. difficile by 15% which equated to 17 fewer cases within our
organization. The pilot unit has not had any healthcare facility onset
infections of C. difficile for the last 6 months. Implementation of the
Clostridium difficile bundle improved staff awareness of C. difficile
disease and the measures required to thwart further transmission and
Managing Clostridium difficile using a Bundled
Approach
Karen Trimberger, RN, MPH, NE-BC, CIC - System Director
Infection Prevention & Control, Memorial Medical Center; Marcy
McGinnis, RN, BSN, CNOR - Infection Preventionist, Memorial
Medical Center
Issue: Clostridium difficile is quickly becoming a leader in the world
of healthcare associated infections. Patients with C. difficile have been
shown to have an increase length of stay by 3.6 days. As a result of
the increased length of stay, increased mortality, and treatment of C.
difficile, costs have increased by up to $18,067 per case; estimating
$3.2 Billion per year in the management of C. difficile. Our review
sought to determine whether implementation of a “Clostridium
difficile bundle” affects the incidence of healthcare facility onset
C. difficile infections on a nursing unit within our organization.
Project: The organization convened a multidisciplinary team
consisting of members from infection prevention, environmental
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acquisition of the disease. Lessons Learned: Environmental
cleaning and the use of friction are paramount. Instituting
preemptive isolation until specimen results are available is important.
Collaboration with all members of the team is critical to ensure
compliance with all bundle components. Auditing of the process
steps is vital and sharing the results with all disciplines is necessary
to maintain engagement. Education must be provided to all team
members including physicians, residents and medical students.
What’s For Dinner?
Maria Vacca, BSN, RN, CIC - Infection Preventionist, Pennsylvania
Hospital
Issue: Food safety is an issue that spans the globe. Everyone needs
to eat food. According to the Centers for Disease Control (CDC),
an estimated 48 million people per year (1 in 6) in the United States
become ill due to ingestion of contaminated food. Foodborne illness
is also responsible for 125,000 hospitalizations and more that 3000
deaths. The United States Department of Agriculture (USDA)
estimates annual costs for Salmonella alone to be $2,708,292,046.
Every type of food can potentially cause foodborne illness. The price
of food contamination each year is considerable costing billions of
dollars. As staggering as these figures are, the majority of Americans
no very little regarding food safety. Massive education of healthcare
workers on ways to prevent foodborne illness is needed. Health care
workers can in turn educate patients and the community on the issue
of food safety and ways to prevent foodborne illness. Project:
An extensive search of the literature on the topic of food safety was
performed. A comprehensive educational session was developed
and implemented on food safety . The program was titled, “What’s
For Dinner? “ and was presented to various groups of health care
providers and community members from September 2011 to
December 2011. The presentation was given at several venues
including: an APIC chapter meeting , Nursing Grand Rounds,
Physician Grand Rounds, lectures to medical students, interns,
residents, and midlevel practitioners. Topics included the prevelance
and incidence of foodborne illness in the United States, recent case
presentations of foodborne illness, sources of food contamination,
Multi Drug Resistant Organism transmission from contaminated
meat, feed lots, food safety regulation, and ways consumers can
prevent foodborne illness. Results: The interest generated from
this subject/presentation was enormous. We had started out hoping
to pass on how Multi Drug Resistant Organisms are transmitted to
humans from contaminated meat. However, after researching the
literature, we realized whan an enormous problem food safety is in
our country and around the world. Every type of food can become
contaminated. We recieved requests for repeat presentations and for
follow up information. We plan to continue the education in the fall
of 2012 and to expand the topics to include other areas of food safety
including seafood and organic foods. Lessons Learned:
Lack of food safety is an enormous public health problem. It is a
multifaceted issue that affects everyone in the world. Education is
needed not only in the community but in the health care realm.
A Model of a Longstanding State Infection
Prevention Collaborative
Virginia Helget, RN, MSN, CIC - Treasurer, Nebraska Infection
Control Network, Program Director, Nebraska Infection Control
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Network; Philip W. Smith, President, Nebraska Infection Control
Network - Professor of Infectious Diseases, University of Nebraska
Medical Center; Angela Hewlett - Assistant Professor of Infectious
Diseases, University of Nebraska Medical Center
Issue: In an era of limited resources, it is a significant advantage to
have collaboration among state organizations involved in healthcare
infection prevention and control. Such collaboration may be difficult
due to obstacles such as organizational territoriality and lack of a
vehicle for shared planning. Project: The Nebraska Infection
Control Network (NICN) is a nonprofit, service-oriented 501(c)
(3) organization, founded in 1980, whose objective was infection
prevention and control in Nebraska hospitals, nursing homes, and
other healthcare facilities by providing a vehicle for collaboration
and sharing of resources. Board members include Nebraska Health
and Human Services (NHHS), the Nebraska Hospital Association
(NHA), the Nebraska Health Care Association (NHCA), the
Greater Omaha Area Chapter of the Association for Professionals
in Infection Control and Epidemiology (APIC), the University of
Nebraska Medical Center, several at large members and a consumer
advocate. Results: The primary activity of the NICN is its
training program for infection preventionists (IPs) held biannually
since 1985. The impetus for this course was the limited ability of
small hospital and long term care facility (LTCF) IPs to travel to
national programs. Over 3000 trainees have attended these intensive,
2-day, low-cost courses, held in Omaha, Nebraska. Training sessions
cover the basic programmatic aspects of infection prevention. Two
tracks are available, one for hospital and ambulatory care IPs, and
one for LTCF IPs. The NICN provided other periodic educational
programs throughout the state to facilitate travel for participants.
These are cosponsored by various organizations with special
interests overlapping with infection control, such as the Nebraska
Adult Immunization Coalition and the state Quality Improvement
Organization. Over 2000 participants have attended these various
conferences. The NICN has also developed a newsletter and a web
site (www.nicn.org). The NICN has coordinated research projects
in various areas including pandemic influenza preparedness, IP
training needs, CMV infections, prevalence of LTCF antimicrobial
resistance, human immunodeficiency virus (HIV) policies, antibiotic
stewardship programs, urinary tract infections, and the status of LTCF
and hospital infection prevention programs in the state. In November
1988, the NICN received a National Community Health Promotion
Award from Dr. Otis Bowen, the Secretary of Health and Human
Services, in recognition of outstanding community health promotion
activities. Lessons Learned: The NICN serves as a model for
a streamlined organization that provides a vehicle for collaboration
among key state organizations involved in infection prevention
and control. The NICN has key stakeholders on its board, but has
remained an independent organization. The model has been effective
for over 30 years. The success of the NICN is due to the dedicated
work of state participants who have subjugated individual goals to the
public health benefits of joint infection prevention efforts.
the Right Direction by Using Data, Knowledge and
Rules to Improve Outcomes
Rebecca Casaday. McKinney, RN, BSN, CIC - Infection
Prevention Manager, St. Vincent Hospital Birmingham; Christine
Walz, RN - Infection Prevention Coordination, St. Vincent
Hospital Birmingham; David W. Barnes, MD, Infectious Disease Chairman of Infection Prevention Committee, St. Vincent Hospital
Birmingham
Issue: Annually Infection Preventionists (IP) are responsible to
create a plan to reduce Healthcare-Associated Infections (HAI),
a challenging aspect for overall patient safety issues. For many
years the infection prevention program (IPP) used recommended
evidence-based best practices (EBBP) for central venous catheters
(CLABSI) and urinary catheters (CAUTI). Despite this effort, our
HAI measures were higher than expected. Our IPP uses an electronic
surveillance system which applies an objective HAI algorithm
resulting in an electronic marker (EM). St. Vincent’s Birmingham
is a 409 bed acute care hospital with 52 adult ICU beds and a large
footprint in cardiac, neuro and orthopedic surgery. Project: For
FY2011 July – June, the plan was to reduce blood and urine EMs to
correlate with EBBP for CLABSI and CAUTI. EM data has been
shared with each nursing unit since 2007. IPs developed a scorecard
(SC) for each inpatient unit and the Emergency Department that
provided unit specific rates and measures for several prevention
efforts. These included rates for EM sources (blood, urine, respiratory,
wound and stool), CLABSI and CAUTI. Additional rates provided
included MRSA, CDIFF, blood and urine contamination, urinary
catheter usage and compliance rates for isolation and hand hygiene.
Hand Hygiene data is collected by “secret shopper” observers. Each
unit holds monthly meetings of their Bug Investigation Team (BIT)
to review SC data and works to resolve and improve process issues
and EM trends. The overall FY2010 EM, CLABSI and CAUTI
rates were average or trending up. Notably a second full-time IP
position began in October 2009. In FY2011 the IPP intensified a
non-cost resource; focus and support for infection prevention from
administration. Results: Comparing FY2010 to FY2011 the IPP
established significant positive EM trends with rate improvements in
double digit percents. Total or house-wide EM rates were decreased
by 19.15%. Blood EM down by 34.19% and urine EM decreased
by 11.42%. CLABSI rates decreased by 2% in adult intensive care
units (ICU) but remarkably decreased by 70% in non-ICU units.
Annual Outcomes for Infection Prevention: Going in
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CAUTI rate decreased by 7% in adult ICUs but again significantly
decrease by 25% in non-ICU units. Lessons Learned:
Excellent results do not just happen by chance. The IPP patient
safety improvements in FY2011 were realized by working the
continuous improvement process with clearly defined goals. A big
gain was how well patient outcome data was communicated to all
levels of staff (front line to administrative). The process became
effectual with the addition of IP staff and responsibility changes in
FY2011. The current state is for IPs to spend more time with unit
staff interactions, observations and assisting the BIT on scorecard
findings. The challenge now is to maintain these excellent results
and implement new projects to further reduce HAIs.
Increasing Hand Hygiene Compliance By Changing
the Culture
Can We Reduce Surgical Site Infections?
Autumn Langford, RN, BSN - Infection Control Coordinator,
Crestwood Medical Center; Ali Hassoun, MD, FACP, AAHIVS Infectious Diseases Specialist, Clinical Assistant Professor, UABHuntsville campus
Issue: Surgical site infections (SSIs) are the second most common
healthcare associated infections. According to the CDC, SSIs affect
2-5 percent of all patients undergoing surgery. These infections are
associated with significant mortality and morbidity, as well as an
increase in the length of hospital stay and the total cost for patients
and healthcare facilities. Project: Despite historically low
overall surgical site infection rates, in 2009, our 150-bed acute care
facility experienced one of our highest surgical site infection rates of
0.39 per 100 surgical cases for both wound class I and II surgeries.
To immediately address the issue, we introduced a Methicillin
Resistant Staphylococcus aureus (MRSA) surveillance program and
a decolonization method for patients in the preoperative period
for elective surgeries. In the initial phase, we targeted high risk
surgeries including total hips, knee, and spine surgeries. Patients were
instructed during their preoperative testing appointment to shower
with the provided 4% chlorhexidine gluconate solution the night
before and the morning of their scheduled surgery. The patients were
instructed to wear clean pajamas to bed and freshly laundered clothes
to the hospital the day of their surgery. Patients were reminded
not to shave any body part. In addition, we implemented MRSA
surveillance targeting patients to have devices implanted. Our plan
included screening the patients 7 days prior to surgery with a nasal
swab sent for culture to check for MRSA colonization. If positive, the
physician’s office would be notified and provided a decolonization
protocol. The protocol, if prescribed by the physician, instructed the
patient to use 1% muciprocin nasal cream in each nostril twice a day
for five days prior to surgery. Also, these patients were instructed to
bathe with a 4% chlorhexidine gluconate solution approximatley
5-7 days prior to surgery. Results: The overall annual rate of
SSIs decreased from 0.39 per 100 surgeries in 2009 to 0.25 per 100
in 2010 with rate reduction of 35%. Our wound class I surgical site
infection rate reduced by 61% as it dropped dramatically from 0.39
per 100 in 2009 to 0.15 per 100 in 2010. After initiating the second
phase of our project in May 2010, we continued to see a further rate
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reduction of 24% with a drop in the overall SSIs from 0.25 in 2010 to a
current rate of 0.19. Lessons Learned: MRSA surveillance and
decolonization protocol with chlorhexidine is an effective method to
reduce surgical site infections. During the third phase of this project,
we will include patients who require surgical intervention during their
hospitalization. Additionally, we will implement a process to use CHG
wipes the day of surgery for those patients who were unable to complete
the preoperative bathing protocol.
Maria Vacca, BSN, RN, CIC - Infection Preventionist, Pennsylvania
Hospital
Issue: Hand Hygiene rates in our facility remained low despite
continuous education. It occurred to us that just providing rates to
the staff was of little value. We wanted to find a way to increase hand
hygiene rates by changing the culture of the hospital. Project:
The project consisted of several parts: 1. Observations: Our Infection
Prevention Department obtained a grant from the Pennsylvania
Department of Health to purchase several iPads. We downloaded a
hand hygiene app onto the ipads and encouraged staff, volunteers, off
shift administration and students to down load the app as well to use for
hand hygiene observations. All observations performed using the app
are downloaded into an excel spread sheet for easy, accurate tallying. 2.
Interventions/Staff Empowering: The Infection Prevention Department
took every available opportunity to educate staff on “culture change”.
Any health care worker who is observed not performing hand hygiene
should expect to be informed of the occurrence. Any discipline should
feel comfortable approaching another discipline. For example, a unit
clerk should feel comfortable informing a physician that they forgot to
perform hand hygiene, etc. Reminder cards are given out when someone
is observed being noncompliant with the hand hygiene policy. The card
states “You Missed a Hand Hygiene Opportunity”. Reat time education
occurs at the same time. The recipient of the card is encouraged to pass
it on to someone they observe forgetting to perform hand hygiene.
3. Patient and Family Education/Empowering: Part of the money
obtained from the PA Department of Health grant was used to have
greeting cards made for every new admission and their family. The
greeting card is educational as to the importance of hand hygiene and
encourages the patient and their family to ask if the health care worker
remembered to clean their hands. Results: Our hand hygiene rates
increased slightly since starting the project a little over 1 year ago.
We hope to see a continued increase in our hand hygiene rates as the
culture continues to change and staff feel more comfortable performing
interventions. We also hope to maintain the change in culture that has
developed since origin of this project. Lessons Learned: Hand
Hygiene is an issue that requires constant education and intervention.
Education has to be done at the time of the missed opportunity to make
an impact. Health care workers need to know that this is not something
that will go away. They are expected as patient care providers to do what
is right for the patient and can expect to be held accountable it if they
fail to perform hand hygiene when appropriate. Also, Patients and their
families need to be included in hand hygiene education and programs.
the flu shot isn’t effective in preventing the flu, the cost associated
with flu vaccination (our flu shots are free to our members). Flu
vaccination marketing materials were historically too wordy and
members couldn’t relate to the images used. This year’s flu campaign
was designed to educate our members using messages that are simple
and clear to dispel their current flu misinformation and to encourage
and motivate flu vaccination in themselves and their families. Our
flu vaccination rate is currently 1,135,076 members; 11.7% higher
than this same time last year. Lessons Learned: The Kaiser
Permanente flu campaign addressed misinformation and attempted
to clarify confusion on the part of our members using messages that
were simple and clear. These educational messages were also placed in
the context of a marketing campaign, selected by the primary health
care decision makers in 440 households that resonated with and
motivated them to take action (getting themselves and their families
vaccinated against the flu). The campaign visuals were created to
resonate with the intrinsic qualities and values of all of our members
regardless of age, gender, or race, specifically the importance of caring
for those we love. The campaign concepts also emphasized what was
most important to the member, time and lifestyle considerations, in
addition to protection against the flu virus.
Survey of Literature, Patient Advisory Councils, and 440 Members
Leads to New Flu Campaign and Increased Flu Vaccination Rates.
Gale M. Ivie, MPH - Senior Consultant, Kaiser Permanente; Enid
K. Eck, RN, MPH - Regional Director, Infection Prevention and
Control, Kaiser Permanente, Southern California
Issue: Every year Kaiser Permanente Southern California invests
a great deal of time, energy, and financial resources to insure our
members and employees are immunized against the flu. This year’s
flu campaign was created to educate our members in a simple,
motivating way to dispel current flu misinformation and encourage
them to get vaccinated against the flu. Project: A literature
review of national research as to why individuals do not get
themselves or their children vaccinated against the flu was conducted.
A survey and discussion with four of our Patient Advisory Councils
followed to determine whether or not they get the flu vaccination
each year and, if not, what would motivate them to do so. These
councils consist of health care workers, some physicians, and
members who are age, SES, and ethnically diverse. An online survey
was conducted of 440 members, who identified themselves as the
health care decision maker in the family, to determine which one of
the four potential marketing concepts would motivate them to get
themselves and their families vaccinated against the flu. Results:
These efforts revealed key information about why people do not get
the flu vaccination. The primary reasons sited include: many think
a bad cold and the flu are the same thing; the flu shot gives you the
flu; only the elderly get the flu – healthy people don’t get the flu;
Control of Legionella Contamination with
Monochloramine Disinfection in a Large Urban
Hospital Hot Water System
Sheetal Kandiah, MD, MPH - Assistant Clinical Professor of
Medicine - Division of Infectious Diseases, Emory University;
Mohamed H. Yassin, MD, PhD - Medical Director of Infection
Control, UPMC Mercy; Rahman Hariri, PhD - Head of
Microbiology, UPMC Mercy; Julliet Ferrelli, MS, MT(ASCP),CIC
- Infection Control Coordinator, UPMC Mercy; Janet Stout, PhD Director Special Pathogen Lab, Laboratory and consulting service
Issue: Legionella species, mainly L. pneumophila is the etiologic
agent causing “Legionnaires disease” which is a systemic infection
obtained through the aerosolization of Legionella from contaminated
water sources. Multiple outbreaks of Legionnaires disease have occurred
within hospitals and extended care facilities due to contaminated water
supply with Legionella. Legionella sp is known to create biofilm in
plumbing systems making it very difficult to eradicate using current
methods. Monochloramine has been found to be effective against
Legionella in vitro and against biofilm-associated Legionella in model
plumbing systems. Monochloramine disinfection of municipal water
supplies has been associated with decreased risk for Legionnaires’
disease. To our knowledge, the use of monochloramine in a single
hospital water supply has never been evaluated in the USA. We
describe our experience with monochloramine disinfection in a
490 bed urban hospital in Pittsburgh, PA implemented after using
a copper-silver ionization system for many years. Project: As
part of a Legionella control plan, multiple sites in the hospital are
tested routinely every month. The cultures were obtained using swabs
of faucets and processed using Legionella enriched culture in our
Microbiology laboratory. In 2011, increasing levels of Legionella
67
were found particularly in sensor sinks (recently installed) and in
areas with water shut down due to construction and renovation
projects. Appropriate flushing procedures and cleaning of the faucets
with a bleach-based solution were unsuccessful in the eradication
of Legionella species despite adequate copper and silver levels. In
September of 2011 the hospital consulted and collaborated with the
Special Pathogens Laboratory in Pittsburgh to implement a hospitalbased monochloramine delivery system manufactured in Italy by
Sanipur. The monochloramine was only applied to the hot water
system and the levels of the monochloramine as well as other chemical
parameters were monitored closely and remained well within the
appropriate range. Routine Legionella cultures were obtained as well as
first draw water sample cultures on a monthly basis. Results: From
January 2011-September 2011, 23 faucets swabs were done monthly
with an overall average positivity rate of 33%. Sensor sinks cultures had
a higher positivity rate of 57%. After monochloramine introduction
into the hot water system in September 2011, faucets swabs revealed
a positivity rate of 0.00 %. All sensor faucets also converted negative
after only three weeks of monochloramine installation. Additional
water cultures by the Special Pathogens laboratory revealed a similar
decrease in positive cultures. Lessons Learned: This is the first
report of evaluation of monochloramine delivery system for eradication
of Legionella within the US health system. This new delivery system
allows the use of monochloramine on a small scale. The eradication of
Legionella was successful in a surprisingly shorter period than what
was anticipated. Monochloramine was very effective in eradicating
Legionella from sensor faucets that are particularly problematic. These
results suggest that, monochloramine can penetrate biofilm more
effectively than the copper-silver ionization system.
First Do No Harm - Efficacy of Influenza Vaccine
Mandate or Mask Mandate for the Healthcare
Worker
increase HCW vaccination rates, this healthcare system achieved
an average of 60% vaccination rate during the 2010-2011 Influenza
season. Previous strategies included free vaccine, targeted education,
accessibility and multiple clinics “No flu” stickers were placed on
employee ID badges to encourage coworker participation and as
a visual patient safety strategy. Position statements addressing the
need for mandatory vaccination for all HCWs have been reviewed
(including those from the APIC and SHEA). Project: Early
2011, this healthcare system of six acute care hospitals and multiple
outpatient facilities began an endeavor to mandate influenza vaccine
for all 10,000 HCWs. The process included obtaining support
from executive and medical staff, human resource departments,
and unions. Policies were reviewed and revised to satisfy corporate,
legal, and ethical concerns. By September, only one of the acute
care hospitals could support mandatory vaccine as a condition of
employment with the only exemptions being physician documented
medical contraindications. The other hospitals supported mandatory
wearing of a surgical mask for HCWs who were unable to take
the vaccine due to medical contraindications or employees who
refuse the influenza vaccine due to other reasons. This study will
demonstrate a difference in HCW vaccination rates comparing
Influenza Vaccine as a condition of employment vs. mandatory mask
wearing or vaccine as a condition of employment. Results: As of
Jan 1, 2012, the five hospitals with a policy of vaccination or required
masking attained an average vaccination rate of 93.2%. The hospital
with a CEO-supported vaccine mandate for employment attained a
vaccine rate of 99%. Lessons Learned: An important first step
is garnering the support of system administration. Steps included:
1.Organize a planning group including key policy makers at your
institution. 2. Gather scientific evidence supporting the importance
of HCW Influenza Vaccine. 3. Create a time table with reasonable
goals for the process. 4. Communicate frequently with all levels of
the organization so that you will have their input and engagement in
the process. 5. Address perceived risks of staff (accepting influenza
vaccine is paramount as actual risks are often sidelined by fears and
concerns perpetuated by non-evidence based sources). 6. Evaluate
where your support is strong as well as where you are most likely to
meet opposition. 7. Educate, educate, educate.
Linda Faris, BSN, MSEd, CIC, CPHQ - Director of Quality
Management, Summa Western Reserve Hospital; Patricia Wells, RN,
CIC - Infection Preventionist, Summa Akron City and St. Thomas
Hospitals; Virginia Abell, RN, BA, CIC - Director, Infection
Control and Clinical Safety, Summa Akron City and St. Thomas
Hospitals; Nancy Reynolds, RN, BSN, CIC - Regional Director
Infection Prevention and Control Summa Barberton Hospital
Summa Wadsworth Rittman Hospital Nurse Manager Clinic/
Wound Care Summa Barberton Hospital, Summa Health System;
Therese Sheffer, RN, BSN, MBA, CIC - Infection Preventionist
Crystal Clinic Orthopaedic Center , Summa Health System; Joan
Seidel, MA, RN, BSN - Infection Preventionist, Summa Robinson
Memorial Hospital
Issue: The stakeholders in this healthcare system strive to
continuously improve patient safety. However healthcare worker
(HCW) influenza vaccination rates have historically remained
low. HCW includes anyone employed by the hospital system or
affiliates. Independent physicians and volunteers are excluded from
rates but not from the required vaccine or mask. Despite efforts to
68
Intervention to Reduce Central Line Associated
Blood Stream Infections in Adult Critical Care
Hospital
Elham R. Ghonim, MT, ASCP, CIC - Director of Infection
Prevention, University of Mississippi Medical Center, Jackson, MS;
Rathel Nolan, MD - Director of the Division of Infectious Diseases,
University of Mississippi Medical Center, Jackson, MS; Michael H.
Baumann, MD - Chief Quality Officer, University of Mississippi
Medical Center, Jacskon, MS
Issue: Central Line Associated Blood Stream Infections
(CLABSIs) are a major source of morbidity, mortality, and cost for
healthcare facilities. During 2010 calendar year (CY), we observed an
increase in CLABSIs rates in our 84-bed adult critical care hospital.
CLABSIs rates were higher than the National HealthCare Safety
Network (NHSN) pooled mean. Retrospective analysis of all cases
led to the development of an intervention, which led to a noticeable
decrease in CLABSIs. Project: Phase 1 began in September
2010 and consisted of a retrospective review of line insertion and
maintenance practices. Data collected included site of insertion,
type of line, time interval between insertion and infection, device
utilization rate etc. Analysis of data revealed that most CLABSIs
occurred one week or greater following insertion, indicating issues
with line maintenance. Device utilization rate was higher than
NHSN pooled mean. Phase 2 began in January 2011 and focused on
improving practices regarding skin care and line maintenance. Hand
hygiene was strictly monitored. Education regarding best practices
in line maintenance was conducted using patient mannequins. A
needleless access device associated with increased rate of CLABSIs
was replaced. Use of a disinfection cap to cover needleless connector
was implemented to improve aseptic technique in accessing lines.
Standardized kits for line insertion and maintenance were provided.
Patient/family education was improved. Daily documentation
of necessity of use of all temporary central venous catheters was
required. Phase 3 is ongoing and focuses on accountability and
ownership of the process of line insertion and maintenance by
physicians and staff. Rates of CLABSIs by patient care unit are
published and distributed to all units, stakeholders and pertinent
committees. Physicians whose patients suffer CLABSI are required to
complete a form in attempt to document circumstances/risk factors
for each infection. Managers and infection prevention practitioners
reinforce use of best practices. Results: NHSN Standardized
Infection Ratio (SIR) demonstrates decrease in CLABSIs. SIR
indicated a 50% decrease in CLABSIs during 2011 compared to
2010 CY. Seventeen percent fewer CLABSIs than expected by
NHSN were observed during this same period. Central line days
slightly decreased during 2011 CY. Please refer to table 1 and figure
1. Lessons Learned: A multi-pronged effort focused on
improving technique in central line maintenance was successful in
reducing rates of CLABSI at an 84-bed adult critical care hospital.
Education, accountability, communication, and ownership among
staff, administration and infection prevention were keys to success.
Publishing a routine CLABSI report increased staff awareness of the
problem and increased trust in the data. Efforts to decrease rates of
infection and unnecessary use of central venous catheters are ongoing.
Hand Hygiene: There’s an APP for that?
Issue: Hand hygiene (HH) is the single most effective modality
to prevent the spread of infection in healthcare. HH is also one
of the most difficult quality measures to monitor. In a 722 bed
tertiary referral teaching hospital, collection of accurate and timely
HH compliance data on 25 inpatient units was problematic. We
needed a process that avoided confrontation and kept secret the
identity of HH surveyors to avoid compromise of professional work
relationships. Using easily recognized Infection Preventionists and
collecting the data on paper records was impractical. Our solution
was to employ a unique handheld device. Project: iScrub, a
hand-held application developed by The University of Iowa, is used
to record compliance with HH. Dates of intervention were January
1st – December 31st, 2011. HH observations were collected by
trained nursing volunteers and displayed on a central intranet –
based database using SharePoint software®, then included in quality
scorecard, and in the Infection Prevention (IP) monthly report.
Data collected included: number of observations, distribution of
observations among different job categories, names of observed
individuals, unit, occupation, HH indication, time, date, and
method used to perform HH. Episodes of non-compliance with
HH generated e-mail notifications with escalating consequences
that might end with termination of employment. Incentives were
provided to individuals showing consistent compliance with HH.
Results: During January 2011, 1,653 observations were collected,
HH compliance was 91%, physicians’ compliance (MDs) was 74%,
and nurses’ (RNs) compliance was 98%. Gaining administrative
support, publishing HH compliance data on monthly quality
scorecard and IP report, in addition to applying strict consequences
for individuals with poor compliance with HH, led to a gradual
increase of HH observations and compliance. During December
2011, we collected 4,553 HH observations. HH compliance was
96%, MDs’ compliance was 89%, and RNs’ compliance was 99%.
During the intervention we collected 26,657 observations. Average
HH compliance was 95%, average MDs compliance was 88%, and
69
average RNs compliance was 98% (Figure1). Non-compliance
occurred at a similar frequency both before and after patient contact.
Alcohol hand rub was the most frequently used method to perform
HH. Physicians often scored the lowest compliance rates among
healthcare workers. Time and date had no effect on compliance.
Lessons Learned: Hiding the identity of HH observers
eliminated confrontation, and probably increased the accuracy level
of collected data. Applying strict consequences for non-compliance
with HH aided in increasing compliance among staff and physicians.
Publishing HH data analysis aided in increasing the compliance with
HH. Data analysis identified issues related to the current application
and led to creating a new HH application that will be implemented
starting February1, 2012.
Emergence of Klebsiella pneumoniae Producing
KPC-Type Enzymes and Infection Control
Measures for Containing Hospital Spread
Patrizia Monti - Medical Director, Azienda Ospedaliera della
Provincia di Lecco; Fiorenza Folsi - Medical Director, A. Manzoni
Hospital (Lecco, Italy); Paolo Bonfanti - Director of Infectious
Diseases Unit, A. Manzoni Hospital (Lecco, Italy); Beatrice
Pini - Microbiologist, A. Manzoni Hospital (Lecco, Italy); Flavia
Regazzoni - Infection Control Nurse, A. Manzoni Hospital
(Lecco, Italy); Cristina Tentori - Infection Control Nurse, A.
Manzoni Hospital (Lecco, Italy); Francesco Luzzaro - Director of
Microbiology, A. Manzoni Hospital (Lecco, Italy)
Issue: Infections caused by Klebsiella pneumoniae producing
KPC-type enzymes (KPC-KP) are emerging worldwide as an
important challenge in health-care settings. Notably, these isolates
are resistant to almost all antibiotics (including carbapenems)
and are associated with high rates of morbidity and mortality. In
Italy, KPC-KP was first detected in November 2008. Beginning in
January 2009, appropriate infection control procedures (including
contact precautions and guidelines for laboratory detection of
carbapenemases) were adopted at our institution, as recommended
in areas where KPC-KP are not endemics. Here we describe the
dynamics of the emergence of KPC-KP as well as infection control
measures implemented for containing hospital spread. Project:
Identification and antimicrobial susceptibility of bacterial isolates
70
were routinely performed using the Vitek2 System (bioMérieux,
Marcy l’Etoile, France). When KPC production was suspected
on the basis of increased MICs for carbapenems (ertapenem >
0.5 mg/L, and/or imipenem > 1 mg/L, and/or meropenem > 0.5
mg/L) clinicians were promptly informed and contact isolation of
patients was applied. Carbapenemase production was then confirmed
by phenotypic and molecular methods. Treatment with colistin
(eventually associated with other antibiotics based on susceptibility
results) was implemented for infected patients only. Surveillance
rectal swabs were performed in patients with epidemiological link
to persons from whom KPC-KP had been recovered. Results:
Over a three-year period (2009-2011), a total of 13 KPC-KP were
detected from inpatients colonized (n=4) or infected (n=9). Most of
them were obtained from bronchoaspirate and/or urine cultures of
ICU patients (n=11), whereas the remaining were from Neurology
(n=1) and Orthopedics (n=1). In one case only, following urinary
tract infection, KPC-KP was recovered from blood despite adequate
therapy. The epidemiological analysis showed that 6/13 patients were
already colonized or infected at admission. All of them came from
ICUs of other hospitals or long-term care facilities. In the remaining
7/13 cases a presumable hospital hand transmission occurred. It
is noting that antimicrobial therapy was able to successfully treat
KPC-KP infections in 7/9 cases. Lessons Learned: So far,
infection control procedures adopted in 2009 have been effective to
contain the hospital spread of KPC-KP isolates at our institution.
Nevertheless, the high risk of transmission associated to these
worrisome strains (especially in ICUs) and the rapid increase of
carbapenem-resistant K. pneumoniae in Italy (as reported from
EARS-Net surveillance in 2010) suggest to reinforce infection
control measures (e.g., by implementing active surveillance based on
rectal swab in all patients admitted to ICUs).
Repeated Intervention Programmes to reduce VAP
rates and focus on effective components of the
Prevention Bundle in an Indian ICU
Namita Jaggi - Director, Labs and Infection control, NA; Pushpa
Sissodia - Executive Microbiologist, Artemis Health Institute; Ekta
Narayana - Infection control Nurrse, Artemis Health Insitute
Background/Objectives: Ventilator-associated
pneumonia (VAP) is the second most common hospital-acquired
infection and is associated with high morbidity and mortality rates
in the intensive care unit (ICU). Prevention of VAP can be achieved
by the adoption of ‘ventilator bundles’, but significant, yet labor and
cost effective interventions are yet to be identified. The objective of
the study was to examine the impact of bundled interventions in the
ICU on VAP rates and to find out the more effective and low cost
interventions from the bundle. Methods: The study was carried
out in three Phases in a 36 bedded ICU in an Indian Tertiary care
private Hospital setting over a three years period. VAP data over a
period of one year (2009, Phase I) was collected and retrospectively
analyzed for the incidence of VAP.The first supervision programme
was introduced in December 2009 where the VAP prevention bundle
was introduced and the staff trained. Regular surveillance audits
were carried out to evaluate the compliance to bundle components
and the impact of each component was critically evaluated in year
2010 (Phase II). The second supervision program was introduced
in December 2010 in which reiteration of the bundle components
was done. The impact was analysed in the subsequent year 2011
(Phase III) and the most effective components of the bundle showing
statistically significant effect on VAP were determined. Results:
• The VAP rates over the entire study period varied between 0 and
30.9/1000 ventilator days. • An overall reduction of 85.9% occurred
in the VAP rates over a three year period. The reduction in VAP rates
was observed from 9.72 (Phase I) to 3.43 (Phase II, 64.7% decrease)
and 1.37 (Phase III, 60.05% decrease) respectively as a result of
the interventions. • The mean VAP reduction (M=9.86, SD=8.23,
N=12) was significant, t(11)=4.14, two-tail p=0.0016, providing
evidence that the intervention programmes are effective in reducing
VAP rates. A 95% C.I. about mean VAP reduction is (4.63, 15.09).
• The most effective intervention components analyzed were head
of bed elevation, sub glottic suction, hand hygiene compliance of
healthcare workers and daily assessment of weaning and extubation
for ventilated patients showing p<0.05. Conclusions: 1.
Repeated supervision programmes are effective in reducing VAP rates
as evidenced by our study ( 86% reduction between the first and third
phase ). Repeated programmes balance out the negative impact of
staff attrition and positively impact the staff behavioural mind sets
towards compliance to set protocols. 2. However in a high workload
and stressful environment as the intensive care unit, we must move
towards focusing on labour and cost effective measures and possibly
truncating the prevention bundle in order to focus on interventions
that have maximum impact. This would free the staff to perform high
yield measures as opposed to just tick the boxes in the checklist.
Carol Vinci, MS, CIC, CPHQ, CPHRM, HEM, CPSO Director Risk Management, Regulatory Affairs, & Accreditation,
and Patient Safety Officer, Magee Rehabilitation Hospital; Jessica
Bunson, MT(ASCP), MS, CIC - Infection Preventionist, Magee
Rehabilitation Hospital
John Govednik, MS - Program Manager, McGuckin Methods
International; Maryanne McGuckin, Dr. ScEd, MT (ASCP)
- President; Senior Fellow, McGuckin Methods International;
Jefferson School of Population Health,Thomas Jefferson University
Background/Objectives: Hand Hygiene (HH) is the
single most important practice in the prevention of healthcareassociated infections (HAIs). Much research exists on the optimal
HH-events-per-bed-day (HH/bd) rates for ICUs and NonICUs, based on observation of opportunities. However, there is
little published research which determines the optimal HH/bd
rate for rehabilitation and long term care units (Rehab/LTCs).
OBJECTIVES 1) To establish HH/bd benchmarks for Rehab/
LTCs, and 2) to discover factors that influence HH/bd rates in
a rehabilitation hospital by tracking four years of HH education,
monitoring, and feedback. Methods: Using a national
measurement and benchmarking program, acute care hospitals with
rehab/LTCs and independent rehabilitation/long term care facilities
submitted tallies of soap and sanitizer used monthly per unit, along
with the corresponding periods’ patient census. Data were used to
calculate the HH/bd rate. Results were analyzed to determine the
mean for the aggregated data. The goal for all units in the study was
20HH/bd based on observation; this goal was used in monthly
reporting feedback as a goal for staff to strive to achieve. A 96 bed
rehabilitation hospital in Philadelphia, USA participated in the
program for over four years and provided qualitative observations to
suggest factors that influenced fluctuations in their monthly HH/
bd rates. Results: 12 months of HH tracking data were compiled
from 50 Rehab/LTCs in order to determine the benchmarks.
The mean was 14HH/bd at baseline (standard deviation (STD)
8.7); 19HH/bd at 12 months (STD 8) (Fig.1). The Philadelphia
hospital tracked three units for four years. Infection Preventionists
connected milestones in their hand hygiene education and training
interventions to fluctuations along their time-trend lines respective
of the national mean and goal. Conclusions: Our results show
Hand Hygiene Rates for Rehabilitation and Long
Term Care Facilities: One Hospital’s Journey
through the National Goal and Benchmarks
71
that there is a relatively wide STD for each monthly rate calculated
for the national database (STD ranging from 8 to 9.8 depending
on month). This suggests the difficulty in reaching a common
optimal rate, or goal, for HH/bd for Rehab/LTCs. The variation in
patient therapy (in room or out of room) may influence a hospital’s
rate respective to the mean or goal. Comparing the Philadelphia
hospital’s progress along the national timeline for the first 12 months,
a change in product suppliers impacted hand hygiene practice
and measurement for months 3 & 4, followed by increase in rates
possibly due to the attention of new product. However, continuing
on for months 18-36, HH rates dipped below the national goal as
staff became complacent in practices. In the final months (42-48)
of tracking, HH became part of the nurse manager’s performance
evaluation. HH rates show dramatic increases thereafter.
equivalent to approximately 8 lives and 2 ½ million dollars saved.
While the collaborative initiative ended in June 2010, the SCN
continued the practice changes that were made and celebrated one
year with zero CABSIs on November 2, 2011. We have now started
the second project with PQCNC, and expect continued success.
Lessons Learned: While the SCN had a very low rate of
CABSIs in previous years, it is now known that having zero CABSIs
is achievable. The evidence based practices that were put into practice
will continue and new ideas will be implemented to prevent CABSIs
in neonates.
Attaining Zero Catheter Associated Bloodstream
Infections in a Level III Nursery
Prevention & Environmental Services, Catawba Valley Medical Center;
Andrea Flynn, RN-C, MS - Clinical Development Coordinator,
Nurseries and Pediatrics, Catawba Valley Medical Center
Issue: The Special Care Nursery (SCN) at a community
Magnet hospital had a total of nine Catheter Associated Blood
Stream Infections (CABSIs) from January 2008 to August 2009.
Project: The Special Care Nursery (SCN) is a 12-bed Level III
Nursery within a 258-bed, not-for-profit, Magnet hospital located
in North Carolina that offers a full range of medical services and
specialties to a 5-county region. From September 2009-June 2010,
the SCN participated with the Perinatal Quality Collaborative
of North Carolina (PQCNC) in a project to decrease CABSIs in
neonates. A total of 13 intensive care nurseries participated. While
the SCN CABSI rate was considered low for a unit of its size, even
one CABSI was too many. The PDSA (Plan, Do, Study, Act) cycle
for process improvement for the SCN included implementing
new evidence-based practices to decrease the chance of infections.
These practices included: • Discontinuing the central lines as soon
as possible (to decrease the possibility of an infection occurring), •
Using sterile gloves during tubing changes (to maintain line sterility),
• Applying 3.15% Chlorhexidine on hubs, 2% Chlorhexidine on
infants that qualify (a more effective skin disinfectant), • Utilizing
a closed system for umbilical arterial catheters (less likely to cause
an infection), and • Obtaining a dedicated X-ray machine that stays
in the SCN (to prevent contamination throughout the hospital).
During the duration of this project, nurses completed forms every
shift documenting insertion and maintenance techniques. Chart
audits, observations and data entry ensured compliance from nurses,
mid-level practitioners and physicians. Results: The goal for
this project from September 2009-June 2010 was to decrease the
CABSI infections by 50%. This goal was met, and exceeded in the
months to follow. In 2010, the SCN had 2 CABSIs, with a rate of
3.19. In 2011, the SCN had zero CABSIs. Overall, the PQCNC
experienced a 62% decrease in CABSIs across the state, which is
72
Taxonomical Risk Assessment
Jackie E. McFarlin, RN, MPH, MS, CIC - Infection Prevention and
Control Coordinator, VA North Texas Health Care System
Issue: Risk Assessments most often are developed intuitively
or based on regulatory expectations, but we have found that a
taxonomical risk assessment is more useful in improving infection
prevention outcomes and processes. Project: The project took
place at a Veteran’s Affairs medical center with multiple clinical
services. A hierarchial taxonomy with four tiers was developed
representing evidence based risk characteristics related to Man (the
patient), Environment, Microorganism Patterns, and Processes.
Intrinsic patient characteristics such as demographics, health status,
lifestyle patterns, and immune compromise predispose the person
to infections, and may increase exposure risks for other patients. The
environment, a likely source for transmission of microorganisms,
includes a gradient of risks based on whether surfaces are high,
medium, or low touch. Clinical unit cultures based on the types
of patients seen, the environment, or various staffing issues often
develop and influence the frequency of organism transmissions,
confirmed infections, and communicable disease outbreaks. Finally,
process behaviors for treating patients may contribute to various
infections, dialysis related adverse events, surgical site complication,
and pathogen transmission. Risk characteristics are determined
from administrative data, laboratory data, observational checklists,
process evaluations, and questionnaires. Binomial scores of zero and
one are assigned to reflect the presence or absence of characteristics
in most data collection, but some scores are computed from ordinal
scales. A cumulative score for each tier is computed by multiplying
the sum of all risk characteristic scores by a “risk constant”. The risk
constant for the tier representing characteristics of Man is one, and
risk constants increase by one as the rank order of the tier increases.
The comprehensive risk assessment is the foundation for infection
prevention and control (IPC) work. IPC Coordinators concentrate
work in clinical areas with cumulative scores exceeding the median of
all clinical arenas evaluated. Process improvement projects germane
to the specific risk characteristics for the ward are implemented.
Results: During the two years of implementing the taxonomical
risk assessment, we have seen a decline in the number of blood
stream infections, transmission of MRSA and other pathogens, and
surgical site infections. Staff engagement in the processes of infection
prevention has also increased. Lessons Learned: A method of
automating data is essential for using a taxonomical risk assessment.
Continuous update of the risk assessment is less useful than semiannual or annual update. Quantified results from a taxonomical
risk assessment can be used to affect process control and ultimately
outcomes.
sample acquisition component of the system is brought into play.
Conclusions: We analyzed the response of an ATP based
monitoring system to various clinically relevant sources of ATP. The
system has a very high sensitivity to neat ATP (1 femtomole/swab)
and to samples of diluted whole blood (detected down to a 1x10^-7
dilution). For bacterial samples, the system can detect both Gram
negative (G-) and Gram positive (G+) organisms with a different
efficiency. In general, sensitivity is higher for G- organisms where for
certain bacteria it’s possible to detect samples of 1,000-2,000 CFUs/
swab. G+ organisms can also be effectively detected, but in slightly
higher concentrations. Of note is the ability to detect a resistant
strain (MRSA) with comparable sensitivity to the sensitive strain.
Finally, the system can also efficiently detect bacterial specimens
collected from the surface of an inoculated coupon, albeit with a
lower sensitivity when compared to swabs directly inoculated with
a similar sample. This is because the efficiency of collecting a sample
using a swab has to be taken into account.
Detection Capabilities of an ATP (Adenosine
Triphosphate) Based Monitoring System for
Clinically Relevant Sources of ATP
Kathleen Baxter, SM, AAM - Director, Quality Assurance, Hill Top
Research; Marco Bommarito, PhD - Senior Research Specialist,
3M Infection Prevention Division; Julie B. Stahl - Senior Clinical
Research Specialist, 3M Infection Prevention Division; Dan J. Morse
- Senior Biostatistical Specialist, 3M Infection Prevention Division
Background/Objectives: ATP based detection systems
are becoming a more prominent tool for monitoring the patient’s
environment. Thus, it is important to understand the detection
capabilities of these ATP monitoring systems with respect to
clinically relevant sources of ATP. Methods: Two basic test
methods were employed in this study. In the first, the swab of
the ATP test was inoculated with a sample containing a known
concentration of one of the following ATP sources: neat adenosine
triphosphate, bacterial cells, blood. Several dilutions were measured
to construct a dose-response relationship. The diluents used consisted
of either a PBS (phosphate buffer saline) buffer or an artificial
test soil (ATS from Healthmark). In the second method, a 100uL
volume of PBS buffer spiked with different concentrations of
bacteria was applied to a 316L stainless steel coupon. A sample for
analysis was collected by swabbing this surface. ATP was measured
in RLUs (Relative Light Units) using a bioluminescent luminometer.
Results: The tables below show the range of the lowest detectable
amounts from the various ATP sources tested. These ranges were
determined by identifying where the positive response signal in RLUs
from multiple runs of the sample tested, intersected the average
background RLU signal from swabs not exposed to the sample.
Table I shows the results from dose-response measurements of swabs
inoculated directly with different sources of ATP. These data are an
indication of the analytical performance for the assay. Table II shows
the results from dose-response measurements of swabs collected from
stainless steel coupons inoculated with different sources of ATP.
These data give an indication of the detection capability when the
Monitoring the Cleaning of Surgical Instruments
with an ATP Detection System
David M. Jagrosse, CRCST, CSPDT, AAMI ST79 workgroup
- Manager CSSD, Middlesex Hospital; Marco Bommarito, PhD
- Senior Research Specialist, 3M Infection Prevention Division;
Julie B. Stahl - Senior Clinical Research Specialist, 3M Infection
Prevention Division
Background/Objectives: The primary objective of
this study was to demonstrate the feasibility of using an ATP
assay to monitor the cleanliness of surgical instruments during the
decontamination and cleaning process. The data obtained could be
used to define process control parameters for each step of the manual
cleaning and automated wash/disinfection. These control parameters
can then be applied in an auditing fashion to monitor quality control
and drive process improvement. Methods: Surgical instruments
from surgical procedure trays in the CSS of Middlesex Hospital
were tested using an ATP assay. The method entailed collecting a
sample using a 3M™ Clean-TraceTM ATP Surface Test swab and
determining the amount of ATP in relative light units (RLUs) with a
73
3M™ Clean-TraceTM luminometer. Instruments were sampled after
manual cleaning and after automated wash/disinfection. The study
consisted of two phases. In Phase 1, data was collected from two types
of surgical instruments (forceps and scissors), and used to define pass,
caution, and fail values for each step of the process. In Phase 2, the
same instruments were monitored to validate whether the cleaning
and disinfection process remained in control. Instruments that could
only be cleaned manually prior to terminal sterilization were tested
to understand how different pass, caution, and fail values may be for
this subcategory of instruments. Results: In Phase 1 two types
of surgical instruments were benchmarked with action limits (pass,
caution and fail values) established for both the manual cleaning and
automated wash/disinfection steps of the decontamination process
(see Table I below). In Phase 2, sampling and analysis of the data was
duplicated to generate a new set of action limits (Table II). A set of
instruments that could only be cleaned manually was benchmarked
with the following action limits observed (Table III). Table III –
Means and action limits for instruments that could only be cleaned
manually. Conclusions: Successful quality control using this
method appears highly feasible. The decontamination process was
observed at two time points. The manual cleaning step showed action
limits that were similar. The automated wash/disinfection cycle
action limits were different. Although the mean RLU values for each
phase were very similar for this step of the process, the variability
increased significantly, leading to higher values for the pass-caution
and caution-fail thresholds. Action limits for instruments that cannot
be processed in an automated washer/disinfector are significantly
higher. This may be an important consideration for reprocessing of
these instruments. The study demonstrates: 1) use of this objective
method to establish pass-caution-fail criteria to monitor cleanliness
of surgical instruments on an ongoing basis 2) use of the ATP assay as
a training tool, leveraging the real-time nature to provide immediate
feedback to the technician on manual and automated wash
techniques and processes.
74
From Good to Great with Strategic Planning
Beverly J. Gray, RN, MS, CIC - Infection Prevention and
Control Program Director, VA North Texas Health Care
System
Issue: Good Infection Prevention and Control (IPC)
Programs strive to satisfy regulatory and stakeholder
expectations. A Great IPC Program is viewed as one in
which expectations are met in an efficient manner and
effective actions are taken to improve and sustain practices
for prevention of infections. Faced with the same challenges
as other programs, we turned to strategic planning as a means
for our IPC Coordinators to work smarter and accomplish
greater outcomes. Project: Strategic planning begins with
envisioning a desired future and applying a defined process
to accomplish the vision. In a large VA Health Care System,
we elected to use the logical framework method for strategic
planning which is a tool for outlining goals, objectives, and
actions necessary to accomplish the vision. The vision for our
program is for all healthcare providers to comply with clinical
practice guidelines for prevention of infections. Actions of
the IPC Coordinators are to assess, guide, support, and direct
others to facilitate this vision. IPC Coordinators are assigned
to work with specific clinical areas identified with the greatest
risks for patients developing infections. A logical framework
chart was developed specifically for each high risk clinical
unit with objectives or outcomes based on results of a risk
assessment. Activities were defined in terms of clinical practice
behaviors needed to reduce risks and specific IPC Coordinator
roles needed to assist staff. Measurable indicators and means of
verifying outcomes were specified. Careful consideration was
given to all of the extraneous events which we assumed would
be held constant for each input to be effective and possible.
Using an if-then logic we examined the logical framework
chart using the following questions: (1) If the assumptions
were satisfied and the inputs accomplished, would the outcome
then be achieved? (2) If the outcome was realized would the
purpose and goal then be accomplished? Results: The
logical framework charts served as a road map to enable the IPC
Coordinators to clearly communicate plans for improvement
with key stakeholders. Use of the logical framework increased
the amount of time IPC Coordinators were on clinical units
working with staff, decreased the number of crisis demands, and
improved staff compliance with infection prevention behaviors.
IPC program efficiency and sustainable practices for prevention
of infections were increased. Lessons Learned: Strategic
planning requires motivated leadership with evidence based
vision and IPCs who are willing to experiment with alternative
role approaches. The use of a logical framework process
forced the IPC staff to analyze roles and identify purposeful
links between activities and achievement of goals. The logical
framework also proved to be a very useful tool for increasing
collaboration between the IPC Coordinators and clinical staff.
A Nurse Driven Foley Catheter Removal
Protocol Proves Clinically Effective to Reduce
the Incidents of Catheter Related Urinary Tract
Infections
Lynn P. Roser, PhD Candidate, MSN, RN- Nurse
Epidemiologist, Central Baptist Hospital; Terry Altpeter, PhD,
JD, RN - Executive Director, Outcomes, Central Baptist Hospital
Issue: The Centers for Disease Control (CDC), attributes
catheter associated urinary tract infections (CAUTIs) to 30% of the
infections in acute care hospitals. CAUTI causes major complications
resulting in longer hospital stays, increased healthcare costs and
mortality. This hospital implemented a nurse driven urinary catheter
removal protocol the first in Kentucky to reduce urinary catheter
associated infections in the intensive care units and general floor
units. The Infection Control Team, along with Unit Directors,
developed and implemented the protocol, empowered nurses to
initiate the protocol, and worked with physicians to remove catheters.
Project: In 2011 the hospital infection prevention team
implemented an evidence based nurse driven urinary catheter removal
protocol that identified indicators for urinary catheter insertion,
maintenance, and discontinuation. The protocol empowered nurses
to communicate with physicians to determine the medical necessity
for the catheter, and remove the urinary catheter within 24 hours
unless contraindicated. (Figure 1.) The Nurse Epidemiologist
received electronic reports of all urinary catheters in the hospital
and information related to catheter medical necessity. If the medical
necessity did not support the catheter remaining in the patient, the
nurses removed the catheter. The Nurse Epidemiologist launched
an intensive education plan to inform the nurses of the protocol.
The Infection Prevention Team conducted surveillance rounds to
evaluate medical necessity and appropriate catheter care. Education
continued with new nursing staff and reminders to existing staff of
the importance of removing catheters. The Physician Epidemiologist
responsible for the hospital’s overall infection prevention program
assured that physicians understood the hospital’s quality initiative and
reviewed data weekly in IC team meetings. The hospital’s senior team
reviewed CAUTI data by unit each month. The hospital also entered
into a collaborative program with the state Quality Improvement
75
Organization (QIO) to report CAUTI’s and the AHRQ’s 2009
Comprehensive Unit Based Safety Program (CUSP) to end
healthcare associated infections HAI’s. Results: Data collected
prior to the nurse driven protocol demonstrated physicians ordered
Foley catheters for inappropriate reasons (Graph 1). Physicians
misunderstood criteria for catheter use for patients requiring comfort
care at the end of life. Nurse educators and the Infection Control
(IC) team provided educational sessions to staff about appropriate
urinary catheter uses. The IC team rounded reinforcing proper
catheter use. After implementation of the protocol, the facility found
a decrease in catheter utilization in the intensive care units (ICUs)
and the medical/surgical units (Graphs 2 and 3). Catheter utilization
rates and number of CAUTIs show a significant decrease from
2010 to 2011 (Tables 1 and 2). Lessons Learned: Medical
providers now look at catheter use seriously. Many alternatives to
a catheter exist such as a bedpan, bedside commode, in and out
catheterization of the patient, and adult diapers. Nurses’ exhibit
empowerment to remove the catheter when no longer needed.
Enhancing Infection Prevention’s Role during
Construction in a University Medical Center
project, ensuring that these parties are part of the process of issuing
Infection Control Risk Assessment (ICRA), and that an Infection
Control (IC) permit was issued to each project. • Maintain
contractors in compliance with Infection Prevention and Control
(IP&C) guidelines during construction. Project: After gaining
the support and approval of the hospital administration, the IPD
identified parties involved in the ICRA to be Physical Facilities,
Environment Health and Safety (EHS), Architect, and the IPD. The
IPD rules during construction were restructured as follows: • Prior
to construction, the IPD initiates a meeting with involved parties
to ensure that the construction design is in compliance with the
guidelines of the American Institute of Architects (AIA), and The
Joint Commission (TJC) standard, and to verify the environmental
safety of employees, patients, and visitors during construction. •
During construction, Infection Preventionist Practitioner (IP)
perform routine walk through survey to ensure compliance with the
IP&C guidelines. • Upon construction completion, IP Practitioners
perform a final walkthrough survey to verify the area is free of dust,
utilities are properly working, and to ensure availability of hand
hygiene products, isolation rooms, etc. IPD was empowered by
Hospital Administration to stop any construction project upon
contractors’ deviation from IP&C guidelines. To ensure that the IPD
is involved in all construction projects and satisfied with the permit
process, Physical Facilities creates an infection prevention survey for
each construction project. Education was developed and performed
by the IP Practitioners and the EHS safety officer, and provided to
contractors and staff prior to each project. Results: Education to
contractors and staff increased the level of awareness of construction
effect on healthcare setting and their roles during construction.
Empowering the IPD to stop construction forced the contractors to
comply with the IP&C guidelines. During 2011 calendar year, the
IPD issued over 30 IC permits, provided over 60 educational sessions,
and performed over 300 surveys. As a result, construction is running
in a smooth manner with minimum exposure to dust or construction
material. Physical Facilities’ survey plays an important role in ensuring
that the IPD is involved in each construction project and that an
IC permit is issued for each project, prior to this survey multiple
non- permitted projects exist. Lessons Learned: Education,
team work, administration support, and communication between
IPD, contractors, and staff are vital tools in increasing awareness and
compliance with the IP&C guidelines
Personal and Household Hygiene, Microbial
Contamination, and Health Status in
Undergraduate Residence Halls in New York City
Issue: In a 722 bed tertiary teaching hospital, the Infection
Prevention Department (IPD) faced multiple challenges during
construction that included: • Defining rules of the IPD during
construction, gaining the support from administration to implement
these rules, • Identifying parties involved in the construction
Bevin Cohen, MPH - Project Coordinator, Columbia University
School of Nursing; Benjamin A. Miko, MD - Fellow, Division of
Infectious Diseases, College of Physicians and Surgeons, Columbia
University; Laurie Conway, RN, MS, CIC - Doctoral Student,
Columbia University School of Nursing; Nicole Kelly - Research
76
Katharine G. Haxall, RN, MPH - Research Assistant, Columbia
Assistant, Columbia University School of Nursing; Dianne Stare,
MPH - Research Assistant, Columbia University School of Nursing;
Christina Tropiano - Research Assistant, Columbia University
School of Nursing; Allan Gilman, MS, M(ASCP), M(NCA) Assistant Professor, Bronx Community College; Samuel Seward Jr.,
MD - Assistant Vice President of Health Services, Assistant Professor
of Clinical Medicine, Columbia University; Elaine L. Larson, RN,
PhD, CIC - Associate Dean for Research, Columbia University
School of Nursing
Background/Objectives: Studies have described college
students’ hygienic practices but not the association between hygiene
and microbial contamination or frequency of illnesses. The purposes
of this study were to describe students’ knowledge, practices, and
beliefs about hygiene; examine microbial flora in dormitories;
and assess whether microbial contamination varied according to
frequency of cleaning, dormitory style, and frequency of illnesses.
Methods: Undergraduate students at Columbia University,
New York, NY were recruited at a campus dining location.
Students completed a 10-minute survey assessing demographics,
health history, and knowledge, practices, and beliefs about
hygiene. A subsample of survey respondents volunteered to have
their dormitory environments sampled. Two trained researchers
swabbed, with a sterile DACRON®-tipped applicator, a 2-cm2
area of these surfaces in each student’s dorm: computer keyboard,
bookshelf, desk, reusable cup/dish, television remote, overhead light
switch, refrigerator handle, toilet flush handle, and bathroom stall/
door handle. Bacterial contamination was assessed using standard
quantitative bacterial culture techniques. Results: Four hundred
and fourteen students (196 men, 217 women, 1 transgender), 17-23
years old, completed the survey. Less than half of students were
aware that hand washing reduces transmission of colds, flu, and
gastroenteritis, and 39.8% believed that hand washing is unimportant
to prevent disease (Table 1). More women than men reported hand
washing always or most of the time for all indications surveyed and
reported that hand washing can prevent colds, flu, and gastroenteritis.
More underclassmen than upperclassmen reported hand washing
prior to preparing food and eating, but no significant differences were
noted between science and humanities majors. Most students (56%)
felt that their personal hygiene was the same as others’, and only 5%
felt theirs was worse. Microbiologic data were collected from the
dorms of 40 participants (18 men and 22 women). Bacterial growth
ranged from 0-35 colony forming units (CFUs) with little variation
by type of dorm, frequency of cleaning, or frequency of illnesses
(Table 2). Staphylococcus aureus was detected in three participants’
rooms (on a dish, bookshelf, and remote control), and coliforms were
present in six students’ rooms (on a remote control, keyboard, desk,
light switch, refrigerator handle, bathroom door handle, and three
bookshelves). Two of these students reported cleaning daily, three
weekly, two monthly, and one never. Conclusions: Despite
reporting frequent cleaning, coliforms were found in some students’
rooms, on surfaces used for cooking and eating, and on surfaces
shared by multiple students, suggesting that opportunities for
transmission may be possible, even when hygienic measures are taken.
You are What You Eat: Engaging Long-Term Care
Residents in Meal Time Hand Hygiene
Marguerite O’Donnell, RN, BSN, CIC - Infection Control
Nurse, Infection Control Department, Louis Stokes Cleveland VA
Medical Center; Tony Harris - Nursing Assistant, Nursing Service,
Louis Stokes Cleveland VA Medical Center; Terancita Horn, RN
- Registered Nurse, Nursing Service, Louis Stokes Cleveland VA
Medical Center; Blondelle Midamba, MS, RD, LD - Dietitian,
Medical Service, Louis Stokes Cleveland VA Medical Center; Vickie
Primes, DTR - Dietary Tech, Louis Stokes Cleveland VA Medical
Center; Rosalyn Shuler, NP - Nurse Practitioner, Nursing Service,
Louis Stokes Cleveland VA Medical Center; Nancy Sullivan ,
RN - Registered Nurse, Nursing Service, Louis Stokes Cleveland
VA Medical Center; Trina Zabarsky, RN, MSN, CIC - Infection
Control Practitioner, Nursing Service, Louis Stokes Cleveland VA
Medical Center; Curtis J. Donskey, MD - Chair, Infection Control
Committee, Louis Stokes Cleveland VA Medical Center
Background/Objectives: Healthcare workers are the
focus of most hand hygiene improvement initiatives. Hand hygiene
by patients may also be an important means to prevent acquisition
of healthcare-associated pathogens, but few interventions have
involved patients. Our objective was to examine the frequency of
hand hygiene prior to meals in a long-term care facility (LTCF)
and implement an intervention to improve mealtime hand hygiene
practices. Methods: We conducted observations to assess the
frequency of performance of hand hygiene prior to meals on one
unit of a Department of Veterans Affairs LTCF. Residents were
surveyed regarding their opinions and knowledge of hand hygiene
77
and of perceived barriers to hand hygiene. A team including LTCF
residents, administration, nurses and nursing assistants, dieticians,
and Infection Prevention performed an intervention to increase
hand hygiene performance. Results: Before the intervention,
hand hygiene prior to meals was performed in only 4 of 240 (2%)
observations. Of 21 residents surveyed, 20 (95%) knew that hand
hygiene would protect them from infections and 20 (95%) were
aware that contact with devices such as wheelchairs, walkers, and
canes could result in hand contamination with pathogens. Although
non-antimicrobial towelettes were available on each tray, most
residents were either unaware that they were present or unable to
open them due to lack of dexterity. Based on the initial assessment,
an intervention was performed that included providing education
on the importance of hand hygiene, reminders to perform hand
hygiene prior to meals, a hand hygiene stand at the entrance to the
dining room with antimicrobial wipes and an automated dispenser of
alcohol gel, and resident participation in education and distribution
of wipes. As shown in the figure, there was a significant increase
in the percentage of residents performing hand hygiene prior to
meals on the unit by month (P<0.0001). The decrease in June was
attributed to lack of timely re-stocking of the stands which was
corrected by engaging housekeepers support. Conclusions:
LTCF residents are aware of the importance of hand hygiene before
meals, but barriers such as inaccessible or difficult to use products
may limit compliance. In our LTCF, a dramatic and sustained
improvement in mealtime hand hygiene was achieved through an
interdisciplinary team effort.
Chasity Daugherty, RN - Registered Nurse, Nursing Service, Louis
Stokes Cleveland VA Medical Center; Holly Hovan, RN - Registered
Nurse, Nursing Service, Louis Stokes Cleveland VA Medical Center;
Michelle Stewart, RN - Registered Nurse, Nursing Service, Louis
Stokes Cleveland VA Medical Center; Dyanne Thomas, RN Registered Nurse, Nursing Service, Louis Stokes Cleveland VA
Medical Center; Curtis J. Donskey, MD - Chair, Infection Control
Committee, Louis Stokes Cleveland VA Medical Center
Issue: Rates of influenza vaccination are often suboptimal
in healthcare workers. Buy in from staff members and the
administration may be a key factor in determining the success of
initiatives to improve vaccination rates among healthcare workers.
Our objective was to test whether recruiting nurse champions on each
unit of a long-term care facility (LTCF) would result in improved
rates of staff influenza vaccination. Project: At the beginning
of 2011-2012 influenza season, the Infection Prevention program
and the administration recruited RN nurse champions on 5 units of
the Cleveland VA Medical Center’s community-living center. The
nurse champions received education on influenza and participated
in ongoing promotion of influenza vaccination of staff members on
their unit. Small incentives were provided for units that provided
education to 100% of staff members and achieved staff vaccination
rates of 85%. The infection Preventionist provided real-time feedback
to staff and leadership. Units with a staff vaccination rate of less
than 85% were reassessed for barriers to staff acceptance of influenza
vaccination. Percentages of staff members receiving vaccination
on each unit were compared with the percentages from previous
years. Results: One-hundred percent of the staff members
on the 5 units received education on the importance of influenza
vaccination. The overall percentage of nursing staff members who
received vaccination was 78% (118/152 nurses) compared with 62%
to 69% in 4 prior influenza seasons. The percentages of vaccinated
staff members varied widely on different wards, ranging from 61%
to 91%. Interviews with staff members on the unit with the lowest
level of compliance indicated that some influential nurses were vocal
in their opposition to vaccination and there had been an observed
adverse reaction to vaccination in an employee on the unit during the
previous year. Lessons Learned: Nurses can play a powerful
role in promoting or discouraging influenza vaccination among
their colleagues. Recruiting ward-level nurse champions was a useful
strategy to improve staff vaccination rates in our facility.
The STOP (Staff Taking Ownership for
Prevention) FLU Initiative: Improving Influenza
Vaccination Rates among Staff in a Long-Term
Care Facility
Marguerite O’Donnell, RN, BSN, CIC - Infection Control
Nurse, Infection Control Department, Louis Stokes Cleveland
VA Medical Center; Kelli Bachman, RN - Registered Nurse,
Nursing Service, Louis Stokes Cleveland VA Medical Center;
78
Automatic Foley Catheter Stop Order
Romeo P. Mamon Jr., RN, BSN - Infection Prevention Practitioner,
Atlantic Health System
Background/Objectives: Use of foley catheters can
lead to complications, most commonly catheter-associated urinary
tract infections (CAUTI). Duration of foley catheter use is one
the major risk factor. To implement and evaluate the efficacy of an
intervention to reduce catheter-associated urinary tract infections
in 4AB (cardiology/ medical unit) by implementing an automatic
foley catheter stop order. And further, to evaluate the impact of
the protocol on foley catheter days. Methods: Indications for
continuing urinary catheterization with indwelling devices were
developed by the infection prevention department and key physicians
in infectious disease. For a planned 6-month intervention period
(from December 2009 to May 2010), patients in 4AB who had
foley catheters were evaluated on day 2 of having a foley catheter
by using a set of criteria for appropriate catheter continuance.
Recommendations were made to PMD to discontinue indwelling
urinary catheters in patients who did not meet the criteria. If order
is not written to continue foley at 72 hours, it will be discontinued
in the morning at 6 am if patient does not meet identified criteria.
Medmined, a data mining tool is used to determine any positive
urine culture monthly in the said unit. Those with positive urine
cultures are further filtered whether they have a foley catheter or not.
NHSN definition for catheter-associated urinary infection is used
to determine CAUTI rates monthly for those with foley catheters.
Foley catheter days, unit census and rates of catheter-associated
urinary tract infections during the intervention were compared with
those of the preceding 3 months. Results: During the 6-month
intervention period, the foley catheter days was reduced to an average
of 201 days/month compared to the baseline 3-month average rate
of 228 days/month (from September 2009 to November 2009).
This result represented a 9% decrease in foley catheter days. It is
important to note that the average baseline monthly unit census
was 1129 patients/month compared to 1183 patients/month of the
intervention period which represented a 9.5% increase. The rate of
catheter-associated urinary tract infections per 1000 days of use was
2.9/month before the protocol was initiated and zero during the
6-month intervention period. Conclusions: Implementation
of an intervention to automatically stop foley catheter that doesn’t fit
in the indicated set of guidelines may result in significant reductions
in duration of catheterization and occurrences of catheter-associated
urinary tract infections.
Clostridium difficile infection prevention initiative
to reduce the incidence and prevalence of
Clostridium difficile among Veterans in acute-care
inpatient facilities
Marla Clifton, RN, MSN, CIC - MDRO Clinical Program
Coordinator, National Infectious Diseases Service, VA Central
Office, Department of Veterans Affairs/VHA; Judith Whitlock,
RN, MSN, APRN, CIC - MDRO Program Education Coordinator/
Specialist, National Infectious Diseases Service, VA Central Office,
Department of Veterans Affairs/VHA; Martin Evans, MD - VHA
MDRO Program Director, National Infectious Diseases Service,
VA Central Office, Department of Veterans Affairs/VHA; Stephen
Kralovic, MD, MPH - Medical Epidemiologist, National Infectious
Diseases Service, VA Central Office, Department of Veterans Affairs/
VHA; Rajiv Jain, MD - Acting Chief Officer, Patient Care Services,
VA Central Office, Department of Veterans Affairs/VHA; Gary
Roselle, MD - Director, National Infectious Diseases Service, VA
Central Office, Department of Veterans Affairs/VHA
Issue: Clostridium difficile infection (CDI) is the leading cause of
healthcare-associated infectious diarrhea in United States hospitals.
The severity ranges from mild colitis to toxic megacolon and death.
C. difficile contends with Methicillin-Resistant Staphylococcus
aureus (MRSA) as the most common organism to cause healthcare
associated infection in the United States. Because CDI is an
important cause of morbidity and mortality among Veterans in acutecare inpatient facilities, a national initiative to reduce the incidence
and prevalence of this infection was developed. Project: In order
to reduce the incidence of CDI in the inpatient acute care setting, a
bundle- based approach of infection prevention and control strategies
will be employed which includes: 1) hand hygiene, 2) contact
precautions for those symptomatic CDI patients, 3) environmental
management, 4) cultural transformation where infection prevention
and control becomes everyone’s business. Care bundles are groupings
of best practices with respect to a disease process that individually
improve care, but when applied together result in substantially greater
improvement than when implemented individually. The CDI bundle
follows principles similar to that of Veterans Affairs (VA) MRSA
bundle that has proven successful in reducing MRSA infections
across VA hospitals. The CDI bundle is comparable to the MRSA
bundle with the exception of environmental management being
substituted for the active surveillance strategy in the CDI bundle.
The CDI bundle will be implemented in all VA inpatient acute
care hospitals. A separate initiative for antimicrobial stewardship
complementary to the CDI initiative has begun. Before nationwide
distribution, the CDI bundle was beta-tested. Results: The CDI
bundle was tested in 37 different VA hospitals across the United
States. All facilities were able to implement the CDI bundle elements
of hand hygiene, contact precautions, environmental cleaning, and
culture transformation. Even though the CDI bundle is directed to
a particular pathogen (vertical approach), the preventive strategies
recommended are horizontal interventions that will be beneficial
for the prevention of all pathogens. Based on feedback from the
beta-test sites, the bundle infection prevention strategies have been
improved for national distribution. Surveillance of CDI cases will be
done nationwide to evaluate program implementation. Lessons
Learned: The successful implementation of VA’s MRSA
Prevention Initiative paved the way for further such initiatives. While
the MRSA Prevention Initiative used both vertical and horizontal
infection prevention approaches, the CDI prevention initiative
employs primarily horizontal strategies. We hope to enjoy success
similar to that achieved in the MRSA Prevention Initiative using the
CDI prevention initiative.
79
Utilizing Electronic Surveillance to Enhance
Patient Safety
Re-Ingineering Hand Hygiene Surveillance: Shifting
the focus, sharing the responsability.
Charlene Head, RN, CIC - Infection Preventionist, Carolinas
Healthcare System; Shelley Kester, RN, BSN, CIC - Manager,
Infection Prevention, Carolinas Healthcare System; Wendy
Betts, RN, BSN, CIC - Manager, Infection Prevention, carolinas
Healthcare System; Martha Alspaugh, RN, BA, BS, CIC Infection Preventionist, Carolinas Healthcare System
Olga E. Guzman, RN, BSN, CIC - Infection Control Preventionist,
Kaiser Permanente Fontana Medical Center; Melody S. Kulsic,
MSN, PHN, RN - Project Manager III, Kaiser Permanente
Fontana Medical Center; Jeanine E. Martin, RN - Infection
Control Preventionist, Kaiser Permanente Fontana Medical
Center; Armando De Amaya, RN, BSN, PHN - Infection Control
Preventionist, Kaiser Permanente Fontana Medical Center; Maria
T. Canola, RN, MSN, MPH, CIC - Director of Infection Control,
Kaiser Permanente Fontana Medical Center; Jea H. Lee, MD - Chair
of Infection Control and Infectious Disease, Kaiser Permanente
Fontana Medical Center
Issue: Healthcare associated infections (HAIs) are common,
costly and deadly complications of hospital care. Over the past
several decades multidrug resistant organisms have become more
prevalent and utilization of invasive devices such as central lines
and ventilators has skyrocketed. As such, the role of the Infection
Preventionist (IP) has expanded exponentially, oftentimes without
a concomitant increase in the infection prevention workforce.
The increased attention and responsiblity placed on Infection
Prevention departments necessitates methods to streamline
collection and summary of HAI data. Project: The impact of
computerized infection prevention software (TheraDoc) on the role
of the IP and HAI outcomes was evaluated at 4 acute care facilities
within a large healthcare system. Rates of central line associated
bloodstream infections (CLBSI), ventilator associated pneumonias
(VAP), catheter associated urinary tract infections (CAUTI),
surgical site infections (SSI), and hopsital acquired infections with
multi-drug resistant organisms (MDROs) were compared to preimplementation time frames of the software at year one and year
two. Various activities were tracked in a log by the IP, including time
spent on existing and expanding surveillance activities, time saved
with utilization of the “alert” features of the program, and changes
in IP workflow. Results: The computerized infection control
software system resulted in increased productivity and effectiveness
of the IP. Rapid data extraction and analysis by the software allowed
the IP to intervene quickly at the unit level, giving real-time
guidance and support. A total of 0.7 full time equivelant (FTE)
employee was saved with the implementation of the software which
allowed for expanded surveillance activities. MDROs were easily
tracked and trended, with time from identification of a MDRO to
patient isolation decreasing by 24 hours. During the first year of
use, CLBSI decreased 23%, VAP decreased 85%, and MethicillinResistant Staphylococcus aureus (MRSA) infection decreased
60%. Lessons Learned: Implementation of computerized
infection prevention software was associated with significant
improvements in HAI outcomes and increased efficiency in
surveillance and reporting of infection issues at our institution. Real
time feedback to stakeholders and expanded surveillance allowed
for identification of infection trends and can be used to mitigate
outbreak risks. The program allowed for ease and efficiency to track
infections by unit, procedure and organism. Time was additionally
saved for the IP with the ability of the program to directly export
data to the National Healthcare Safety Network (NHSN) for state
reporting. Electronic surveillance has enhanced the ability of the
IPs at our institution to prevent infections, improve patient safety
and save lives.
80
Issue: Despite multiple interventions to increase Hand Hygiene
(HH) compliance, we were not able to sustain a housewide
compliance rate above 90%. Project: A HH task force was
created to increase and sustain HH compliance beyond 90%. The
team was comprised of a Nursing, a Quality, a Patient Safety and an
Infection Prevention representative. The team met monthly until
the project was completed. The WHO “5 moments” was used as the
measurement for compliance. The observation method was switched
from secret observers to Nursing performing the observations and
providing immediate feedback to the non-compliant employees.
Monthly observations were increased from 20 to 40 per Nursing
Unit a total of about 1000 observations/month. Results were shared
with Nursing and Hospital leadership on a weekly basis. Ancillary
department managers were recruited to perform observations of their
own staff. For quality control purposes, Infection Control performed
a validation study after the new data collection process in order to
identify any inconsistencies in collection methodology. Observations
were performed in conjunction with managers of identified units.
Patient’s satisfaction survey which includes a question on HH
performance was compared to our observed results. Individual
Physicians assigned to specialty units were observed by Nursing
and given direct feedback by their Chief of Service. Physician HH
observations were repeated to measure improvement from the initial
study. Promotional activities included window displays with posters
representing different departments: Laboratory, Environmental
Services, Nursing and Physicians performing HH. Elevator wrappers
were installed in all staff elevators displaying HH messages by
various health care workers. A “Hand Hygiene Excellence” trophy
was introduced to award Nursing units that achieve and sustain
>90% compliance. The CDC HH video was added to the patients’
educational television channel, encouraging patients and visitors to
remind the staff to perform HH. Nursing adopted “Scripting” to be
incorporated into their “Patient- Nurse Knowledge Exchange” and
on their patient’s “care boards” regarding HH and their commitment
to patient safety. The Safety Advisory Committee comprised of
Patient Safety and designated Kaiser Permanente members were
consulted. They suggested the use of new educational signs that
were installed above all alcohol based hand rub dispensers and sinks.
Results: The following outcome was measured: House-wide
compliance increased from 78% to 93%. Physician’s compliance
increased from72% to 90% Nursing compliance increased from
82% to 95% Ancillary Departments increased from 64% to 87%.
Lessons Learned: A focused, and dedicated team supported
by administration was the key for success for this project. Using a
team approach to elicit ideas and group consensus decision making
is vital. A heightened awareness of HH practices by the staff can only
be achieved through education and accountability. Evaluation of the
program must be an ongoing process from beginning to end.
from home or from another facility. Finally, staff hand hygiene
compliance is audited regularly with a goal of >90% compliance.
Lessons Learned: NICU’s Infection Control Committee is
effective because it is a small group focused on NICU and passionate
about providing safe patient care to premature infants. The committee
provides structure for ongoing program development and improved
patient safety strategies. Networking and consultation with generous
experts was invaluable. There is a need for evidence-based, infection
prevention guidelines specifically for NICUs.
Developing an Infection Prevention Program as a
Result of a Transition From a Level II to a Level III
NICU
Shannon G. Hansen, MT(ASCP), CIC - Infection Control
Coordinator, Altru Health System; Virginia Bren, RN, MPH,
CIC - Infection Control Coordinator, Altru Health System; James
Hargreaves, DO - Infectious Diseases, Altru Health System
Issue: A successful infection prevention and control program must
identify changes in the patient population and level of services. In
2009, Neonatal Intensive Care Unit (NICU) services were enhanced
from Level II to Level IIIB, thus adding a population of very low
birth weight (VLBW) infants. The organization’s commitment to
provide safe care for high risk infants created a need to perform a risk
assessment and develop goals and strategies for infection prevention
relevant to an anticipated population of VLBW infants. Project:
The risk assessment included 1) a review of the literature, including
guidelines and resources; 2) input from stakeholders, including
physicians, staff, and administration; and 3) consultation with
regional and national NICU experts, including an onsite visit to a
large, tertiary care NICU in our region. Goals included: 1) creation
of an NICU Infection Control Committee; 2) determination of the
scope of infection surveillance and operationalization of indicators;
3) optimization and standardization of vascular access care; 4)
setting parameters for active surveillance testing (AST); 5) initiation
of an effective illness screening process for visitors; 6) clarification
of readmission/cohort policies; and 7) maintenance of high hand
hygiene compliance. Results: The NICU Infection Prevention
and Control Committee meets monthly. It is chaired by infection
control and includes nurse managers, staff nurses, an administrator,
and neonatologists. Ad hoc members include hospital epidemiologist,
pharmacy, and respiratory care. Strategies were developed to meet
program goals. Surveillance indicators were defined to include the
following: central-line bloodstream infection (CLABSI), acute
respiratory illness, multi-drug resistant organisms (MDRO), and hand
hygiene compliance. The development of a detailed table describes
vascular access procedures and a new policy of gloving when touching
any component of a vascular access was adopted. After a cluster of
Staphylococcus aureus skin infections and hospital onset respiratory
syncytial virus (RSV) in 2011, the microbiology lab optimized viral
testing, the NICU’s readmission policy was clarified, and plans are
underway to strengthen visitor screening. To evaluate and modify
the risk of transmitting Methicillin-Resistant Staphylococcus aureus
(MRSA) from colonized infants, the NICU Infection Control
Committee created a policy to screen infants readmitted to NICU
Successful Implementation of a Mandatory
Influenza Vaccination Program across a 12
Hospital System
Donna Currie, MSN, RN - Director of Clinical Support Services,
Advocate Health Care; James Malow, MD, FIDSA - Chairman
Internal Medicine, Chairman Infection Prevention Committee,
Medical Director Advocate Healthcare Infection Prevention Team,
Advocate Illinois Masonic Medical Center
Issue: There is an increasing movement toward requiring Health
Care Worker’s (HCW’s) to receive annual influenza vaccination.
Several professional and regulatory organizations “highly
recommend” influenza vaccinations for HCW’s, but fall just short
of requiring the vaccine.1,2 Most recently, the Infectious Diseases
Society of America (IDSA) has formally asked federal health
officials to recommend making influenza vaccination mandatory
for healthcare workers (HCWs),3 For the purpose of this project,
HCW’s are defined as associates, volunteers, and physicians
physically located or working in health care settings with the
potential for exposure to infectious materials. While some HCW’s
provide direct patient care, others have jobs that may put them into
close contact with patients or the patient environment. Transmission
of influenza to patients by HCW’s is well documented.4 HCW’s
may acquire influenza both in the health care setting and in the
community, and they can easily transmit the virus to patients in
their care. Though there is strong evidence to support vaccination
of HCW’s with influenza vaccine, success remains low nationally.
The Centers for Disease Control and Prevention (CDC) estimates
that only about 40% of HCW’s in the United States are vaccinated
against influenza annually.6 The organization in this abstract has
offered free influenza vaccines to all associates, physicians, volunteers,
and students as required by The Joint Commission.7 The associate
vaccination rate has remained consistently low over the past several
years between 40% to 50%. Project: A mandatory influenza
vaccination program was implemented for a large healthcare system
for the 2011-2012 flu season. All associates, including employed
physicians, at clinical sites (hospitals, medical groups, clinics) were
mandated to receive the vaccination. Non-employed physicians
aligned with the Physician Hospital Organization (PHO) received
credit the influenza vaccine through the clinical integration model.
The influenza vaccine was highly recommended for other nonemployed physicians and associates at non-clinical sites. Key elements
of the program include: • Interdisciplinary partnership • Leadership
81
support • Communication • Exemption Review Oversight
Committee. Results: The program was very successful • Achieved
a compliance rate of 99.5% for mandated sites. (See table 1) • Five
percent of associates (1510) applied for either a medical exemption
or a religious exemption. Of those reviewed by the oversight
committee, 183 were denied. (See Graph 1) • 18 associates (out of
30,000) were terminated for failure to comply with the mandatory
flu vaccine program. Lessons Learned: Implementation of
a mandatory influenza vaccination requires the full support and
collaboration of a large interdisciplinary team. Identified below are
several opportunities identified during the first year and will provide
direction as we work to improve the program for next year. 1. Sharing
information amongst data bases 2. Establish definitive criteria for
exemptions. 3. Adherence to defined deadlines
82
Resistant Organisms: An Innovative Approach to
Preventing Healthcare Transmission
Prevention, Catawba Valley Medical Center; Alisa Leonard, MHA,
RN, CIC - Infection Prevention Coordinator, Catawba Valley
Medical Center; Danielle Thurman, BSN, RN, CPEN - Patient Care
Coordinator, Catawba Valley Medical Center
Issue: Incidence and prevalence of all multidrug resistant organisms
are on the rise. Highly resistant organisms such as Klebsiella pneumoniae
Carbapenemase (KPC), Acinetobacter, C. difficile, and Extended
Spectrum Beta Lactamases (ESBLs) have become a new threat to the
hospitalized patient. Infection Prevention (IP) at a community Magnet
hospital recognized a potential risk point after identifying a newly
admitted KPC positive patient during surveillance in January, 2011.
Upon investigation, it was determined that the possible incidence of
admitting patients with a highly resistant organism and not placing the
patient on isolation was a great risk. In 2010 a Multi-Drug Resistant
Organism (MDRO) Prevention Team was formed to address patient
care issues with Methicillin-Resistant Staphylococcus aureus (MRSA)
and C. difficile. In 2011, the team was asked to also address care
issues related to highly resistant organisms. Project: The MDRO
Prevention Team, comprised of interdisciplinary representatives from
administration, IP, pharmacy, lab, Environmental Services (EVS),
inpatient units, emergency department and operating room, accepted
the task of improving identification, surveillance, and care of the
patient having a highly resistant organism. To improve identification
of C. difficile, in 2011 the lab initiated Polymerase Chain Reaction
(PCR) testing. In 2010 the MDRO Prevention Team created a “C.
diff bundle”, including a small cart for soiled linen and Clorox-based
disinfectant wipes in each contact enteric isolation room. In addition,
EVS began cleaning these rooms with a Clorox-based disinfectant. The
team developed a process for identifying isolates that need further KPC
testing using a Modified Hodge Test. In 2011 this team developed a new
isolation for highly resistant organisms. Patients having a highly resistant
organism are placed on “Strict Contact Isolation”. The major difference
in Contact and Strict Contact is the cleaning requirements, keeping
patients located in one room and using dedicated equipment. Nursing
staff clean high touch surfaces once per shift. Upon discharge EVS
clean the patient room twice with different EVS staff at different times.
Infection prevention educated administration, clinical staff, medical
staff and EVS about highly resistant microorganisms and transmission
prevention. EVS staff are monitored every week randomly using a black
light process to ensure thorough cleaning. Results: The incidence
of patients with a MDRO present on admission has steadily increased
since 2009. After creating the MDRO committee and implementing
transmission risk reduction strategies the health care acquired MRSA
and C. difficile rates have steadily decreased, with an 86% reduction
of MRSA and a 25% reduction of C. difficile from 2009 to 2011. Our
other health care acquired MDROs have remained stable at a rate of .06
for 2010 and 2011, although the present on admission have increased
showing higher prevalence in the community. Lessons Learned:
Implementing Evidence Based Practices to prevent MDROs requires
an interdisciplinary approach, with stakeholder buy-in. In addition,
MDRO transmission prevention requires innovative thinking from
front-line staff to initiate and sustain improvement.
The Dynamics of a Hand Hygiene Program in a
Pediatric Oncology Service in El Salvador: Success
Factors and Lessons Learned
Elsie L. Gerhardt, MA, MPH candidate - Administrative Specialist,
St. Jude Children’s Research Hospital, University of Memphis;
Roberto Vasquez, MD - Director Oncology Service, Hospital
Nacional de Ninos Benjamin Bloom; Soad Fuentes, MD - Director
- Centro Medico Ayudame a Vivir - Fundacion Rafael Meza Ayau
- outpatient clinic, Hopspital Nacional de Ninos Benjamin Bloom;
Gabriela Maron, MD - Staff, Hospital Nacional de Ninos Benjamin
Bloom; Dinora Barrera, nurse - Head nurse of the inpatient area
of Hospital Nacional de Ninos Benjamin Bloom - El Salvador,
Hospital Nacional de Ninos Benjamin Bloom - El Salvador; Miriam
Gonzalez, MD - Student, University of Memphis; Don Guimera,
BSN, RN, CIC, CCRP - International Epidemiology Coordinator,
St. Jude Childrens Research Hospital; Miriam De Lourdes. Duenas
- Pediatric Infectious Diseases Department, Infection Control,
Pediatric Infectious Diseases; Magister in Infection Control
Mario Gamero, MD - Director Infectious Diseases Hospital
Nacional de Ninos Benjamin Bloom, Hospital Nacional de Ninos
Benjamin Bloom - San Salvador, El Salvador; Kyle M. Johnson, PhD,
CCRP - Clinical Research Associate II, St. Jude Children’s Research
Hospital; Miguela Caniza, MD - Director of Infectious DiseasesInternational Outreach Division, St. Jude Children’s Research
Hospital
Issue: Safety and cost containment are key aspects of infection
prevention and control (IPC) efforts. Optimum hand hygiene
(HH) decreases the rates of healthcare-associated infections, and
implementing a HH program is a first step toward safe care. However,
sustaining a HH program can be challenging for a public hospital
faced with budget constraints and multiple competing needs. Our
U.S. hospital (USH) has collaborated with a public hospital in El
Salvador to improve pediatric cancer care for 10 years. Here we report
the result of a recent evaluation of the HH program and outline
success factors for sustainability, as this relates to the dynamics among
IPC team members, unit leaders, personnel, educators, a commercial
provider, and patients’ families. Project: In 2007, our USH
collaborated to implement a HH program by providing alcohol gel
to the oncology service of a 300-bed pediatric hospital in El Salvador.
Oncology services include 26 inpatient beds and an outpatient clinic.
While providing gel, we optimized HH education and promotion,
and compliance monitoring. Alcohol-gel handrubs were chosen as
an effective solution that can be placed by every bed and elsewhere
for maximum access and compliance. A local gel manufacturer has
provided service since the program’s inception, monitors usage,
and distributes the product throughout the oncology service. The
USH funded the HH program since the beginning, purchasing gel,
and supplementing the salary of a local physician who monitors
infection rates and HH practices, and periodically reports this
information. Additionally, the USH visits and monitors the site once
a year. In November 2011, a USH team assessed the HH program
and interviewed oncology service personnel regarding satisfaction
with the program, gel, supplier service, and the gel monitoring and
ordering process. Results: After 4 years, the HH program is still
strong. In the inpatient area, one gel dispenser per bed was available
in 22 of the 26 beds; and 2 of the 6 sinks had soap and towels. In the
outpatient and short-term stay areas, a gel dispenser was available
in all but one of the existing 37 beds and recliners; all of the 3 sinks
had soap and towels. Nurses and families are involved in monitoring
gel availability. The supplier enjoys a good relationship with hospital
staff. Visual reminders of HH are ubiquitous. Rotating personnel
are trained in HH every month. Monthly use of gel has remained
stable, averaging 18 gallons; this suggests high compliance levels.
Lessons Learned: Sustaining a HH program needs consistent
funding, education, communication, feedback, collaboration among
stakeholders, and a good relationship with a committed vendor. Our
model proved to be successful in El Salvador and we believe that this
model is applicable to other hospitals facing similar challenges in lowincome countries.
A Multidisciplinary Team Approach to Reducing
Ventilator Asscociated Pneumonia
Tracey Terrell, CCRN, RN CNIV - Durham Regional Hospital
Issue: Durham Regional Hospital is a 369-bed community hospital
located in Durham, North Carolina. The critical care staff provides
care to a diverse population of patients within a 22-bed med-surg
unit. Controlling ventilator associated pneumonia is crucial to
83
both patient care and finance. VAP occurs in up to 25% of all
patients requiring mechanical ventilation. VAP is the leading
cause of death among hospital acquired infections, prolongs
days on ventilator, increases total length of stay by 4.3 days, and
adds $40,000 to cost of hospital stay. Project: The CCU
nursing staff developed a multidisciplinary team approach to
decrease the incidence of ventilator associated pneumonia.
This team includes Physicians, Registered Nurses, Respiratory
Therapists, Certified Nursing Assistants, Infection Control, and
Pharmacists. Collaboration of this team led to the following
changes: • Incorporated VAP bundle information and sedation
vacation algorithm in bedside reference books for quick access. •
Acronym SLAP VAP created: o S - strict oral care o L - liberation
from ventilator o A - aspiration precautions o P - prophylaxis (GI
and DVT) • Reported VAP rate and compliance with bundle
to unit nurses on monthly basis. • Organized a Bundle Bash to
educate over 60 nurses and support personnel on HAI bundles. •
Celebrate success in VAP reduction. • Computerized monitoring
of VAP bundle compliance. • Peer to peer accountability for
noncompliance with bundle. • In-line suction with dedicated
suction set up. • Increased use of HiLo evac endotracheal tubes
for continuous subglottic secretion suctioning. • Charge Nurse and
Respiratory Therapist collaborate daily in planning for sedation
vacation and vent weaning. • VAP education and prevention
strategies added to orientation. • Staff education focused on: o
Pulmonary rotation 18 hours per day o Vibration or percussion
every 2 hrs o Consistent documentation of interventions performed
o Sedation vacation and daily awakening o Hand washing o
Richmond Agitation Sedation Scale assessed every 2 hours o Training
Certified Nursing Assistants to perform oral care. Results:
The work of the group was an ongoing process over two years that
included implementing strategies then following up with the critical
thinking to address the next steps to achieve the desired outcome.
This program was successful in increasing bundle compliance and
decreasing the incidence of ventilator associated pneumonia in
critically ill patients. Our VAP rate decreased by 53% for FY2010
and by 42% for FY2011. Overall decrease from FY2009 to FY2011
was 73%. Lessons Learned: •Developing a team with a staff
nurse and physician as champions is essential to facilitate successful
buy-in from all physicians, nurses, and support personnel •Ongoing
education is the foundation of successful outcomes •Peer to peer
accountability promotes ownership of patient care and outcomes,
as well as allows real-time feedback on bundle noncompliance
•Frequent audits quickly identified real-time opportunities
for reinforcement and improvement, but also celebration of
individual staff successes as it related to bundle compliance
•Ventilator associated pneumonia rates reported to staff monthly
showing the results of their efforts and celebrate successes
84
Building and Maintaining Best Practices to
decrease Vascular Access-Associated Infections
in the Use of Peripherally Inserted Central
Catheters
Joanna Acebo, MD - Pediatric Infectious Diseases Physician,
Hospital SOLCA-Núcleo de Quito; Carlos Vicuna, MD - Pediatric
Oncology Surgeon, Hospital SOLCA-Núcleo de Quito; Jose M.
Eguiguren, MD - Chief of Pediatrics, Hospital SOLCA-Núcleo
de Quito; Don Guimera, BSN, RN, CIC, CCRP - International
Epidemiology Coordinator, St. Jude Childrens Research Hospital;
Kyle M. Johnson, PhD, CCRP - Clinical Research Associate II, St.
Jude Children’s Research Hospital; Miguela Caniza, MD - Director
of Infectious Diseases-International Outreach Division, St. Jude
Children’s Research Hospital
Background/Objectives: Central venous catheters
are indispensable devices in oncology that are used to administer
intravenous therapies, parenteral nutrition or blood products. The
advantages of PICC include: easy insertion and removal, long term
usability (up to six months), and insertion with local anesthesia.
In this study we ascertain infection rates of PICCs, and report
the results of introducing best practices and continuous quality
improvement in inserting and caring for this type of catheter.
Methods: We prospectively evaluated all PICCs inserted
between July 2009 and December 2011 among pediatric oncology
patients in a 160-bed oncology hospital in Quito, Ecuador. In the 30bed pediatric wards, 14 nurses and five physicians care for children.
A multidisciplinary vascular care team includes nurses, physicians,
a surgeon, and a pediatric infectologist. Best practices in the use of
PICCs were: 1) develop institutional policies and procedures for
insertion and maintenance of a PICC, such as performing hand
hygiene before handling and inserting the catheters, using appropriate
barrier methods for insertion, and doing skin antisepsis before the
procedure; 2) train all care providers in the policies and procedures;
and 3) monitor performance continuously through a surveillance
system. We analyzed two periods. During the first period, July 2009
to June 2010, the devices were inserted in the outpatient procedure
room and polyvinyl pyrrolidone was used for skin antisepsis. In the
second period, July 2010 to December 2011, insertion was done
in the operating room, using 2% chlorhexidine for skin antisepsis.
The evaluation of infection rates in the two groups ensued. Bed rate
occupation in the first and second period were 61.4% and 66.7%
respectively. During the study, 58.4% of children with cancer had
central venous access and 2.5% corresponded to PICC. Care postinsertion remained similar between the two periods and all other
periodic education and training remained unchanged. Results:
The total number of PICCs inserted was 58, with 442 catheter-days.
The global PICC infection rate during the observation period was
1.8 infections per 100 catheter days. Comparing the first with the
second period, we observed 3 catheter infections during 120 catheter
days (2.5 infections per 100 catheter days) vs. 5 infections during 322
catheter days (1.5 infections per 100 catheter days) with RR=1.6
(95% CI 0.39-6.63). Conclusions: Infection complications
rates of PICCs are similar to those published in the literature. PICC
insertion in the operating room resulted in a decreasing trend for
infection, though not statistically significant. Possible reasons for
this outcome are better compliance with barrier precautions and
use of chlorhexidine. Ongoing surveillance is an integral part of
best practices for continuous quality control in vascular access and
outcomes.
Implementing Mandatory Influenza Vaccination
policy for Health Care Workers at a Long Term
Acute Care Facility
Teena Chopra, MD, MPH - Associate Coorporate Director,
Infection Prevention, Epidemiology and Antibiotic Stewardship,
Detroit Medical Center and Kindred Hospital Detroit
Background/Objectives: Although annual influenza
vaccination is recommended for healthcare workers (HCW) by
the Center for Disease Control and Prevention (CDC), the rate
of HCW who receive vaccination continue to be low. Whereas,
many acute care centers have mandated influenza vaccination
policy, scant data exits on such policy in long term acute centers
(LTACs). This study determined the effect of implementation of a
mandatory influenza vaccination at a long Term Acute Care hospital
in Detroit, Michigan. Methods: Annual influenza vaccination
data from 2008 to 2011 was reviewed to identify vaccination rates
among different job categories in HCWs at Kindred hospital, a
77 bed LTAC in Detroit Michigan. In 2011, with support from
administration, mandatory influenza vaccination and educational
campaigns were included as part of annual mandatory competency
health fair. At competency fair, employees who received flu
shot or showed proof of vaccination from somewhere else were
given stickers that identified them as being compliant with the
mandatory flu vaccination. Employees who declined vaccination
were required to wear a mask within six feet of patient care during
influenza season. Vaccination data from 2008 to 2011 was analyzed
using descriptive statistics. Results: Influenza vaccination rate
increased from 25% (n=272) in 2008–2009 to 65% (n=279)
in 2010 - 2011 influenza season (n= 145) in 2010–2011 (p <
0.05). However, rate among physicians in 2008–2009 was not
significantly different from rate in 2010–2011 [27% (n= 23) vs
29% (n= 19]. The reasons for declination as given by some HCWs
included fear of needle (6%), fear getting influenza from vaccine
(5.3%), non-belief in vaccination in general (12%), and no reason
(73%).Conclusions: Long-term care facilities have very high
risk elderly patient population and hence mandatory influenza
vaccination seems to be an effective measure to improve vaccination
rates among health care workers in LTACs. Annual competencies
done routinely at LTACs seem to be the right time for instituting
a mandatory influenza policy to improve rates. However, lack of
knowledge about the safety and effectiveness of the vaccine continue
to have effect on influenza vaccination rates.
85
Education and Communication: Improving Patient
Safety and Increasing Employee Knowledge in an
Acute Hospital Setting
Infection Control Liaisons: Weapons Against
Hospital Acquired Infections
Louise Hesse - Infection Prevention Specialist, Desert Springs
Hospital Medical Center
Saungi A. McCalla, MSN, MPH, RN, CIC - Director of Infection
Prevention and Control, White Plains Hospital; White Plains
Hospital Infection Control Liaison Team - Hospital, White Plains
Hospital
Issue: The Nevada State Health Division of Healthcare Quality
and Compliance sponsored a grant based on the Centers for
Disease Control and Prevention (CDC) guideline, “Management
of Multidrug-Resistant Organisms in Healthcare Settings, 2006.”
The hospital performed a self assessment based on this guideline and
found that Education and Communication were areas in need of
improvement. Project: The Infection Prevention Department
developed a program to increase education and communication
among employees, patients and their families relating to the
management of multidrug-resistant organisms in the healthcare
setting. A patient education flyer was produced outlining the
prevention, risks and care of the patient with a multidrug-resistant
infection. An Infections Present on Admission/Hospital Course
form was created and placed in the patient’s chart to communicate
with employees the patient’s infection and isolation status and
document that the patient education flyer is given. The inter-facility
transfer form was developed to alert the receiving facility of the
type of infection, and the patient’s need for isolation. The Infection
Prevention Department is responsible for identifying patients with
infections and placing the study related forms in the patient’s chart.
A magenta sticker on the front of the chart alerts the employee that
their patient is a study participant. Outcome measures for this project
include healthcare associated infections at or below the National
Healthcare Safety Network (NHSN) benchmarks, documentation
that the patient education flyer was given, and the inter-facility
transfer form was initiated eighty percent of the time. Results:
The study began September 20, 2011 and is due to continue through
April 2013. The following results are from the time period September
20, 2011 through December 20, 2011. The results are based on these
outcome measures, healthcare acquired infections, documentation
of the use of the educational flyer and implementation of the
inter-facility transfer form upon patient transfer. The healthcare
acquired infections measured are central line blood stream infections,
catheter associated urinary tract infections, ventilator associated
pneumonia, surgical site infections, laminectomies, Clostridium
difficile and Methicillin-Resistant Staphylococcus aureus infections.
The measurements of these infections were within the benchmarks
of NHSN. From September 20, 2011 through December 20, 2011
the Inter-facility transfer form was implemented 44%, 68% and
47% respectively. The use of the educational flyer for the same
time period was 62%, 69% and 69% respectively. The percentages
were determined by dividing the number of patients who received
the paperwork by all the patients who were eligible to receive the
paperwork. Lessons Learned: Providing employees the data
from outcome measures provides a sense of ownership. Continued
education and multiple daily rounds have improved communication
and compliance with isolation protocols. Perseverance with the
Inter-facility transfer form and follow up with patients in the study is
crucial for success of the project.
Issue: Hospital-acquired infections are adverse patient events
that affect approximately 2 million persons annually. Multi-Drug
Resistant Organisms (MDROs) are often hospital acquired and
can cause devastating effects on patients and hospitals such as
increase length of stay, increase costs and increase morbidity and
mortality. According to the CDC, during the last several decades,
the prevalence of MDROs in U.S. hospitals and medical centers has
increased steadily. In 2008, the Infection Control Department at a
community hospital in New York developed a multidisciplinary IC
Liaison Committee with representation from many departments
across our hospital. The goal of this committee is to create awareness
and to increase staff understanding of infection prevention and
control at the unit/department level. The team meets monthly for
education, to discuss issues and to work on solutions. In 2009, the
liaisons reported that they were seeing more MDRO on their units.
Review of the 2009 surveillance data revealed significant hospital
acquired MDROs (HA- MDRO) infections on the units. Overall,
there were a total of 104 infections for a rate of 1.6 per1000 patient
days. The committee’s main objective for 2010 was to reduce
HA-MDRO infections on the units. Project: The committee
reviewed our current policies and compared it to all pertinent
evidenced-based guidelines and recommendations to identify gaps
any in practice. The review identified that the policies were consistent
with the current guidelines, but that compliance was lacking in key
areas such hand hygiene and personal protective equipment (PPE).
The committee decided to focus their efforts on hand hygiene,
PPE and isolation. They re-educated staff on their respective units/
departments on hand hygiene, PPE and isolation, and the importance
of compliance. They also adopted the slogan “if you see something,
say something,” engaging all staff including environmental services
and unit secretaries to intervene immediately whenever they
observed non-compliant behaviors. Through this process the staff
was empowered to be true infection control champions on the units
with strong support from hospital leadership. Results: For the
surveillance period of January-December 2010, the number of HAMDRO infections decreased on the units from 104 in 2009 to 59
in 2010 and from a rate of 1.6 per 1000 patient days to 0.9 per 1000
patient days. By decreasing the number of HA-MDRO infections
the IC Liaison Committee were able to demonstrate a significant
cost avoidance of approximately $400, 000 in one year, along with a
substantial reduction in patient morbidity and mortality. Lessons
Learned: Collaboration is key to infection prevention. The
liaisons are especially effective in the implementation of new
infection control policies and initiatives because of the rapport
with staff on the units, an understanding of unit specific challenges,
and the ability to promote strategies that are most likely to be
successful on their particular units. The liaison program is vital in our
organization in promoting quality patient care and patient safety.
86
Hospital Hand Hygiene Compliance Improves with
Increased Monitoring and Immediate Feedback
Judith ( Judy) L. Walker, RN, BSN, MHSA, CIC - Director of
Infection Prevention, Mercy Hospital Springfield; William Sistrunk,
MD, FACP - Medical Director Infection Prevention, Mercy Hospital
Springfield MO; Mary Ann Higginbotham, BSN, CIC - Infection
Preventionist, Mercy Hospital Springfield MO; Kristi Burks, RN
- Infection Preventionist, Mercy Hospital Springfield MO; Linda
Halford, BSN, CIC - Infection Preventionist, Mercy Hospital
Springfield MO; Linda Goddard, BS - Infection Preventionist,
Mercy Hospital Springfield MO; Phillip J Finley, PhD - Mercy
Medical Research Institute, Division of Trauma and Burn Research,
Mercy Hospital Springfield MO; Lindsay Bellm - Master of Public
Health Program- Student, Missouri State University, Springfield
MO; Jamie Shank - Master of Public Health Program- Student,
Missouri State University, Springfield MO; Vickie Sanchez, EdD,
MPH, CHES - Faculty , Missouri State University, Springfield MO
Background/Objectives: Similar to most hospitals
across the Nation, Mercy Hospital Springfield is concerned with
hand hygiene compliance. ‘Secret shoppers’ monitoring hand
hygiene compliance reported a rate of 95%. However, Infection
Prevention found the actual rate to be 50-55%. This discrepancy
was hypothesized to be due to reporting bias of the ‘secret shoppers.’
In 2009, Duke University Medical Center (DUMC) initiated a
technology-based hand hygiene monitoring system. Independent,
visible observers monitored healthcare workers’ (HCW) hand
hygiene (‘foam-in foam-out’) when entering and exiting patient care
areas and provided real-time data to hospital leadership. DUMC has
increased compliance rates to 90% for the last 3 years (50% above
national average). Methods: Mercy Hospital Springfield, in
collaboration with Missouri State University Master of Public Health
Program, developed a pilot study following the DUMC model.
Four hospital departments served as pilot units for this study (2
experimental and 2 control). Following Institutional Review Board
approval, baseline hand hygiene data were collected. A new education
program was provided to the experimental units, physicians, and
ancillary staff. Infection Prevention performed observations of hand
hygiene compliance during a five month period. Compliance was
operationally defined as HCW foaming in and out of every patient
room. If non-compliant, the HCW was immediately approached
and educated. Observations continued in control units without
intervention. Data were recorded on electronic hand-held devices and
disseminated to hospital leadership. Results: Data were screened
prior to analysis for accuracy and normality. Crosstabulation and
the chi-square test for independence were used to analyze the data.
An alpha criterion of p < 0.05 was used throughout the analysis.
During the study period, both experimental departments showed
statistically significant increases in hand-hygiene compliance p <
.05. Experimental Department 1 increased compliance from 49%
to 86% and Experimental Department 2 increased from 60% to
95%. In addition, by the conclusion of the study, compliance in both
experimental departments (86% and 95%) were significantly higher
(p <.05) compared to either of the control departments (Control
1 = 52%, Control 2 = 37%). No clinically significant changes in
hand-hygiene compliance were observed in the control departments
during the study period. Conclusions: Hand hygiene remains
the most effective practice for decreasing Healthcare Associated
Infections. It is imperative for Infection Prevention departments
to evaluate new methods for the purpose of gaining better HCW
compliance. The implementation of the DUMC-inspired handhygiene monitoring program increased compliance an average of
36% in the experimental departments. Success of this program is
attributed to increased visibility and accountability, immediate
HCW feedback, and providing real-time data to hospital leadership.
Mercy Hospital Springfield plans to expand the program to include
other departments with the goal of increasing hand hygiene
compliance hospital wide.
Using Infection Surveillance to Improve the Quality
of Care in a Cancer Unit in a Children’s Hospital in
Argentina
Sergio M. Gomez, MD - Hematology-Oncology and Bone Marrow
Transplant Physician, Hospital de Niños Sor Maria Ludovica;
Maria Fernanda Sosa Pueyo, RN - Infection Preventionist,
Hospital de Niños Sor Maria Ludovica: ; William Sistrunk, MD,
FACP - Medical Director Infection Prevention, Mercy Hospital
Springfield MO; Mary Ann Higginbotham, BSN, CIC - Infection
Preventionist, Mercy Hospital Springfield MO; Kristi Burks, RN
- Infection Preventionist, Mercy Hospital Springfield MO; Linda
Halford, BSN, CIC - Infection Preventionist, Mercy Hospital
Springfield MO; Linda Goddard, BS - Infection Preventionist,
Mercy Hospital Springfield MO; Phillip J Finley, PhD - Mercy
Medical Research Institute, Division of Trauma and Burn Research,
Mercy Hospital Springfield MO; Lindsay Bellm - Master of Public
Health Program- Student, Missouri State University, Springfield
MO; Jamie Shank - Master of Public Health Program- Student,
Missouri State University, Springfield MO; Vickie Sanchez, EdD,
MPH, CHES - Faculty , Missouri State University, Springfield MO;
Kyle M. Johnson, PhD, CCRP - Clinical Research Associate II, St.
Jude Children’s Research Hospital: Miguela Caniza, MD - Director
Children’s Research Hospital
Background/Objectives: Access to data on infections and
their risk factors provide an objective guide for quality improvement
and infection prevention. Collecting, communicating and acting
on the results of the analysis is the cornerstone for prevention and
control of healthcare associated infections (HAI). We report the
institutional response to the information obtained through use of
the surveillance tool and the infectious outcomes. Methods: The
patient care unit (PCU) has 17 beds (occupancy 90%), 47 nurses and
doctors care for the patients. The Registry of Infections and their Risk
Factors (Registry) is an infection surveillance tool used to, ultimately,
improve care of children with cancer at the PCU. It was developed
by a U.S. Hospital. Those using the Registry in their PCU are given
training on use of the form, manual of procedures and electronic
database. Approval of the Registry was obtained by local ethics
committee. Data is collected using standard definitions in all children
admitted to the PCU. We calculated frequencies, percentages and
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relative risks of infection, and mortality due to infection during
the observation period. Results: From November, 2010 to
November 2011, 308 children were admitted to PCU including 227
(73%) patients with acute lymphoblastic leukemia (ALL), 16 (5.2%)
with acute myeloid leukemia (AML), 37 (12%) with lymphomas,
8 (2.6%) were admitted for other malignancies and 19 (6.1%) had
no malignancy. The global HAI rate was 26/1000 patient days.
For ALL and AML, the HAI rate was 19.0 and 68.3/1000 patient
days, respectively. The most common pathogen identified was
Staphylococcus aureus; soft tissue infections were most common. The
most significant risk factor for HAI acquisition was neutropenia
(RR: 4.968, 95% CI=3.977-6.205) and AML (RR: 3.566, 95%
CI=2.265, 5.616). It was found that 23% (9/39) of the bacteria
isolated were multidrug resistant; therefore active surveillance was
started. Periodically, results were provided to hospital leadership,
and other responsible individuals, to raise awareness and improve
quality of service. Under the guidance of infection preventionists,
best practices were introduced. Patient care areas were cleaned twice a
day, air filters were changed more frequently, water storage tanks were
closed and cleaned at least twice a year, bed sheets are changed once
a day, and patients now wear pajamas. Using standard guidelines,
staff was trained in standard and transmission based precautions and
in the care of immunocompromised children. Patients and families
began to be educated about general and hand hygiene through
workshops. Infections among children with AML and mortality
were further decreased since implementing antibiotic prophylaxis
during neutropenia. Conclusions: The Registry enabled us to
detect important gaps and formulate interventions focusing on staff
education, improving the environment of care, while gaining support
from hospital administration, in a systematic manner, based on the
evidence gathered during this one year time period.
program for HH compliance o A power point presentation at
departmental meetings and dissemination of handouts about proper
practices, current handwashing rates, and an initiative overview o
Visual aids such as posters and stop signs that reminded HCW to
engage in proper HH behavior o Reminders of what appropriate
HH entails • Weekly reminders were sent via email • HCWs were
encouraged to identify others within the ED who were compliant or
non-compliant, by giving a small paper hand cut-out o Compliant
HCWs received a white (clean) hand, with a positive statement
acknowledging good behavior, ex. “You saved a life!” o Noncompliant providers received a green (dirty) hand print, stating “You
Bug Me” • “Hands” of compliant HCWs were posted on a “Good
Hand Hygiene Board” and were entered into a monthly drawing
to win a monetary award • Recipients of a “dirty hand,” had their
name placed in a log and participated in counseling sessions with
supervisors. Repeated infractions required counseling sessions with
senior level administrators and ultimately the CEO of the hospital.
Results: The ED recognized improvements in HH rates from
75.68% in November 2010 to 94.88% in June 2011. A total of 1861
observations were completed from December 2010 to June 2011.
Sub-analysis revealed that among HCWs, nurses tended to have
better HH behaviors as compared to physicians. Two patient care
zones (high-acuity and a low-acuity) were compared to address the
potential variance of HH compliance as a function of patient acuity.
High acuity zones had lower rates of compliance than the low acuity
zone (84% vs. 91%, p=0.007). Overall, rates of compliance postintervention were higher than for the pre-intervention period (85%.
vs. 92%, p=0.0001). Lessons Learned: • Generating HCW
engagement in proper HH practices is essential • The presence
of HH champions is imperative • Multiple modalities of HH
education reinforcement are necessary for continued improvement
• Rapid cycle, real-time feedback initiative allowed for sustained
improvement in HH compliance with low cost
Impact of a Rapid Cycle Hand Hygiene Initiative in
a Pediatric Emergency Department
Andrea Kiernan, MLT (ASCP) CIC - Infection Preventionist,
St. Christopher’s Hospital for Children; Patricia Hennessey, RN,
BSN, MSN, CIC - Manager, Infection Prevention, St. Christopher’s
Hospital for Children
Issue: Despite the hospital’s ability to sustain hand hygiene (HH)
rates above 90%, the ED had rates below the hospital average. Data
indicated ED HH rates to be 76% in November 2010. Prior to
the “Clean Hands/ Dirty Hands” initiative, ED HH compliance
rates for September, October and November 2010 were 87.5%,
85.7% and 76% respectively (mean= 83.1%). Project: A rapid
cycle QI initiative was implemented in the ED to improve HH
compliance rates. The multi-modal initiative consisted of provider
education, direct HH observations, peer-accountability, provider
feedback, visual aids, weekly email reminders, and an incentive and
deterrent program for HH behaviors. • HH observations (further
detail under “data collection”) • Healthcare worker (HCW)
accountability for HH compliance, with no relevance of hospital
hierarchy • Implementation of a multidisciplinary education
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The Quest to Reach Zero Central Line-Associated
Adriene Thornton, RN - Infection Preventionists, Children’s
Hospitals and Clinics of Minnesota; Melanie Kuelbs, RN Registered Nurse, Children’s Hospitals and Clinics of Minnesota;
Erin E. Zielinski, CCRP - Clinical Research Associate, Children’s
Hospitals and Clinics of Minnesota; Meixia Liu, MS - Health
Services Research Specialist, Children’s Hospitals and Clinics
of Minnesota; Stephen Kurachek, MD - Intensivist, Children’s
Hospitals and Clinics of Minnesota
Issue: Prior to 2006, the PICU institutional practice guidelines for
central line care were based on the recommendations of the National
Nosocomial Infections Surveillance (NNIS). These guidelines were
comprehensive but not effective in decreasing central line-associated
bloodstream infection (CLABSI) incidence rates. Project: As
part of a National Association of Children’s Hospitals and Related
Institutions (NACHRI) collaborative, central-line care bundles were
implemented from September 2006-September 2010. The central
line insertion bundle included; hand hygiene prior to inserting a line,
use of full barrier precautions during the insertion of central venous
catheters, cleaning skin with chlorhexidine when not contraindicated,
avoiding use of the femoral site for central lines when possible, daily
assessment of the need to maintain a central line catheter and use of
a checklist when inserting central venous catheters. The central line
maintenance bundle included; hand hygiene prior to beginning a
dressing change, use of dressing change kit (contains a mask, sterile
gloves, transparent dressing and chlorhexidine for cleaning skin),
and use of a checklist when performing a dressing change. Use of
chlorhexidine wipes for all central line cares was also implemented.
A retrospective study reviewed the critically ill patients in the
Pediatric Intensive Care Unit (PICU) and Cardiac-vascular Critical
Care (CVCC) between January 1, 2005 and December 30, 2011
to evaluate the impact of a quality improvement effort. CLABSI
rates from year 2005 and Quarter 1-2 of year 2006 were used as the
baseline to compare to the CLABSI rate of post implementation of
central-line care bundles. Results: The average baseline CLABSI
rate before implementation of the central-line care bundles was 3.6
CLABIs per 1000 central line days. At the conclusion of participation
in the collaborative in 2010, the average rate was significantly
decreased to 0.7 CLABSIs per 1000 central line days (p<0.001).
Consistent implementation of central-line care bundles decreased the
CLABSI rate in the PICU by 80.6% over 4 years. At the end of 2011,
the average rate was 1.2 CLABSIs per 1000 central line days, which
was significantly lower than the baseline rate (p=0.002). Lessons
Learned: Implementation of central line care bundles has been
essential in our patient care practices and supports the sustainability
of the lower CLABSI rates.
Embedding Hand Hygiene into a Patient Centric
Communication Model: C-I-CARE
Alexandra S. Madison, MPH, CIC - Mngr. Infection Control &
Epidemiology Dept., Stanford Hospital & Clinics; Debra Johnson Infection Control Nurse, Stanford Hospital and Clinics
Issue: Hand Hygiene compliance remains a challenge for healthcare
institutions. Re-invigorating existing hand hygiene programs is an
essential component of all hospital infection prevention programs.
One such novel approach was to embed hand hygiene in a patient
centric communication model allowing the medical center to achieve
and sustain its hand hygiene compliance goal of great than 90 percent.
Project: In early 2011 a 452 bed academic medical center began
a patient centric journey utilizing an innovative communication
model called “C-I-CARE” (Connect, Introduce, Communicate,
Ask, Respond and Exit). C-I-CARE is a framework for structuring
best practice communications and developing relationship based
care approaches with patients. This program was a senior leadership
initiative implemented throughout the entire medical center. All
departments were required to create scripted templates to ensure
C-I-CARE was followed in all patient interactions. The Infection
Prevention program saw this innovative model as an opportunity
to re-invigorate the existing hand hygiene program by imbedding
hand hygiene in all the scripted templates and training videos. This
enabled hand hygiene to be seen as an integral part of all patientcentric interactions, and not as a stand-alone activity. The model
requires scripting of variety of scenarios for EVERY department in the
entire medical center. The initial patient greeting template includes
“Connect “as the first step. The script states: “Gel in/perform hand
hygiene” and the video shows the patient care team entering the room
performing hand hygiene. The final step in C-I-CARE is “Exit” at
which point the script and training video again reinforce hand hygiene
concepts. Results: Hand hygiene compliance rates have been
collected on a monthly basis since third quarter, 2006. The C-I-CARE
program education was completed by the end of the second quarter
of 2011. The hand hygiene compliance rate for the third and fourth
quarters, 2011 was greater than 90 percent. Lessons Learned:
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Embedding hand hygiene in the C-I-CARE program not only
increased compliance rates, but made hand hygiene truly an every
time, no exceptions practice.
Interventions to Improve Ventilator-Associated
Pneumonia in the Intensive Care Unit of a Pediatric
Hospital in Nicaragua
Maria Mercedes Somarriba, MD - Infectious Diseases Physician,
Hospital Infantil Manuel de Jesús Rivera; Maria N. Aguilar Nurse Infection control, Hospital Infantil Manuel de Jesus Rivera
- Nicaragua; Miriam Chamorro - Intensivist Pediatrician, Hospital
Infantil Manuel de Jesus Rivera; Grania I. Obando - Intensivist
Pediatrician, Hospital Infantil Manuel de Jesus Rivera; Sergio Lopez
- Medical Microbiologist, USAID-HCI
Issue: A systematized process for surveillance and control
of ventilator-associated pneumonia (VAP) did not exist in the
intensive care unit (ICU) of Hospital Infantil, a pediatric hospital
in Nicaragua, before July 2008. Surveillance and interventions to
improve rates of VAP were organized with the assistance of the
USAID/HCI Project, and changes geared toward VAP prevention
were implemented based on cycles of continuous improvement.
Before the intervention, the VAP rate was 40 per 1,000 ventilator
days. Project: We planned and implemented a quality
improvement program for ventilator use in the ICU. The first step
was organizing a team of physicians and nurses to implement changes
in quality improvement to prevent VAP. Deficient clinical practices,
such as lack of appropriate hand hygiene, inadequate aspiration of
respiratory secretions, patient head position at an angle lower than
the recommended 30 degrees, incorrectly positioned ventilator
circuits, and condensation inside the circuits, were identified, and
corrections were implemented. VAP rates served as indicators of
the effectiveness of the changes implemented. The interventions
consisted of simple, low-cost measures, including the correct use of
antibacterials and disinfectants; appropriate hand hygiene before,
during, and after handling and administering mechanical ventilation;
aspiration of secretions; drainage of condensation in circuits;
verification of a patient’s 30-degree head angle; and administration
of H2 blockers, if applicable. We conducted research into the costeffectiveness of the intervention measures and the extent to which
VAPs were avoided (in press, International Journal of Pediatrics).
The organized team was responsible for monitoring the prevention
standards and VAP indicators. Monthly meetings were held with
the USAID/HCI consultant to analyze results and propose
improvements based on identified benchmarks. During the yearlong
intervention period, we shared our experiences with professionals
from other hospitals who were conducting the same interventions,
and a VAP prevention algorithm was jointly created as a result. This
algorithm was approved by the Ministry of Health and is now used
in all of the ICUs in the country. Results: The result was that
the VAP rate was reduced from 40 to 9 per 1,000 ventilator-days
with a median of 12.5 in a 30-month surveillance period. The VAPs
that were detected were associated with a lack of spare parts (filters,
90
circuits, or alcohol gel) or a shift of untrained nursing personnel. At
present, alcohol gel and trained nurses are available, and the Ministry
of Health is in the process of purchasing spare parts. Lessons
Learned: Improvement measures for the prevention of VAPs
are sustainable and entail a low cost of investment in relation to the
excess cost represented by the cases. Effective implementation of
these measures is also feasible in the context of continuous quality
improvement in the prevention of VAPs.
Reporting Capabilities and Data Extrapolation
Using an Electronic Hand Hygiene System Versus
the Traditional Covert/Secret Shopper Visual
Observation Method
Jill N. Goetzinger, RN - Infection Preventionist, Miami Children’s;
Deise Granado-Villar, MD - Chief Medical Officer, Miami
Children’s Hospital
Issue: Covert or secret shopper visual observation had long been
the standard for collecting data on hand hygiene practices among
healthcare workers (HCW). This method has been found to be (i)
limited in regards to subjectivity and opportunities for observation,
(ii) time consuming, and (iii) labor intensive during aggregation
of data in a standardized, readable format. Project: Miami
Children’s Hospital implemented an electronic hand hygiene
monitoring system (EHHS) in a 22-bed unit in August, 2010. In
August/September 2011, EHHS was introduced on the medical/
surgical floors covering a further 174 beds. Information regarding
hand hygiene for all patient interactions within the defined bed zone
area were transmitted to a web based reporting system. A comparative
review of the fourth quarter results for the nursing floors from
2008-2011 (study period) was completed. Data from the EHHS was
viewable by bed, unit, time, employee, department, and discipline.
The data was obtained objectively, i.e., the employee either did or
did not use an alcohol-containing cleansing product (soap or alcohol
based hand rub [ABHR]) before approaching the patient care area.
Information was drilled down to individuals or beds with an exact
number of patient interactions (both compliant and non-compliant)
and was converted into a compliance rate. If a hospital-acquired
was also accessible by individual employees on the computer. Any
of the data was able to be accessed with the click of a mouse for any
defined time period. Data was able to be stratified by individual,
unit, department, and discipline. EHHS was also able to send email
reports regarding usage and rates to selective HCWs. Results:
During the study period, hand hygiene compliance was as follows:
97% in 2011 (97,442 patient interactions); 94% in 2010 (9,788
interactions); 99% in 2009 (160 interactions); 98% in 2008 (102
interactions). Lessons Learned: Traditional data collection
and extrapolation methods are time consuming and labor intensive to
use. They tend to be biased by user subjectivity and offer a finite view
of select patient interactions. EHHS reporting saves time and labor
costs, objectively measures hand hygiene compliance continuously,
presents information clearly and concisely, can be easily disseminated
for real time feedback, and is available 24/7. Non-compliance can
be addressed almost immediately. This newer technology allows for
enhanced surveillance and improvement in both clinical outcomes
and patient safety.
Infection Prevention and Control Program
in a Public Pediatric Hospital in Argentina:
Opportunities for Improvement
Carlos Daniel Acevedo, RN - Nurse Preventionist, Hospital
Humberto Notti; Hector Jose Abate, MD - Chief of Infectious
Diseases, Hospital; Ana M. Rosaenz, MD - Pediatric Infectious
Diseases, Hospital Humberto Notti; Andrea Falaschi, MD Pediatric Infectious Diseases, Hospital Humberto Notti; Pablo
Melonari, MD - Pediatric Infectious Diseases Physician, Hospital
Humberto Notti; Liliana Rosaenz, MD - Bacteriology, Hospital
Humberto Notti; Elsie L. Gerhardt, MA, MPH candidate Administrative Specialist, St. Jude Children’s Research Hospital,
University of Memphis; Don Guimera, BSN, RN, CIC, CCRP
- International Epidemiology Coordinator, St. Jude Childrens
Research Hospital; Kyle M. Johnson, PhD, CCRP - Clinical
Research Associate II, St. Jude Children’s Research Hospital; Miguela
Caniza, MD - Director of Infectious Diseases-International Outreach
Division, St. Jude Children’s Research Hospital
infection (HAI) was identified, the interactions leading up to the
event was reviewed to ascertain whether hand hygiene adherence
played a possible role in transmission. The aggregated information,
was posted electronically on a monitor for real-time feedback to
staff and included data on current usage and compliance rates and
Issue: Infection prevention and control (IPC) programs are
essential in hospitals to deliver safe care and decrease costs. In
low-income countries, most public hospital budgets cannot fully
support IPC programs, and the infection preventionists (IP) are
too overworked to perform all of their duties. In addition, although
IPC programs save lives and money in the longer term, necessary
resources inevitably compete with the immediate needs of the
hospital. Project: An IPC program was established in 1994 in a
270-bed, regional tertiary children’s hospital to decrease healthcareassociated infections (HAIs). Program components are an IP and a
multidisciplinary committee that meets monthly to review HAI rates
and to establish strategies for decreasing HAI-associated mortality,
morbidity and costs. All committee decisions are binding. IPC
activities are regulated by policies and procedures (P&Ps) developed
and approved by the program. The program conducts periodic
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Poster Abstracts: Outbreak Investigation
training in IPC and enforces compliance with hospital personnel
hepatitis-B vaccination. The microbiology laboratory collaborates
with WHONET and provides data on isolated pathogens, and the
pharmacy advises on the availability and use of antibiotics. Hospital
leaders support the program and the IP answers to the president of
the IPC program. Most of the activities charged to the IPC program
are conducted by the IP and include ongoing surveillance, patient
rounds, microbiological analyses, isolation, and data entry. The
IP trains personnel in IPC practices, products use, and behavior
modification, and he also manages compliance issues, reports data
to a national network, and identifies ways to decrease the risk of
HAIs. Results: Since its inception, the IPC program has become
a key facet of the hospital. The IP works hard in his traditional
role overseeing surveillance, teaching and quality control, and has
additional roles in administration and data-management. He is
supported and respected by his colleagues, and collaborates with all
hospital departments. The catheter-related urinary tract infection
and the ventilator-associated pneumonia rates have decreased steadily
since 2005, specifically in the pediatric ICU. However, catheterrelated sepsis and bacteremia rates have remained high as well as
infections among neonates. In 2005, the IPC program joined the
Programa Nacional de Vigilancia de Infecciones Hospitalarias de
Argentina (VIHdA), a national HAI system that uses the National
Healthcare Safety Network definitions, to provide database and
technical support. This collaboration calculates and reports on rates
and trends and allows comparison to national trends. Lessons
Learned: The IPC program has been in place for the past 17
years. Successes include organization structure, multidisciplinary IPC
membership, support from hospital leaders and staff, and dedicated
IP personnel. However, to move forward and address the high rates
of infection, the institution must invest in program administrative
support. The IP can then devote more time to surveillance, education,
and other strategies for decreasing the infection rates.
of behavioral health occupies 3 floors and includes an inpatient
psychiatric unit, psychiatric day treatment program, neuropsychiatric
specialty care unit, eating disorders unit, medical day treatment
unit and several outpatient clinics which provide a wide range of
psychiatric care to pediatric patients and their families. At the start
of the investigation, on October 3, 2011, 32 staff and patients,
with gastrointestinal symptoms had been identified dating back to
September 21, 2011. Due to the number of individuals affected and
illness presentation, norovirus was assumed to be the causative agent.
The inpatient psychiatric unit was immediately closed to further
admits, all patients were placed on contact precautions, visitation
was limited to 1 parent, and environmental services was contacted
to begin terminal cleaning with Dispatch. A case definition was
identified which included any Children’s Hospital Colorado staff,
patient or family member whom had contact with the inpatient
psychiatric unit, staff and/or patients in the previous 72 hours and
was experiencing at least one symptom including vomiting, diarrhea,
fever/chills, abdominal cramping or body aches. Results:
Overall, 118 individuals became ill during the course of the outbreak
(71 staff; 30pts; 17 family members). Five of these individuals
required hospitalization for dehydration. The outbreak lasted from
September 21, 2011 to October 28, 2011. Two of 8 submitted stool
samples were positive for norovirus by PCR. The initial cases were
identified on the 6th floor of the behavioral health department and
then spread to the 5th and 4th floors. Spread was thought to occur
as a result of staff working between multiple floors. The outbreak
resulted in closure of all inpatient, day treatment units and outpatient
clinics from October 3rd through October 28th. Environmental
Services staff full-time equivalents were increased 3-fold. Lessons
Learned: Inpatient psychiatric units are a particularly challenging
area to prevent and/or contain infectious outbreaks due to the nature
of the environmental setting and patient population. Strict adherence
to isolation precautions and hospital policy and procedures for
staying home when ill are critical to the prevention of outbreaks.
During the course of an outbreak, early and open communication
lines are essential between hospital employees, epidemiology, and
executive leadership to limit confusion and misconceptions regarding
the outbreak. Heightened awareness and early reporting of clusters of
illness in both patients and staff are essential for early recognition and
containment of outbreaks.
Outbreak Management of Norovirus in a Pediatric
Behavioral Health Setting
Kelly West, MS, RN, CPON - Clinical Practice SpecialistInfection Prevention, Children’s Hospital Colorado; Samuel R.
Dominguez, MD, PhD - Assistant Professor and Hospital Microbial
Epidemiologist, University of Colorado School of Medicine and
Children’s Hospital Colorado
Issue: In October 2011, an outbreak investigation of a cluster
of cases of patients and staff with gastroenteritis on the inpatient
psychiatric unit at Children’s Hospital Colorado began. Nearly three
fourths of cases affected hospital staff. Project: The inpatient
psychiatric unit is part of the department of behavioral health at
Children’s Hospital Colorado and is located in a separate building
but connected via hallways to the main hospital. The department
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93
Methicillin-resistant Staphylococcus aureus
Outbreak in the Neonatal Intensive Care Unit
Suzanne Rutledge, RN, BSN, CIC - Infection Preventionist,
Presbyterian Hospital - Charlotte, Novant Health
Issue: An outbreak of methicillin-resistant Staphylococcus aureus
(MRSA) infection was identified in our neonatal intensive care
unit (NICU) in the Spring of 2011. The index case was a neonate
who developed MRSA bacteremia and conjunctivitis in March,
followed by a second neonate with MRSA conjunctivitis. In
April, 2 additional neonates developed MRSA infections (1 case
of conjunctivitis, 1 cellulitis). A subsequent investigation with
changes in infection prevention practices resulted in resolution
of the outbreak. Project: Our NICU is a Level 3B unit with
an average daily census of 45. Prior to the outbreak, only neonates
transferred from outside facilities were screened upon admission
for presence of MRSA nasal colonization using rapid PCR assay.
When these infections were identified, all neonates sharing the same
pods as the infected neonates were screened for MRSA. All infected
and colonized neonates were cohorted and placed on contact
precautions, and healthcare workers were also cohorted whenever
possible. As additional colonized neonates were identified, MRSA
screening was broadened to include all neonates in the NICU, with
initiation of weekly surveillance. Colonized neonates were treated
with topical nasal and umbilical mupirocin for 5 days, and were
rescreened 1 week later to determine if decolonization was effective.
If MRSA nasal colonization persisted, the neonate received 1
additional course of topical mupirocin therapy. Regardless of the
repeat screening results, all neonates remained on contact isolation
for the duration of their stay. The NICU Multidisciplinary Task
Force (already in place) increased frequency of meetings in order to
address this specific issue. Infection prevention recommendations
were communicated to all departments involved in care of the
neonates, including respiratory therapy and physical therapy.
Environmental services intensified cleaning practices in the unit,
with special attention to high-touch surfaces. Nursing leaders
and physician leaders were actively involved, assisting in direct
observations of practices in the unit with frequent communication
and feedback to staff. Results: A total of 4 neonates developed
MRSA infections over a 1 month period. At least 2 different
strains of MRSA were identified based on antibiotic susceptibility
profile. At one point, there were 12 neonates with MRSA. With
the above interventions the outbreak was contained with a
continued decline in incidence of MRSA in the unit. Currently
there are 5 neonates with MRSA colonization in the NICU. No
additional MRSA infections have occurred since April 2011.
Lessons Learned: We had excellent adherence to infection
prevention recommendations and practices as physicians, nursing,
environmental services and other healthcare providers recognized
the critical role they play as individuals in the care and protection
of the neonates in their unit. All staff were empowered to enforce
infection prevention practices. Hospital-acquired infections
decreased as a result of increased awareness and adherence to
established infection control practices, including hand hygiene and
strict precautions, as well as enhanced environmental cleaning..
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Why Every Hospital should be a “No Fly Zone”
Ann Marie Pettis, RN, BSN, CIC - Director of Infection
Prevention, University of Rochester Medical Center; Lynn Fine,
MPH, PhD, CIC - Infection Preventionist, URMC; Lynne Brown,
RN, BSN, MBA - Infection Preventionist, Highland Hospital;
Melissa Z. Bronstein, RN, MPA, CIC - Infection Preventionist,
URMC; Richelle Pappalau, RN - Infection Preventionist, Rochester
General Hospital ; Mark Shelly, MD - Highland Hospital; Paul
Graman, MD - URMC
Issue: Myiasis is the term for the invasion of living tissue by fly
larvae. This occurs when a gravid fly lays it’s eggs in an orifice or an
uncovered wound. Noninvasive wound myiasis is one of the more
common forms discussed , however reports of nosocomial wound
myiasis are relatively rare. This may be explained by several facts; this
is not a mandatorily reportable condition, it can be interpreted as
a surrogate for medical negligence, and providers may not feel it is
worthy of reporting. As a result, the true frequency of myiasis cannot
accurately be estimated A case of nosocomial wound myiasis in a 55
year old male with coronary artery disease (CAD) and peripheral
vascular disease (PVD) that occurred in a 750 bed university tertiary
hospital was investigated. Project: On August 3 Infection
Prevention was alerted that maggots had been found when a patient’s
dressing was removed in the OR prior to performing a below the knee
amputation. The surgery occurred in a 260 bed community teaching
hospital, affiliated with the university hospital previously mentioned,
where the patient had been transferred from the day before, after
a one month stay. The case was clearly nosocomial but two things
needed to be determined; where was the patient exposed and how?
Results: The gangrenous amputated limb was immediately
transferred to Pathology and continuously refrigerated at 3-5
degrees C. On August 8 a sample of maggots was collected, placed
in isopropyl alcohol, and sent to the New York State Department of
Health’s regional entomologist for identification. All were larvae of
a blow fly in the genus Lucilia (order Diptera, family Calliphoridae)
which is the most common cause of wound myiasis in North
America. Most case reports, including this one, occur in late Spring
or early Fall, in lower extremities of patients with PVD and/or CAD.
The age of the larvae (45 hours) proved that exposure occurred at the
university hospital. It was also determined that exposure most likely
occurred when the patient’s wife took him outside, 48 hours before
maggots were discovered. Lessons Learned: Myiasis, although
not life threatening, is a condition which must be prevented since it
not only presents health implications, but aesthetic and cultural ones
as well . Prevention requires effort on two fronts: minimize patient
risk factors and reduce fly populations in the environment. There
should be heightened awareness and zero tolerance for flies in the
clinical setting. In this particular case, the main lesson shared was
the importance of keeping wounds clean and covered at all times.
The importance of replacing a dressing that is leaking, soiled or
malodorous promptly ,and ensuring that it is secure before allowing a
patient outdoors was reinforced.
Norovirus Outbreak in a Long Term Care Facility
Les Chock, MS, SM (ASCP),CIC, CHEP - Regional Manager,
Infection Control, Kaiser Permanente Medical Center
Issue: An outbreak of gastrointestinal illness occurred in a Long
Term Care Facility. Infection Control was notified and conducted
and outbreak investigation to successfully control the outbreak.
Project: Infection Control was notified about an outbreak of
gastrointestinal illness in our Long Term Care Facility. Five patients
with nausea and vomiting were initially reported. A Situation
Management Team was formed that included Infection Control,
Administration, Nursing, Security, Risk Management, Environmental
Services and Dietary. The 13 step Outbreak Investigation process
from the APIC Text and EPI 201 was utilized to investigate and
successfully control the outbreak. Results: Infection Control
immediately initiated an Oubtreak Investigation after being notified
of the situation. Control measures were implemented that included
cohorting patients, enhanced environmental cleaning, education for
staff, patients and visitors and controlling access to the unit. As the
number of cases continued to increase additional control measures
were taken. These included hand hygiene posters, disposable meal
trays and supplies, implementing a vistor check-in process, and
finally closing the unit to new admissions. Initial investion led to
the hypothesis that Norovirus was the leading suspect as the cause
of the illness. Within a week the number of new cases dropped and
the unit was re-opened. Lessons Learned: This was the first
time than an outbreak had occurred in this facility. Use of the 13 step
Outbreak Investigaton process from the APIC Text and the reference
material from the EPI 201 course had a dramatic effect in sucessfully
controlling the outbreak. Several weeks later the State Department of
Health Laboratory confirmed the cause as Norovirus.
A Multidisciplinary Approach toward Successful
Bed Bug Elimination in a Homeless Domiciliary
Setting
Angela Christie-Smith, RN, BSN - Infection Prevention and
Control Coordinator, VA North Texas Health Care System
Issue: Bed bugs (Cimex lectularis) are problematic in homeless
domiciliaries (HDOM) due to the transient population who
have been exposed to contaminated clothing , property and
environments.. Existing practice guidance for homeless domicillaries
is rare. Project: In response to multiple bed bug outbreaks in
a 30 bed HDOM setting, an eradication and prevention project
management plan (PMP) utilizing a multidisciplinary approach was
developed including the HDOM staff and residents, Environmental
Management Service (EMS), Microbiology laboratory, and the
Infection Prevention and Control (IPC) Coordinator. The Chief
of EMS served as the project manager and the IPC Coordinator
served in a consultant role. EMS, Laundry Service, Pest Management,
IPC and HDOM staff developed a workable PMP for ongoing
pest control while HDOM staff and EMS developed an admission
process algorithm. To obtain resident “buy-in” and assistance; a
resident “press conference” was held to provide an open forum for
education, questions, and discussion regarding the new process.
HDOM staff monitored resident compliance. A “buddy system”
among residents who work opposite shifts was created to assist each
other with necessary tasks. Results: Since January 2011, no
further recurrences of bed bugs have been identified. Initially, the
amount of work was overwhelming to staff and residents. Additional
equipment was needed due to the limited number of washing
machines, dryers and other options, such as clothing steamers, and
the staff time required to utilize these methods for eradication of bed
bugs. Heat packs for patient belongings were purchased to place all
resident belongings in upon admission. Because the type of mattresses
required for the furniture in the HDOM did not have impenetrable
covers, affected mattresses were destroyed and specialized mattress
covers were purchased to eliminate entry of bed bugs on remaining
mattresses. EMS obtained a contract pest control service that include
a bed bug-sniffing dog to inspect the HDOM and floors above and
below to ensure all potential areas of infestation were identified. To
ensure future bed bug infestations are identified in a timely manner,
prevention efforts now include weekly visual inspections with a unit
representative, EMS and pest control; quarterly inspection includes
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a bed bug sniffing dog. Lessons Learned: • Successful efforts,
require a multidisciplinary approach with a long term plan. • IPC
Coordinators can serve in a consultant role as liaison between
multiple services (e.g. reinforcement and promotion of service level
expertise, education, guidance, communication, etc.) • Eradication
and prevention measures are labor intensive, which makes staff “buy
in” difficult. Staff needed to see failure to increase motivation to
better coordinate and follow through with tasks. • In settings such
as a HDOM, the unit manager or designated staff and EMS must
perform ongoing routine inspection and pest control measures of the
affected unit and surrounding units at frequent, consistent intervals.
Outbreak of Enterococcus faecium with Low-Level
Resistance to Vancomycin in Japan
Yukihiro Yamaguchi, MD - Vice Medical Director, Kenwakai
Otemachi Hospital, KRICT; Yukiko Moronaga - Infection Control
Nurse, Kenwakai Otemachi Hospital, KRICT; Chie Nagahara Chief of Microbiology, Kenwakai Otemachi Hospital, KRICT
Issue: Vancomycin resistant Enterococcus (VRE) is rare but
emerging problem in Japan. We describe the difficulties in control of
a hospital-wide vancomycin low-level resistant Enterococcus faecium
outbreak in 635-bed community teaching hospital in Kitakyushu,
Japan. Despite of implementing standard infection control methods
such as standard precaution, contact precaution of colonized
patient and staff education, the outbreak had not controlled. The
endemic VRE strain in Kitakyushu area is Enterococcus faecium
with van B gene. The strain is known to have low-level resistance
to vancomycin and standard screening method may not detect the
strain correctly. We applied three additional methods to halt the
outbreak. Project: From August 2009 to October 2009, forty
vancomycin resistant Enterococcus and vancomycin intermediate
resistant Enterococcus faecium was identified. Following interventions
were implemented to control the outbreak. 1) Extend incubation
period of screening culture from 48 hours to 72 hours. 2) Cohort all
Enterococcus faecium with MIC ≥ 4 mg/L like VRE. 3) Routine rectal
swab check for every patient on antibiotics. Results: Numbers
of patient with colonized decreased gradually. In August 2011 no
new VRE carriage had been detected. A hospital-wide outbreak
was successfully controlled by new screening methods. Lessons
Learned: Enterococcus faecium with low-level resistance to
vancomycin is difficult to identify correctly. The difficulty of
identification may prolong outbreak. Better identification and cohort
is a key to control VRE outbreak.
Reported Endoscope Reprocessing Breaches,
Minnesota, 2010-2011
and Antimicrobial Resistance Unit, Minnesota Department of
Health
Background/Objectives: Endoscopic diagnostics and
therapeutics increasingly are replacing invasive surgical procedures
and are being performed in ambulatory and inpatient settings.
Cleaning and disinfection of endoscopes and their accessories is
complex and must be performed according to U. S. Food and Drug
Administration (FDA) labeling and manufacturer instructions.
Breaches in endoscope reprocessing can expose patients to viral
and bacterial pathogens and must be addressed on a case-bycase basis. Infection preventionists (IPs) play a fundamental
role in identifying and investigating such breaches. State health
departments have an expanding role in healthcare-associated
infection prevention and consultation separate from regulatory
functions. We discuss a state health department infectious disease
epidemiology program’s experience of providing public health
consultation to guide the investigation of endoscope reprocessing
breaches. Methods: Over the past 18 months, IPs from several
healthcare facilities requested assistance after identifying incidents of
inadequate endoscope reprocessing. In each situation, IPs collected
information on the nature of the breach, facility type, clinical
practices, endoscope/endoscopic accessories used, and cleaning/
disinfection procedures. In consultation with Centers for Disease
Control and Prevention (CDC), the risk to patients, including
pathogen transmission, was evaluated. Interventions such as patient
notification, internal facility communication, and FDA notification
were assessed and implemented as appropriate. Results: From
5/2010-9/2011, 7 endoscope reprocessing breaches were reported
from 5 healthcare facilities (1 clinic, 1 ambulatory surgical center,
3 hospitals) and involved various endoscope types (upper GI
endoscope [3], cystoscope [1], hysteroscope [1], colonoscope
[1], transesophageal echocardiography scope [1]). Breaches were
recognized by technicians (blood in the scope after reprocessing,
scope occlusion due to broken accessory piece) or by IPs (cluster of
bacterial infections post-endoscopic procedure, observation/audit
of technician practices). These incidents resulted from incorrect
use of endoscopic accessories, reprocessing of single use devices, or
failure to follow FDA labeling and/or manufacturer reprocessing
instructions. Four breaches were reported to FDA because the
manufacturer and/or vendor representative provided incorrect
instructions. To assist future breaches, we developed an endoscope
breach assessment tool and list of resources. Conclusions: IPs
associated with healthcare facilities where endoscopic procedures are
performed should be familiar with national endoscope reprocessing
guidelines. Reprocessing protocols and procedures must be assessed
regularly, particularly when implementing equipment or procedure
changes, and all staff involved with endoscopic procedures and/
or reprocessing must receive regular education, training, and
competency testing. State health departments should also be aware
of national endoscope reprocessing guidelines and other resources in
order to assist healthcare facilities in investigating breaches, including
notifying patients, and reporting to FDA. IPs should be aware
that the investigation of endoscope reprocessing breaches can be
enhanced by involving state health departments who can contribute
epidemiologic expertise, facilitate additional laboratory testing, and
engage consultation with CDC as indicated.
Jane E . Harper, BSN, MS, CIC - Supervisor, Infection Prevention
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Outbreak Investigation at a Dialysis Center
Associated with a Multi-use Dialyzer with
Removable Headers and O-rings, Los Angeles
County
L’Tanya English, RN, MPH - Program Specialist, Public Health
Nurse, County of Los Angeles Department of Public Health; Patricia
Marquez, MPH - Epidemiologist, County of Los Angeles Dept.
of Public Health; Dawn Terashita, MD - Medical Epidemiologist,
County of Los Angeles Dept. of Public Health; Kelsey Oyong,
MPH - CDC/CSTE Applied Epidemiology Fellow, County of Los
Angeles Dept. of Public Health; Hector Rivas, BS - Public Health
Microbiology Supervisor, County of Los Angeles Dept. of Public
Health; Sheena Chu, MS - Public Health Microbiology Supervisor,
County of Los Angeles Dept. of Public Health; David Dassey, MD,
MPH - Deputy Chief, Acute Communicable Disease Control,
County of Los Angeles Dept. of Public Health; Laurene Mascola,
MD, MPH - Chief, Acute Communicable Disease Control, County
of Los Angeles Dept. of Public Health
Issue: Dialyzer reuse has become the standard practice in many
dialysis centers. Dialyzer reprocessing is a complex, multi-step
procedure frequently provided by unlicensed healthcare workers. In
August 2011, Los Angeles County (LAC) Department of Public
Health (DPH), received notification of five patients diagnosed
with bacteremia among hemodialysis patients in Dialysis Center
A (DCA), four of which were positive for Stenotrophomonas
maltophilia (S. maltophilia); two of these four were also positive for
Candida parapsilosis (C. parapsilosis). Project: An extensive
epidemiologic and environmental investigation was conducted
and outbreak management and prevention recommendations are
described. DCA has 25 dialysis stations, operates three shifts daily,
six days per week. The average monthly census is 110. Cases were
defined as hemodialysis patients from May to July 2011 with a
positive S. maltophilia blood culture. Microbiologic analysis was
conducted on four case isolates and two case dialyzers. A joint site
investigation with Licensing and Certification was conducted which
included a facility walk-through, observation of dialysis cleaning and
disinfection, review of reprocessing and adverse occurrence logs, and
collection of environmental specimens. A second site investigation
was conducted to observe the reprocessing procedure. Post-treatment
flow sheets were reviewed for all cases for each dialysis session in the
two months prior to positive blood culture. Results: Four case
blood cultures were positive for S. maltophilia. Three case blood
isolates and two case dialyzer isolates had indistinguishable PFGE
pattern indicating transmission from a common source. Blood
and dialyzer isolates from the index case and one environmental
isolate (reverse osmosis water faucet) in the reprocessing room
tested positive for C. parapsilosis and matched on molecular typing.
Epidemiologic analysis revealed three PFGE matching cases were
assigned the same treatment area and on occasion shared the same
shift. These cases also used the same brand/model multi-use dialyzer.
They were the only patients in the facility to use this type of dialyzer,
which contained removable headers and o-rings. Lapses in staff
infection control observed during the first site investigation were
noted to be corrected on the second visit. There was no quality
measure to verify that the o-ring is removed and properly disinfected
during dialyzer reprocessing. Lessons Learned: The results
of the PFGE analysis indicate that a common source likely served
as the mode of transmission between patients. The results of the
environmental samples indicate that the contaminated environment
in the reprocessing room was a possible source of infection. Literature
reviews suggest that o-ring contamination of the reprocessed dialyzer
can occur when disinfection and reprocessing procedures are not
properly followed. If multi-use dialyzers with removable headers and
o-rings are used, processes to ensure proper disinfection must be in
place. In this facility, which used this type of dialyzer infrequently,
we recommended discontinued use unless an automated process is
implemented.
Use of Molecular Biology to Confirm a Bacteremia Outbreak Caused
by Burkholderia cepacia in a Pediatric Intensive Care Unit
Hilda G Orozco. Hernandez - Infectious Comittee Doctor, Instituto
Nacional de Pediatria; Genny Sanchez - Infectious Disease Physician,
INP; Miguela Caniza, MD - Director of Infectious DiseasesInternational Outreach Division, St. Jude Children’s Research
Hospital; Don Guimera, BSN, RN, CIC, CCRP - International
Epidemiology Coordinator, St. Jude Childrens Research Hospital;
Kyle M. Johnson, PhD, CCRP - Cinical Research Associated
Departament of Infectious Disease; Gonzalez Saldaña - Instituto
nacional de Pediatria; Jose Luis Castañeda Narvaez, MD Infectious Disease Physician, INP; Patricia Zarate, MD - Intensive
Caere Unit, INP
Background/Objectives: Since1980 Burkholderia
cepacia (BC) has been identified as a pathogen that causes healthcare
associated infections (HAI) and 80% of these infections occur
in intensive care units (ICU) Bacteremia mortality rate in BC
bacteremia close to 50%. Pulsed field gel electrophoresis (PFGE)
of chromosomic DNA is the gold standard to genotype BC clones.
Methods: We conducted an epidemiological descriptive study of
an outbreak to confirm the event by using the all patients with fever
and positive blood culture for BC from April 6 to May 12, 2010. The
BC epidemiological frequency, localization, and risk factors were
determined. Laboratory isolation, identification and susceptibility
were done by using Bact/ALERT, and commercial identification
and antimicrobial susceptibility kits. Through PFGE we find the
strain genotypes with contour-clamped homogeneous electric field
mapping system electrophoresis (CHEF) and Bio Rad. Results:
A probable nosocomial outbreak with an endemic channel base
of zero cases between 2005 and 2009 and an epidemiological
relationship were established when three patients out of 63
admissions in the ICU contracted bacteremia caused by B. cepacia.
The hospital length of stay was longer among these cases (median, 33
days) compared with other (median, 6 days) patients in the ICU. The
outbreak had an attack rate of 4.76%, and was 9% in those < 2 years
of age. The mortality rate was 33%, which is greater than the global
pediatric ICU rate of 19%. BC producing the outbreak and isolated
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from blood had similar biochemical profiles and antimicrobial
susceptibility pattern. Likewise, PFGE band patterns were
compatible with the B. cepacia genotype, and they were identical
when restricted with the Spe I enzyme, indicating similar bacterial
clone, confirming the outbreak. Conclusions: We suspected
an outbreak because of the epidemiological, clinical, and laboratorial
characteristics and confirmed it by means of molecular biology
techniques. A nosocomial transmission of B. cepacia among the
bacteremia cases in the pediatric ICU was demonstrated. Infection
prevention and control measures, including optimum compliance
with hand hygiene were reinforced, and no new case of bacteremia
caused by B. cepacia were reported in the pediatric ICU since the
outbreak, until late 2010, demonstrating the role of hand hygiene to
stop an outbreak.
received steroids. During hospitalization 2 patients died from septic
shock. All the strains had vancomycin MIC >64mcg/mL; the isolates
were also found resistant to amikacin (>32mcg/ml), gentamicin
(>500mcg/ml) and teicoplanin (>32mcg/ml), and were susceptible
to streptomycin (>1000mcg/ml), linezolid (2mcg/ml) and
quinupristin (0.5mcg/ml). Multiplex PCR reported VanA genotype
in all the strains. PFGE showed the same banding pattern and similar
molecular size. Dendrogram showed strains were epidemiological
related. All the evidence supports the same clone of VRE was the
cause of the outbreaks. Conclusions: Increase in bacterial
resistance to antibiotics in the hospital setting is a serious problem
nowadays. A reinforce on infection control measures and control
of vancomycin use is necessary to limit emerge of resistant strains.
Hand hygiene, barrier precaution, environmental cleaning and early
screening are key hospital interventions for infection control.
Characterization of Two Outbreaks of Vancomycin
Resistant Enterococcus faecium in a Pediatric Care
Center in Mexico City
Martha Aviles - Infectious Diseases Attending, Hospital Infantil de
México Federico Gómez
Background/Objectives: Antimicrobial resistance is an
increasing problem and challenge worldwide. Vancomycin-Resistant
Enterococcus (VRE) has emerged as an important nosocomial
pathogen because of its increasing frequency of multidrug resistance,
rapid spread and the possibility to transfer of Vancomycin resistance
to other pathogens such as Staphylococcus aureus. In Mexico, VRE
has rarely been reported. Methods: Our hospital is a Tertiary
Care center, 244 beds facility. Two VRE outbreaks were reported
from August 2009 to October 2009. The first outbreak occurred
in the intensive care unit and the second in the oncology ward.
We performed a retrospective study to describe the isolates. The
identification of the species was based on conventional biochemical
tests. Antimicrobial drug susceptibility pattern was obtained by
Kirby-Bauer disk diffusion method and confirmed by minimum
inhibitory concentration (MIC). A multiplex polymerase chain
reaction (PCR) for detection of the genotype was used. The
molecular characterization of VRE was performed by analysis of
isolated DNA by pulse field gel electrophoresis (PFGE). The aim of
this study was to determinate the strains relatedness and reinforce the
application of preventive measures by health personnel. Results:
A total number of 14 strains obtained from five patients were
identified as VRE. 5 strains were isolated from the bloodstream, 5
from urine, 3 from endotracheal tube aspiration secretions and 1
from soft-tissue. All the patients were female, three were oncology
patients, one had hemophagocytic syndrome and one had medullar
section secondary to trauma. 4 patients had central line, 4 had
mechanical ventilation, 4 had urinary catheter, 2 had pleural tube,
1 had Mahurkar catheter and 1 had cistostomy. All the patients
received antimicrobial drugs, at least, 2 weeks before the isolation of
VRE. The drugs were: third- or fourth- generation cephalosporins,
carbapenems, quinolones, aminoglycosides and metronidazole; of
this patients, 4 received a previous course of vancomycin. 4 patients
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The C. diff Cycle: The Necessity of Going Beyond
the Basics
Kim Stanley, MPH, CIC - Infection Control Coordinator,
California Pacific Medical Center; Peter Kolonoski, RN, MSN,
CIC - Infection Control Coordinator, California Pacific Medical
Center; Karen Anderson - Infection Control Manager, California
Pacific Medical Center
Issue: When Clostridium difficile infection (CDI) rates increased
in 2007, a vigorous campaign was launched at our large tertiary
care teaching hospital to stop transmission of these infections.
Initiatives included: 1) improving prompt communication of positive
laboratory results to the nursing units and the environmental services
staff (EVS), 2) modifying room cleaning protocols by instituting
bleach-cleaning, 3) working with bed control to reduce unnecessary
room transfers, 4) providing education on CDI to staff via videos,
Poster Abstracts: Product Evaluation/Cost-Effectiveness/Cost Benefit Analysis
in-services, focused stand-up meetings, posters, and screen saver
messages, and 5) Contact Precautions at symptom onset with strict
soap and water handwashing. Rates steadied and then began to
decline. Unfortunately in spite of these on-going efforts, C. diff
infection rates again significantly increased in summer of 2011. .
Project: For this performance improvement project our attention
was initially focused on a cluster of infections occurring in May &
June 2011 in the post acute unit. However further investigation
showed that majority of these cases had been transferred from
two of our acute care units: oncology and transplant services. We
determined that one of these units also had a special cause variation
for C. diff during the same time period. We reviewed 35 patient
charts during this two month period looking for commonalities in
these cases. Results: In spite of previous herculean educational
efforts about CDI, we found that staff behavior drifted away from
adherence to contact precautions. The EVS personnel had not
instituted bleach cleaning as we had assumed in post acute services.
Additionally, we found antibiotic usage to be an issue, both selection
and overuse. All 35 patients were on antibiotics at some point in
their hospital stay and on average more than three different types of
antibiotics were given. In our assessment we also reviewed the use of
proton pump inhibitors (PPI) and H2 blockers (H2B) because of a
previous study at our facility that showed PPI and H2B overuse. The
correlation between C. diff and PPI/H2 blockers is still unclear but
we found that 74% of infected patients were on PPIs at some point
during their stay, many times remaining on these medications for no
clear reason. Lessons Learned: In order to have a sustained
decrease of C. diff, we must address all of the big picture issues that
contribute to the disease, as well as keep up the everyday precautions
to prevent transmission. This outbreak has given us the impetus we
need to tackle antibiotic usage in the hospital through an antibiotic
stewardship program. We are making physicians aware of the over
use of PPIs and asking them to discontinue their use when no longer
indicated. We also must stay vigilant and monitor actual practice to
ensure staff members are following policies.
Product Evaluation/CostEffectiveness/Cost Benefit Analysis
Closing the Gap of Inconsistent Hand and Surface
Sanitation
Betty A. von Kohn, RN, BSN, CNOR, CIC - Infection Prevention
Manager, Baptist Memorial Hospital North Mississippi
Background/Objectives: Repetitive actions in hand
hygiene and environmental cleaning present concerns for lapses in
practice. Current healthcare guidelines require frequent sanitizing,
but it is not persistent or long-acting. This allows transmission
of germs between normal cleaning, sanitizing and disinfecting.
The objective of this study is to determine if using a persistent
antimicrobial hand sanitizing lotion and surface disinfectant would
bridge any gaps and reduce healthcare associated infection rates and
healthcare costs. Methods: Trial was conducted at a 217 bed
regional hospital. Healthcare workers were instructed to apply Germ
Pro Hand Sanitizing Lotion at start of their workday and reapply
every four hours. They were also instructed to continue hand hygiene
as per CDC recommendations. Environmental Service employees
were instructed to apply Germ Pro Surface Disinfectant to high
touch points after terminal discharge cleaning in patient rooms
and monthly in other areas. Germ Pro did not replace any products
or sanitizing practices. It was additional.This study is a before and
after comparison of nosocomial infection marker (NIMS) rates as
reported by MedMined. Three months (April-June) NIMS rate
before Germ Pro is compared to three months (August-October)
during Germ Pro use. July was not used in the comparison because
Germ Pro was installed for only half the month. Results: Results
NIMS Rate reduction 43.0% MRSA reduction VRE reduction
Quantity NIMS reduced 62 Cost per NIM $4,055 3 month cost
savings $ 251,410 Projected annual savings $ 1,056,640 Estimated
annual cost $ 20,000. Conclusions: 43% reduction of NIMS
validated the theory that using a persistent antimicrobial sanitizing
lotion and surface disinfectant can fill the gaps in surface disinfection
and hand hygiene. Patient safety is greatly improved, while realizing
significant cost savings. One week’s savings pays for the persistent
products for the entire year. The staff really liked the lotion and they
are using it. The lotion was reported to heal cracked hands and be
non-sticky. Environmental Services staff took ownership of the high
99
touch surface adjunct more and more as project went on. The data
validated the importance of their role in infection prevention and
the role high touch surfaces play in transmission. The trial has been
a positive measure for our facility as we promote a safer environment
for staff, patients and visitors.
The Role Appropriate Isolation Precautions
Contributes to Cost Avoidance: Conducting
Active and Retrospective Isolation Precaution
Surveillance
Kerrie E. VerLee, MPH, CIC - Epidemiologist, Spectrum Health;
Dorine Berriel-Cass, RN, BSN, MA, CIC - Manager, Infection
Control and Prevention, Spectrum Health; Kristen Simpson, RN,
BSN, CCRN-CMC - Infection Preventionist, Spectrum Health
Background/Objectives: Isolation precautions are used
to disrupt the chain of transmission among patients with known or
symptomatic infections. The use of personal protective equipment
may be effective in reducing transmission if used appropriately.
However, overuse of isolation precautions in patients not, or
no longer, at risk may incur increased costs, decreased staff and
patient satisfaction, and decreased direct caregiver time with the
patient. Accurate implementation of isolation precautions may
result in increased cost avoidance without increased transmission.
Methods: Starting in July, 2011, an active daily review of
all inpatients was conducted to evaluate the appropriateness
of the patient’s isolation precaution status. Simultaneously, a
retrospective chart review of all patients with previous positive
cultures of multidrug resistant organisms (MDRO) was
conducted. These discharged patient records were assessed for
continued isolation precaution appropriateness as our electronic
medical record automatically creates an isolation precaution
order upon subsequent re-admission for all historic positive
MDRO cultures. Investigation into costs associated with gowns,
gloves, and masks was conducted as well as additional staff salary
and time involved with adherence to isolation precautions.
Results: From July 7th through December 16th, 2011, 15,287
patients with previous positive MDRO cultures were evaluated for
isolation precaution clearance. Following our isolation precaution
clearance policy, 1,087 patients met criteria through retrospective
chart review. Daily evaluation of all 868 inpatient beds resulted
in 125 patients cleared during the same time period. The daily
cost avoidance for contact isolation was $35.33 per patient, which
reflects 46.2 gowns and pairs of gloves used as well as 46.3 minutes
of daily excess staff time. Staff time was measured by observation
while gown numbers were collected from inventory records.
Length of stay for inpatients was measured and included both new
inpatients and those previously cleared of their MDRO history.
Cost avoidance data was collected with observations spanning
over 40 days of inpatients who were cleared from isolation
precautions. Over this observation period, 61 inpatients no longer
needed isolation precautions; 30 of these inpatients were new,
and 31 inpatients had been retrospectively cleared thus avoiding
isolation precautions with their readmission. The average number
of patients cleared from isolation precautions was 8.1 inpatients
(SD 2.5) per day, corresponding with a daily cost avoidance of
$285.29 (SD $88.4). The average daily Infection Prevention
staff time invested in this project was 3.5 hours and returned a
projected $104,130.85 (95% CI $94,131 – 114,130) in annual
cost avoidance. Additionally, no subsequent raise in MDRO
transmission has been detected and staff and patients have
expressed increased satisfaction. Conclusions: Accurate
implementation of isolation precautions may result in increased
cost avoidance and patient and staff satisfaction without increased
infection transmission. Automating isolation clearance procedures
or algorithms in electronic medical records may be beneficial for
systemizing isolation precaution appropriateness.
Avoiding Unintentional Hypothermia During
Prosthetic Joint Replacement Surgery
Cynthia A. Kohan, MT, MS, CIC - Infection Preventionist,
Hospital of Saint Raphael; Michelle N. Whitbread, MT, MPH-
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Infection Prevention, Hospital of Saint Raphael; John M. Boyce,
MD - Hospital Epidemiologist, Hospital of Saint Raphael; Clinical
Background/Objectives: Hypothermia during
the intraoperative period is associated with an increased risk of
developing a surgical site infection. Despite using both a forced
warm air jacket preoperatively and blanket during surgery, 36% of
prosthetic joint replacement patients did not achieve normothermia
during the intraoperative period. Due to the surgeon’s concern that
the forced air motor would increase room contaminants, the forced
air blanket was not turned on until the patient’s skin preparation
and draping was accomplished, often leading to unintentional
hypothermia. Beginning in September 2011, an underbody
disposable water-based warming pad was added to the operating room
(OR) table to be used in conjunction with the forced air modalities.
Objectives: The objective of this study was to determine if using
an underbody warming device, in addition to the forced warm air
modalities would increase the proportion of patients achieving and
maintaining normothermia during surgery. Methods: From May
to September 2010, the baseline period, intraoperative temperatures
were obtained from anesthesia records of 50 patients who underwent
joint replacement surgery. The underbody disposable water-based
warming pad was implemented for joint replacement surgeries in
September 2011. From September 2011 to January 2012, the post
intervention period, anesthesia records of 56 patients were reviewed
to determine the first and last intraoperative temperatures, as well as
the highest and lowest temperature. Temperatures were taken using
either a bladder probe or an esophageal probe. Results: During
the baseline period 13/50 (26%) of patients were normothermic the
entire time they were in the OR, as compared to 29/56 (52%) of
patients during the post intervention period (p=0.0067). Thirty-six
percent (18/50) of the patients were hypothermic for the duration
of the surgical procedure during the baseline period, while there
were only 12% (7/56) in the post intervention period (p=0.0044).
When comparing the last temperature taken in the operating room;
25/50 (50%) of the patients were normothermic in the baseline
period, but 46/56 (82%) were normothermic in the post intervention
period (p=0.0004). Conclusions: Using the underbody
disposable water based warming pad together with preoperative and
intraoperative forced warm air warming modalities increased and
maintained patients’ body temperature throughout the intraoperative
period. These results have supported continued utilization of the
underbody warming pad. The adoption of this new warming system
contributes to collaborative efforts to reduce postoperative infections
in prosthetic joint replacement patients.
VA Medical Center; Michelle Nerandzic - Research Assistant,
Research Service, Louis Stokes Cleveland VA Medical Center; Brett
Sitzlar - Research Assistant, Geriatric Research, Education, and
Clinical Center, Louis Stokes Cleveland VA Medical Center; Curtis
J. Donskey, MD - Chair, Infection Control Committee, Louis Stokes
Background/Objectives: Hospital equipment
that directly contacts patients may be an important source for
transmission of healthcare-associated pathogens such as Clostridium
difficile and vancomycin-resistant enterococci (VRE). There is
a need for simple, safe, and effective disinfection methods for
equipment that include activity against C. difficile spores. The
objective is to test the hypothesis that spraying equipment with an
electrochemically activated saline solution containing hypochlorous
acid (Solution C) would be an efficient and effective means to
reduce bacterial contamination, including C. difficile spores, on
equipment. Methods: In the laboratory, we examined the
efficacy of Solution C versus a 1 to 10 dilution of household bleach
for killing of 3 strains of C. difficile spores and 3 clinical VRE strains
that were inoculated onto surfaces of portable equipment. On
hospital wards, wall-mounted and portable vital signs equipment
was cultured for C. difficile, VRE, and total facultative and aerobic
bacteria before and after spraying with Solution C. Results: In
the laboratory, Solution C was as effective as a 1 to 10 dilution of
household bleach for disinfection of equipment, resulting in >5 log
and >3 log reductions in recovered counts of C. difficile spores and
VRE in the absence and presence of organic load, respectively. As
shown in the table, Solution C resulted in significant reductions
in total facultative and aerobic bacterial counts and eliminated C.
difficile and VRE contamination. There was no evidence of adverse
effects to surfaces after multiple applications of Solution C and no
reported complaints from nursing staff or patients. The application of
Solution C using a spray bottle required only a few seconds for each
set of portable or wall-mounted equipment. Conclusions:
Spraying equipment with electrochemically-activated saline solution
containing hypochlorous acid is a simple and effective means to
reduce contamination with Clostridium difficile and other healthcareassociated pathogens.
Effectiveness of an Electrochemically Activated
Saline Solution for Disinfection of Hospital
Equipment
Dennis Fertelli - Research Assistant, Infection Control Department,
Louis Stokes Cleveland VA Medical Center; Jennifer Cadnum,
BS - Research Assistant, Research Service, Louis Stokes Cleveland
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Financial Implications of VRE Screening Intensive
Care Units
Christopher S. Hollenbeak, PhD - Associate Professor, Penn
State College of Medicine; Nathan A. Ledeboer, PhD - Assistant
Professor, Medical College of Wisonsin
Background/Objectives: Patients are increasingly
being admitted to hospitals colonized with vancomycin resistant
Enterococcus (VRE). Many hospitals are evaluating methods to screen
patients for VRE, particularly in intensive care units. This study
sought to evaluate the economic implications of VRE screening using
different culture and polymerase chain reaction (PCR) methods.
Methods: We used decision analysis to model VRE screening
using two chromogenic media (CM), one PCR, and one traditional
culture approach. We also modeled a no screening strategy and a
hypothetical perfect screen for comparison. The model estimated the
cost and outcome implications of alternative methods of screening for
VRE in the ICU setting and took into account spread of VRE, spread
of vancomycin resistance, and whether hospitals were prepared to
act immediately upon screening results. Outcomes included correct
classification, unnecessary isolation costs, unnecessary infection costs,
and total costs. Sensitivity analysis tested main model parameters.
Results: Baseline analysis assumed: 1) a 17% colonization rate,
2) only patients with a positive screen were isolated, 3) 18 hours
passed before action was taken on screening results, and 5) no
patients were decolonized. The CM approach was associated with the
highest combined rates of correct classification (99.7% and 99.2%
for CM versus 93.4% for PCR and 77.1% for traditional culture)
and positive predictive value (PPV) (99.0% and 98.5% for CM,
72.6% for PCR, and 42.0% for traditional culture). CM was also
associated with lower unnecessary isolation costs per patient than
PCR ($16.80 and $25.20 for CM, $675 for PCR, and $1962 for
traditional culture) and lower unnecessary infection costs ($3.42 and
$11.79 for CM, $6.09 for PCR, and $30.43 for traditional culture).
Conclusions: For hospitals considering a screening strategy
for VRE in the intensive care unit, a CM approach appears to offer
the highest rates of PPV and correct classification, and lowest overall
unnecessary isolation and infection costs under baseline assumptions.
Hospitals also need to weigh other factors such as time to action and
isolation costs.
appropriate isolation precautions, and cultural transformation. Each
patient entering the hospital or community living center is screened
for MRSA upon admission, transfer and discharge. If screening is
positive, is placed on appropriate isolation precautions that include
wearing gowns and gloves with patient contact. The gap in time
from the screening to the result, presents the possibility of exposure/
transmission of MRSA to the environment, other patients and
healthcare workers. Reducing this gap in time, would also reduce
the infection risks. The decision to use polymerase chain reaction
(PCR) testing for MRSA screening would decrease that gap in
time, but greatly increase the costs of administering the program,
the question is: Is it worth it? Project: A look at screening
using ChromAGAR (AGAR) vs. Polymerase Chain Reaction
(PCR) methods of testing to find the most beneficial test for MRSA
colonization, as it relates to the risk of infection. Prior to May 2011,
we used the AGAR test to determine MRSA colonization. Cost of
this test was about $3.00. Notification of a positive and subsequent
placement of patient in isolation precautions could take up to 2
days, increasing the risk of MRSA transmission. We averaged 5
transmissions per month, and 0.6 infections per month. This meant
that each month, 5 to 6 people acquired MRSA in our facility. We
wanted to close the gap in the notification time. PCR testing could
report results within a couple of hours as opposed to 24+ hours. Cost
of this test was about $41.00. We averaged 1200 tests per month
(Table 1), to save money we changed our screening rules to: 1) all
persons without a history of MRSA culture or screen within the past
12 months (“history”) were screened using PCR on admission and
transfers, and AGAR on discharge, and 2) persons with a “history”
were screened by AGAR on admission only. Still, we averaged
$23,000 a month in PCR testing (Table 2), so to further reduce costs,
we looked at changing the PCR test on transfer to AGAR. We found
that an average of 3% of all transfer screens converted to positive,
this translates to an average of about 3 screens in 80. (Table 3) This
change saved approximately $3,400 per month. Results: Average
monthly transmission rate in Acute Care was 1.63 before PCR and
1.28 after PCR, a reduction of 20%. Average monthly infection
rate in Acute Care was 2.12 before PCR and 0.228 after PCR, a
reduction in MRSA HAIs of 89%. Similar results occurred in the
CLC. Lessons Learned: The reduction in transmissions and
infections made PCR beneficial despite the cost.
Determining an Effective Measure of Testing
for MRSA Colonization for Timely Placement in
Appropriate Isolation Precautions
Cynthia Powell, BSN, RN, CCRN - MDRO Prevention
Coordinator, CTVHCS - Temple
Issue: Measures to prevent the spread of MRSA, either by active
infection or colonization, include hand hygiene, active surveillance,
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Poster Abstracts: Public Reporting/Regulatory Compliance
Cost Effectiveness of an Electronic Hand Hygiene
Monitoring System (EHHMS) in the Prevention of
Healthcare-Associated Infections
Barbara J. Simmonds, RN, BS, CIC - Director of Infection
Prevention, Miami Children’s Hospital; Deise Granado-Villar, MD,
MPH, FAAP - Chief Medical Officer/Senior Vice President For
Medical And Academic Affairs, Miami Children’s Hospital
Issue: Despite the fact that the Centers for Disease Control
and Prevention (CDC) have documented downward trends in
HAI rates in four major anatomic sites (bloodstream, respiratory
tract, urinary tract, and surgical wounds), HAIs caused by resistant
pathogens at these sites continue to increase in US healthcare
facilities. The hands of HCWs invariably play a significant role
in the transmission of HAIs in healthcare facilities. Transmission
of two of the principal microorganisms responsible for HAIs in
US healthcare facilities—Staphylococcus aureus and Enterococcus
species—is commonly facilitated by HCW hands. However, much
of the interventions, guidelines, and existing mechanisms aimed at
improving hand hygiene adherence (e.g., behavior modification and
incentive programs) have been ineffective. Project: In September
2010, we instituted a novel electronic hand hygiene monitoring
system (EHHMS) in an pediatric Hemonc Unit (PHOU) in our
274-bed, stand alone, acute-care children’s hospital. Data collected
prospectively have demonstrated that hand hygiene adherence rates
have improved significantly and maintained consistently above
95%, across all shifts, among both medical and nursing personnel.
In previously presented data, we demonstrated an unequivocal
parallel fall in the occurrence of HAI in the PHOU since EHHMS
was installed. We carried out this analysis to ascertain the cost
effectiveness of implementing the EHHMS. First, we ascertained the
number of HAIs registered in the PHOU for the first two quarters of
2011 and the additional hospitalization costs attributable to HAIs.
Next, we compared these costs with parallel HAI costs for the first
two quarters of 2010 and 2009 before the official institution of the
EHHMS in our facility. Results: The total cost of installing
the EHHMS was $72,800 (i.e., $2,800 per bed). During the first
two quarters of 2011, six patients acquired HAIs. The aggregate
cost attributed to HAIs among these 6 patients was $756,207 (this
amount was ascertained by comparing the cost of care for these six
patients with six patients with similar diagnoses and duration of
hospital stay who did not acquire HAIs.) Thus, the mean cost per
patient attributable to HAI was $126,034. For parallel quarters
in 2009 and 2010, the overall HAI costs were $1,260,034 (10
infections) and $1,134,306 (9 infections), respectively. Lessons
Learned: Electronic hand hygiene monitoring and tracking has
played an important role in our facility in enhancing hand hygiene
compliance among medical and nursing personal and in reducing
HAI occurrences. Hand hygiene adherence rates can be maintained
consistently above 95% across all shifts. Finally, the cost of installing
and instituting the EHHMS in our PHOU has been more than
offset by the savings engendered by the decrease in the number of
HAIs since institution of the EHHMS.
Public Reporting/Regulatory
Compliance
Who Should Be in Charge of What? (Components
of a State-Level Healthcare-Associated Infections
Prevention Effort)
Amber Taylor, MPH - Health Policy Analyst, US Dept. of Health
& Human Services/Office of the Asst. Secretary for Health/Office
of Healthcare Quality; Ian Kramer, MS - Health Policy Analyst,
Office of Healthcare Quality/Office of the Asssistant Secretary for
Health/U.S. Department of Health & Human Services; Rani Jeeva,
MPH - Team Leader, Healthcare-Associated Infections Initiative, US
Dept of Health & Human Services/Office of the Assistant Secretary
for Health/Office of Healthcare Quality
Issue: Public Reporting of healthcare-associated infections (HAIs)
has expanded tremendously over the last several years, from the
number of states now requiring at least on type of HAI measures
to the number of different entities that require reporting. To date
there are 28 states that have state-level public reporting HAI data
legislation, compared to just four states in 2004. In addition to
state-reporting, federal legislation has passed for reporting for certain
HAIs as they relate to pay-for-performance (incentive measures),
thus creating new tasks for infection preventionsists (IPs) in addition
to their other daily data collections. Thus, the major issue is how to
drive results with heterogeneous and sometimes competing entities
at different maturity levels, while still protecting the public’s health
and allowing IPs to do what they do best : educating and preventing
infections. Project: In September 2011, the Office of Healthcare
Quality in the Office of the Assistant Secretary for Health in the
U.S. Department of Health & Human Services, convened a focus
group on the “Essential Components of State Healthcare-Associated
Infection Efforts” and a broader meeting State-Level Partners
Collaborating to Eliminate Healthcare-Associated Infections”,
Dallas/Fort Worth, TX. The meetings were held to identify
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Poster Abstracts: Public Reporting/Regulatory Compliance
priorities, encourage collaboration and reduce duplication efforts.
Participants at both meetings were asked the same questions listed
below: “What are the essential thematic components required for a
state program?”; “Of these essential components, which are priority
components?”; Which stakeholder is best suited to take the lead
for each component?”; and “What resources and infrastructure
are required and how can the federal government and regional
entities best support these programs?”. At the broader meeting,
participants were asked, “What are the top four priorities of a State
HAI program?” and “Who should take the lead on those priorities?”.
Results: Based on a poll of the over 250 participants at the
broader meeting, the top four priorities, with the lead agencies in
parentheses are: 1. Coordination, collaboration and integration (State
and Local Health Departments), 2. Surveillance, validation, analysis
and reporting (State and Local Health Departments), 3. Culture
of safety, health and learning (QIO) and 4. Quality improvement/
best practices (QIO). These results were in high agreement with the
results of the focus group. Lessons Learned: More needs
to be done to assist the state-level HAI programs, where one of the
biggest challenges is developing the rapidly growing HAI public
health infrastructure as public reporting and the intersection of
public health and HAI is still a burgeoning topic. Coordination and
collaboration is also a big concern as more and more requirements
are being added to state and federal legislation. As such, a detailed
environmental scan of state-HAI activities will be taking place over
the next year to identify current needs and gaps.
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California State Mandated MRSA Screening:
Healthcare Dollars Down the Drain!
Joan Finney, RN, BSN, CIC - Director of Infection Prevention and
Epidemiology, Good Samaritan Hospital, Los Angeles
Issue: On January 1, 2009 our 408-bed acute hospital in Los
Angeles began admission screening for MRSA in accordance with
California Senate Bill 1058. We were required to screen patients
within 24 hours if they were admitted from a skilled nursing facility,
were admitted to an ICU including NICU, discharged from another
hospital within 30 days, on dialysis or undergoing high risk surgery.
The attending physician was required to notify the patient if MRSA
was identified. The intent of the mandated screening was to prevent
transmission of MRSA and reduce antibiotic resistance. Project:
Our infection prevention team began education for nursing staff
and physicians on the new requirements. Standard protocols were
developed to cover the swabbing of the adult patient’s nares and
NICU neonate’s groin. The nursing admission assessment in the
electronic medical record was redesigned by Information Services
to help identify patients meeting criteria. Progress Note reminder
stickers were developed to alert physicians and remind them to
discuss positive findings with the patient. Our lab prepared to handle
a heavy volume of MRSA screens using chromogenic media-based
tests. Results: Rates of our hospital-acquired MRSA infections
remained low from 2005 through 2011, indicating that the increased
screening did not lower HAI MRSA transmission. There was no
Poster Abstracts: Quality Management Systems/Process Improvement/Adverse Outcomes
change in our antimicrobial resistance patterns. We experienced an
847% increase in lab specimen volume beginning in January 2009.
Using our own hospital’s estimate of laboratory costs of $26 per
specimen, we spent additional hard costs of $356,768 between 2009
and 2011 for this testing. Using costs of contact isolation based on
current literature (for isolation supplies, nursing personnel time and
housekeeping disinfection measures) we estimated $1734 per MRSA
colonization case. Our annual costs increased from $88,434 to over
$749,088, for an estimated total of $2.3 million spent between 2009
and 2011 for additional isolation. Three years of testing in-born
neonates showed that of 1554 screens done between 2009 and 2011
only one positive was identified. That neonate was from a known
MRSA positive mom. Lessons Learned: The volume of
specimens this regulatory mandate required significant costs for the
organization. In addition to testing and isolation costs, many other
resources were required administratively. Our policy of initiating
contact precautions for nares colonization may warrant review to
weigh the cost vs. benefits of isolation for colonization of nares only.
The data shows that screening of NICU neonates was of no value.
Feedback to our state health department regarding our data may be
useful to help refine MRSA screening requirements. We did not see
evidence that screening as mandated returned value for the dollars
spent or improved patient safety. Regulatory mandates need to be
carefully promulgated so healthcare dollars are well spent and not go
down the drain.
infection prevention was identified on July 11, 2011. Project:
Class 1 infections are preventable infections that occur within the
ThedaCare System. From January 1, 2010 to May 31, 2011, 29 out of
1,700 Orthopedics’ Hip and Knee replacement patients experienced
a Class 1 infection after surgery. These infections lead to: A readmission rate of 83% (24 out of 29) for patients with a SSI, and a
subsequent additional surgery procedure rate of 79% (23 out of 29).
Additional and long term medication requirements at a rate of 83%
(24 out of 29 ), with a average length of time of 4.2 months. Patients
visit a Infectious Disease Provider an average of 7.6 times, and other
providers an average of 13.4 times (not including surgeries). Patients
visited the Emergency Department one or more times in 41% (12
out of 29) of the patients with a SSI. Patients with a SSI sought
treatment or counsel outside of our system and partners 13.7% (4
out of 29) of the time. Results: Safet/Quality: Orthopedic
SSI Rate Initial 1.7% (29/1700) Target 0.85% (50% Reduction)
Customer Satisfaction: Rate of additional surgical proceudres
Initial 79% (23/29) Target 39.5% (50% Reduction) Number of
Readmissions: Initial 83% (24/29) Target 41.5% (50% Reduction)
Financial Stewardship: Reduce cost associated with SSI’s: Initial
$928,000 Target $464,000 Completed by 07-25-11: 1. Standard
work in relation to bathing procedures 2. Standard Work in relation
Quality Management Systems/
Process Improvement/
Adverse Outcomes
Utilizing Lean Analysis to Conduct a Horizontal
Value Stream focusing on the Reduction of
Orthopedic Surgical Site Infections
Miki Gould - Infection Preventionist, ThedaCare
Issue: In a multi-complex healthcare system containing, 2 acute
care hospitals (Total beds 385), 3 critical access, 5 surgery centers,
34 clinics, 1 home health, LTC, CBRF and Hospice worked in silo’s
and not together as a team and work in individual silo’s. In February
2011, The Improvement System pulled all divisions together to
create an easy process flow for the orthopedic patient. It’s part of the
process the role of the infection prevention was identified in each
step of the patients experience, and a rapid improvement event for
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to bathing timing 3. Standard MRSA testing Algorithm 4. Document
to display Infection Stats on a monthly basis 5. Checklist to ensure
AORN (Association of peri-operative Nursing) Compliance 6.
Posters to highlight AORN requirements Planned Work 1. Create
Patient Education Binder for continuum of care 2. Establish standard
MRSA procedures 3. Create a network of Infection Prevention
Champions 4. Create digital media site for patient education 5.
Standardize all products in OR’s 6. Create a “Infection Cross” that
shows AORN compliance. Lessons Learned: Insights:
(aha) 1. Surgical Site Infections have not been highlighted through
the system 2. Infection Prevention touches everyone 3. The high
impact on Surgical Site Infection Challenges: 1. Our culture may
not be ready 2. Infection Prevention has a very large scope 3. Cost of
Infection Prevention Actions Required to Sustain or Build Change?
1. Building a transparent feedback mechanism 2. Leadership support.
Communicating Critical Surveillance Data for
Improved Outcomes
Crystal R. Heishman, RN - Surveillance, University of Louisville
Hospital; Pamela Nolting , MSN, RN ,CIC - Infection Control
Practitioner, University of Louisville Hospital; Linda Goss , MSN,
APRN-BC, CIC,COHN-S - Director of Infection Prevention and
Vascular Access Specialist Team, University of Louisville Hospital
Issue: Prevention of Healthcare Acquired Infections (HAIs)
requires a multi-faceted approach. Active surveillance identifies
significant changes relative to a patient’s condition that may result
in a HAI. Ventilator Associated Pneumonia (VAP) surveillance is
one example of a HAI that requires near real-time monitoring and
timely communication of the findings in order to facilitate earlier
interventions. A lack of standardized communication techniques
of critical surveillance data was cited by the Intensive Care Unit
(ICU) managers of an urban academic medical center as a potential
reason for inadequate or delayed response to bedside practice. The
objective of this project was to identify and test a novel method of
communication that facilitated earlier identification of potential
infections. Project: In November 2010, the Infection Prevention
department implemented a communication process using a Microsoft
Excel (2007) database for use with VAP surveillance. The database
resided on the facility network drive and “read only” access granted
to the ICU Clinical Managers and physicians. The database
contained pertinent attributes necessary to assist the Infection
Preventionist in identifying potential VAP cases. The database was
updated every 24-48 hours when surveillance criteria identified a
significant change. Potential VAP cases were placed on a “watch
list” which was color coded to enable quick visual review. Managers
and physicians self reported increased awareness of surveillance
trends and earlier response times for interventions. A web based
survey was developed at www.surveymonkey.com and distributed to
the end users to assess the effectiveness and utility of the database.
Infection rates pre-database and post-database were compared.
Results: 83.3% of respondents stated they used the database to
identify potential “at risk” ventilated patients and interventions were
altered or increased based on retrieved information. 100% stated
they used the database weekly and 50% used it daily. 100% of the
respondents stated they preferred the new method of communication
over traditional methods. The overall VAP rate per 1000 ventilator
days decreased from 11.88 in 2010 to 6.71 in 2011. The number of
VAP cases decreased from 91 in 2010 to 49 in 2011. Lessons
Learned: Communication of surveillance data can be enhanced
without duplication of efforts and with minimal process alterations.
Providing a convenient method for reviewing unit specific data can
result in earlier interventions. Although this was not studied, time
106
normally spent by the Infection Preventionist calling, sending email,
or physically locating the appropriate clinician was saved due to the
new process. The project was deemed a success as the positive trend
in VAP reduction was identified. This process can be transferred to
other surveillance reviews, and it can be inferred that all HAI rates
could be positively impacted.
reproducible, the team expanded deployment of the technology to
the Medical Intensive Care Unit (MICU). Results of the secondary
deployment were measured and verified, and are presented here for
consideration. Methods: Researchers selected their MICU
because ICUs typically have higher infection rates due to complexity
of patient mix, frequency of invasive device use, and higher severity
of illness and comorbidity within the patient population. After
recording two months of baseline dispensing activity, employees
(77) were issued Radio Frequency Identification (RFID) badges for
the pilot program. Dispensing counts from both alcohol-based hand
solution and soap dispensers were automatically tracked by hour, day,
and month with the same system. At the end of active monitoring,
hand hygiene solution dispensing data was compared to HAI trends.
Researchers compared from the monitored months with the same
months of the previous year to assess changes. Methods: During the
study period, caregivers wore RFID badges which allowed active 24/7
monitoring of hand hygiene activity. Proximity sensing of caregivers
Reproducibility of Results in Decreasing
Healthcare-Associated Infections with the Use of
Electronic Hand Hygiene Surveillance Technology
Brenda D. Edwards Brazzell, RN, BS - Manager, Infection
Prevention and Employee Health, Princeton Baptist Medical Center
Background/Objectives: Healthcare associated
infections (HAIs) cause the loss of thousands of lives and millions of
dollars every year despite the widely accepted knowledge that hand
hygiene (HH) is the most effective means of reducing HAIs. Clinical
managers responsible for one Medical Center’s post-surgical unit
piloted an automated hand hygiene monitoring system and attained
a 22% reduction in HAIs. In order to verify that these results were
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within the patient room determined hand hygiene opportunities
and hand cleansing activity was confirmed by the activation of a
sensor within the dispenser when the caregiver accessed a solution
for hand washing. HAI data trends were assessed using an electronic
proxy measure called a Nosocomial Infection Marker™. Results:
Researchers noted that during the first month of the study period,
the MICU had a total of 9,995 hand hygiene dispenses, or 30.2
dispenses per patient day. For the sixth and final month, dispenses
had increased to a total of 35,713, or 99.8 dispenses per patient day.
During the same six months the MICU infection markers per 1,000
patient-days rate decreased by 35.1% when compared to the same
months during the previous year. Based on previously published cost
data, the reduction in NIMs corresponds to a decrease of 239 patient
days and reduced net losses of $200,079. Conclusion: These
results suggests the use of an automated hand hygiene surveillance
and communication system can achieve reproducible increases in
hand hygiene activity and associated reductions in HAIs, patient
days, and net losses.
Development of a Health Care Providers Quality
Improvement Team in a Small, Rural Community
Marti Heinze, RN, BS - Infection Preventionist, Gerald Champion
Regional Medical Center; Erva Yarborough, RN, CHPN - Patient
Care Coordinator, Alamogordo Home Care-Hospice
Issue: To improve patient care across the continuum, the health
care facilities in our community initiated monthly meetings of
representatives from nursing homes, homecare/ hospice, assisted
living facilities, physician’s offices and the hospital to improve
the availability of information as patients are transferred among
the healthcare providers in our area. Project: We began by
improving communication on several issues: • Determined each
physicians preferred method of communication, • Developed a
standardized transfer form for information when patients present
to the hospital emergency department, • Developed a form to
notify hospital infection preventionists in the event of a possible
infection post hospital discharge and • Started investigating a
method of notification of Clostridium difficile infection(s) and
date(s) of episode(s) in patient’s medical record easily accessed by
all providers. Results: Our results are as follows: 1. A physician
communication survey form was developed and taken to the doctor’s
offices so that they could indicate how they preferred to be contacted
for both routine items and urgent issues (telephone, fax, email,
text, etc.). 2. After reviewing all available forms, a single transfer
form was developed by combining the most important aspects of
each so the patient’s pertinent information is readily available. The
form provides a single format for the local emergency department
personnel to become familiar with, reducing the time required for
them to locate the important information regarding a specific patient.
3. An infection reporting form was developed for long term care
facilities, physician’s offices, rehabilitation facilities, home health care
providers and assisted living centers. The form is to be completed
and sent to the appropriate hospital Infection Preventionist in the
event of a suspected post-hospitalization infection. The form was
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developed using the CDC/NHSN criteria in a checklist format
identifying the reportable information for UTI, SSI, pneumonia
and/or Clostridium difficile. Instructions are provided for the various
categories, allowing outside agencies to assist in reporting infections
after discharge. 4. Investigation is underway to find a standardized
method to denote Clostridium difficile infection(s) and the date of
the occurrence(s) in the patient’s chart so that health care providers
can determine the patient’s Clostridium difficile status and use this
information to select the most appropriate treatment for that patient.
The current hospital antibiogram will be distributed to physician’s
offices and the health care facilities listed above to aide in choosing
effective and appropriate antibiotic therapy. Lessons Learned:
Improvements in communication in our community have already
had a positive impact on patient care as critical information is easier
to locate as the patient moves between hospital, nursing homes,
hospice/home care agencies and assisted living facilities. There is also
a tremendous potential for education and sharing of ideas now that
the lines of communication have been established. The true “winner”
is the patient.
Process Improvement: Facility wide Reduction in
Hospital-Associated Infections Utilizing CHG for
Oral Care and Preoperative Preparation
BJ Helton, MT (ASCP), MPH, CIC - Manager Patient Safety and
Quality, Covenant HealthCare
Issue: Like our counterparts, our hospital seeks to reduce
healthcare-associated infections (HAIs) through preventative
efforts. To this end, we incorporated Keystone bundles into our
preventive care measures for our critical care units many years ago.
We experienced consistent improvement in both our central line and
ventilator infections. However, in second quarter 2008 we began
to see an unexpected increase in ventilator-associated pneumonia
infections (VAPs). During this same time period we began to see
an increase in the number of surgical site infections (SSIs) that
cultured positive for Methicillin-Resistant Staphylococcus aureus
(MRSA). We focused our energies on a process improvement plan
that would incorporate the use of chlorhexidine gluconate (CHG)
into our preoperative preparation protocol and facility-wide oral care
practices. Project: Both facility-wide and targeted surveillance
methods were used to track and trend HAIs. VAP and SSI infections
were identified using Centers for Disease Control and Prevention
(CDC) definitions. A VAP Taskforce formed in February 2009
consisted of critical care nursing specialists, educators, managers,
speech and respiratory therapy. We reviewed our current practices
and products, realizing the need for a new comprehensive oral
care program. The role of Oral Care Champion was developed
with representatives from both nursing and non-nursing units.
Information gathering by the champions identified several barriers.
One barrier was consistent throughout the facility: limited
knowledge of products and their availability. We immediately began
in-servicing staff to review products and displayed posters on each
unit. Articles on the oral care campaign were published both monthly
and weekly in our facility newsletters. We consistently performed
oral care every 4 hours and using 0.12% oral CHG every 12 hours.
A SSI Taskforce formed in February 2008 consisted of surgical
services director, managers, coordinators, educators, operating room
staff and quality improvement specialist. Records reviewed were
selected from positive wound cultures, return to surgery reports,
and post-discharge letters to surgeons, information gathered from
staff, homecare nursing, wound care center and local hospital
infection prevention information sharing. We began using 2% CHG
cloths for our preoperative preparation in three types of surgical
procedures (cardiac, joint and spine). Staff education was begun and
implementation of progressive use of the 2% CHG preoperative
preparation for other high risk surgeries soon followed. Results:
Following the implementation of these two taskforces and protocols,
we saw a 76.78% decrease in MRSA-positive SSIs and 85.37%
decrease in VAPs. We have maintained a low rate to present day.
Lessons Learned: Compliance and communication were key
issues for both taskforces. Communication barriers were identified
in several different stages during the implementation protocols. The
development of an evaluation tool to assess staff ’s understanding
of the process and products was pivotal for compliance. Consistent
monitoring and concurrent feedback elevated compliance.
and reporting. We designed and implemented a web-based
computer program that allows viewers to see aggregate hand hygiene
performance data as soon as it is entered into the program, allowing
for daily tracking of performance. Project: Observers collect
hand hygiene performance data on 30 to 60 patient encounters
per day throughout the hospital by direct observation. Observers
enter their results into the database each day, including the patient
care unit where the observation was made, the role category of the
person observed, and the work shift. Previously, we analyzed data and
released reports at the end of each month. We designed a web-based
application that uses Crystal Reports (SAP), a business intelligence
report-writing program, to allow viewers to see hand hygiene data as
soon as the data are entered into the database. Data are retrievable
by date range, location of observation, category of staff observed,
weekday versus weekend, and by work shift. Each graph displays
the percent compliance and the number of observations included.
Results: The web application took approximately 100 hours of
information technology programmer time to design and refine. The
Infection Prevention department designed a training document to
teach users how to call up their data. The application was assessed by
managers as being easy to use and useful in tracking the performance
of their staff. Managers who track hand hygiene as a quality
indictor use the program several times each month. The program
eliminates many phone calls to the Infection Prevention department
requesting additional hand hygiene data. Lessons Learned:
Crystal Reports is a useful program with which to display real-time
performance data using a web-based application. A web-based hand
hygiene graphing application provides real-time display of hand
hygiene performance and gives managers immediate information on
their aggregate unit performance and on the performance of each
category of staff on their unit each day.
Three Interventions=Zero Infections
Design and Implementation of a Web Application
for Real-Time Display of Hand Hygiene
Performance Data
April L. VanDerSlik, RN, BSN - Manager, Infection Prevention,
Bronson Methodist Hospital; Krista Hinz - Administrative Extern,
Bronson Methodist Hospital; John Fisher - Analyst, Information
Technology, Bronson Methodist Hospital; Matthew Carpenter Programmer/analyst, Information Technology, Bronson Methodist
Hospital; Richard A. Van Enk, PhD, CIC - Director, Infection
Prevention and Epidemiology, Bronson Methodist Hospital
Issue: Proper hand hygiene prevents the transmission of infection.
Hospitals measure, set goals, and employ strategies to improve
hand hygiene as a quality monitor. Systems that rapidly assess and
immediately report results are more useful to improve performance
than systems that have a long delay between performance assessment
Charlene Stewart, RN, MPA/HSA, CHSP - Infection
Preventionist, Rogue Valley Medical Center; Debbie Hurst, RN,
BSN - Infection Prevention & Control Program Manager, Rogue
Valley Medical Center
Issue: The SSI rate for C Sections for 2008-2009 was 1.9 and
2.1, respectively (infections per 100 C Sections). When the rate
for the first half of 2009 was 2.9, which put our C Section SSI rate
almost at the 75th percentile when benchmarking with CDC, it was
an indication we needed to make some changes in practice to see
improvement in our outcomes. Perioperative patient care was not
standardized across service lines, and there were separate surgical
infection control policies in the OB Operating Room (OR), that
differed from the Main OR and Heart Cath Lab areas. Examples
of differences in practice included: • OB patients did not bathe
with CHG cloths preoperatively • OB did not do preoperative
MDRO screening • Variation in dress code requirements and patient
surgical skin preps. Project: Infection Prevention & Control
staff met with hospital and OB leadership to discuss the issue and to
develop an action plan to reduce the C Section SSI rate. Variations
in practice between service lines were included in the discussion
and ways to bridge the gap that would standardize practice for
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perioperative patients. Three interventions were selected: • Use of
CHG cloths for all patients admitted to Labor & Delivery (L&D)
• MDRO Screening protocol for all patients • Perioperative Policies
revised/standardized. Results: The first two interventions
(CHG cleansing cloths and MDRO screening protocol) resulted
in a C Section SSI rate decrease from 2.9 for the first half of 2009
to 1.3 in the second half. When the third intervention was added
(standardized perioperative policies), the rate decreased further to
1.1. This rate placed us near the 50th percentile when benchmarking
with CDC. The final rate for 2010 was 1.0; the rate for the first
half of 2011 was Zero! While improved patient outcomes were the
primary goal, a positive secondary outcome also became evident. The
estimated cost avoidance for the 12-month period from July 2009
through July 2010 was estimated to be $100,000. Total C-Section
infections 7/08 – 6/09 = 10 Total C-Section infections 7/09-6/10
= 5 Estimated cost per SSI: $20,000 Estimated Cost Avoidance
for 12 months of CHG cloth use in L&D: $100,000. Lessons
Learned: When the interventions were introduced to the OB
clinicians and staff, we were met with the challenge of convincing
them that OB perioperative patients had similar risks to the general
surgical patient population. Key factors that gained their support
included: • Supporting evidence that standardization can lead
to improved patient outcomes • Organizational support to drive
the sometimes unpopular changes • Organizational support to
finance added expense of CHG cloths A key factor to the success of
implementing these changes was engaging a physician champion to
assist with buy-in from other OB physicians.
rooms during open cases. Traffic is hypothesized to contribute to
an increased risk of infection by increasing the microbial burden
in the air through movement and increased personnel in the room.
In addition, when a door opens it disrupts the air pressure in the
OR compromising the effectiveness of the ventilation system.
Project: In an adult 28 suite OR and a pediatric 8 suite OR:
Measure volumes and impacts of selected risk factors of infections
in operation rooms through direct observation and analyses of
operating room and anesthesia databases. Measure traffic in and out
of selected operation rooms (ORs) and reasons for traffic. A similar
study was conducted in Winter 2006 and was published. That
study showed that 20% of traffic was related to supply /eqiupment
retrieval. Now, both ORs are going to case cart systems. The goal
of Infection Control was to establish baseline numbers prior to the
case cart system (with recommendations for improvement). Also,
post studies will be completed after case cart implementation to see
if improvements occur. Results: In Winter 2006,an Industrial
Operations Engineering (IOE) 481 team performed study for
Infection Control on OR foot traffic – 28 cases were observed.
Study results showed that 20% of door openings are due to supply
and equipment retrieval. The Circulator nurse contributed to 30%
of the overall traffic. In Winter 2011, a similar group duplicated
the study- 66 cases were observed. Study results showed that 25%
of door openings are due to supply and equipment retrieval. The
Circulator nurse contributed to 22% of the overall traffic. The
services with the highest traffic were Cardiac, Otolaryngology
and Orthopedics. The circulator nurse exiting and entering the
room retrieving supplies is the main reason for excessive traffic
in the operating rooms. This was most apparent in long complex
surgeries requiring high amounts of instrumentation and supplies.
Other reasons for traffic were practice related, such as supplies,
breaks, and checking on a case. Unecessary or unknown traffic
was observed in all cases. Lessons Learned: The 20062007 results were similar to our finding in the 2011 study, which
supports our decision to implement a case cart system.The
circulator nurse exiting and entering the room retrieving supplies
is the main reason for excessive traffic in the operating rooms.
This was most apparent in long complex surgeries requiring high
amounts of instrumentation and supplies. Some of these reasons
could be eliminated, thereby significantly reducing the overall
traffic volume. All of the unnecessary traffic should be eliminated.
The case cart system should decrease OR traffic, but sustained
education, continued awareness, and workflow solutions are
necessary to the success of new system.
Measurement and Analysis of Foot Traffic in a
University Hospital Operating Room
Lisa K. Sturm, MPH, CIC - Supervisor, Infection Control and
Epidemiology, University of Michigan Health System; Julia A.
Jackson, CST, MEd, FAST - Infection Preventionist, Univeristy of
Michigan Health System; Shawn Murphy, RN, MSN - Director,
Surgical Services and Associate Hospital Admistrator, University
of Michigan Health System; Carol Chenoweth, MD - Hospital
Epidemiologist, Infectious Disease Physician, University of Michigan
Health System
Issue: Past observation studies and anecdotal review had revealed
that there were excessive amounts of foot traffic in the operating
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by post-op day one or two (depending on the type of orthopedic
procedure) was established. Using FOCUS PDCA methodology,
an inter-disciplinary team was formed. Team members included
Physicians, Nurses, Infection Prevention (IP), Quality Management
(QM), Information Technology (IT), Materials Management,
Physical Therapy, Pain Management, and Physicians Assistants (PA).
Current guidelines from the Society for Healthcare Epidemiology
(SHEA) and the Centers for Disease Control and Prevention (CDC)
were reviewed. It was determined that a systematic approach to the
problem would be undertaken to improve performance. Baseline
data and causes of process variation were reviewed including the use
of epidural analgesia, computerized prescriber order entry (CPOE)
issues, and patient satisfaction. Systematic interventions included
rebuilding CPOE order sets to include drop down selections with
specific evidence based criteria for ordering catheters. Nursing
electronic documentation was also revised to include timing of
catheter insertion and removal. Automatic expiration of catheter
orders was set at 24-48 hours dependent on the type of orthopedic
procedure. If the patient assessment indicated a continued need for
an indwelling catheter, daily reordering was required. Non invasive,
hand held devices (bladder scanners) were purchased to reduce
unnecessary invasive catheterizations and an evaluation of current
urinary care products was conducted with Materials Management.
We did not introduce any new catheters due to nursing and patient
satisfaction with current products. Patient education materials were
revised to include information about timely removal of catheters.
Results: • Timely catheter removal improved from 81% to
100%. (Fig 2) • An interdisciplinary standard for management
of patients with indwelling urinary catheters was developed with
defined accountabilities • CPOE order sets were redesigned and
Improving the Management of Orthopedic Surgical
Patients with Indwelling Urinary Catheters Using a
Systematic Evidence Based Approach
Eileen A. Finerty, MS, RN, CIC - Nursing Director; Infection
Control and Occupational Health Services, Hospital for Special
Surgery; Helen Renck, MS, RN - Director of Standards and
Accreditation, Hospital for Special Surgery; Patricia Griffin, MS,
RN, CPHQ - Director of Quality Management, Hospital for Special
Surgery; Mary McDermott, MS, RN - Assistant Vice President;
Nursing, Hospital for Special Surgery
Issue: Urinary tract infections (UTI) account for more than 30%
of all hospital acquired infections (HAI) and more than 80% of UTI
infections are related to unnecessary indwelling urinary catheters.
(CDC, 2009) The risk of UTI is also influenced by the duration of
catheterization and limiting catheter use has been found to be an
important factor in reducing UTI infection rates. (Stephan, 2006).
Project: An Infection Control risk assessment was performed
at an elective orthopedic hospital which included a review of data
and current practices regarding catheter insertion, continuance and
discontinuation. (See figure 1) Opportunities for improvement were
identified and a goal of removing all indwelling urinary catheters
111
implemented • A competency and skills validation for inserters was
developed. Lessons Learned: Lessons learned/ Next Steps A
systematic, evidence based approach to the problem using established
PDCA methodology resulted in sustained performance improvement
regarding timely catheter removal. Additional improvement and
efficiency opportunities surrounding Catheter Associated Urinary
Tract Infection (CAUTI) prevention exist and are being investigated.
plan will be to improve the accuracy of diagnoses, reduce antibiotic
exposure thereby possibly reducing unnecessary hospital admissions.
The Impact of Improperly Collected Urine Cultures
on Patient Treatment in the Emergency Department
Kathleen Francis, RN, BSN - Infection Preventionist, Paoli
Hospital/ Main Line Health; Kathleen M. Lucente, RN, MT, CIC Infection Preventionist, Paoli Hospital, Main Line Health
Background/Objectives: The collection and analysis
of urine cultures are important for diagnosis and treatment of a
urinary tract infection (UTI). These tests are routinely performed
but the quality of collected specimens has not been closely examined.
Prior studies addressing this issue have been limited. Methods:
Multiple system hospital computer databases were queried for clinical
data from January 2011 through May 2011. Soarian ® SmartChart
database was used for data on sample collection, clinical diagnosis
and treatment. The T-System, Inc®, an Emergency Department (ED)
database, was used for data on hospital admission and treatment.
A contaminated urine culture was defined by clinical laboratory as
follows: multiple organisms (2 organisms or more), or mixed growth
(<100,000 colony forming units with multiple organisms). Data from
January were reviewed to determine which patients were diagnosed
with a UTI and how they were treated. The study definition of a
UTI was clinician- documented diagnosis of UTI in Smart Chart or
the T-system. Treatment was defines as antibiotics given specifically
to treat the UTI. This information was found in the same clinical
databases. Results: Urine samples collected and contamination
rates over the 5 month study period are shown in Table 1. Number of
samples taken each month ranged from 578 to 730 with an average
of 657 per month. The contamination rates per month ranged from
32 to 40% with an average of 37%. More females were identified
with contaminated cultures then males. Table 2 shows patients in
the month of January who had a contaminated urine culture and
were treated for UTIs. 97 of the 215 patients, or 45% of patients,
with a contaminated urine specimen were treated for UTIs. 34
were treated as an outpatient and 63 were treated as an inpatient.
Conclusions: Over the 5 month observation period 3,285
urine cultures were taken, 1,098 or 36.4% were contaminated. The
majority of those with contaminated urine cultures were women with
a rate of 79%. This might be because it is more difficult, to get wellcollected urine specimens from women. Of those with contaminated
urine cultures, 45% were treated based upon this faulty data. Prior
studies have been limited but have reported contamination rates of
10-20%. The current study found a higher rate of contamination
than those in the published literature. Many patients were perhaps
misdiagnosed with a UTI. A large fraction, often as inpatients, was
treated based upon this data. The findings of this study identified a
need for a process improvement plan that addresses staff awareness
of the importance of properly collected cultures. The goals of this
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Making it Personal: Utilization of an Electronic
Personal Hand Hygiene System to Increase Hand
Hygiene
Bonnie J. Schleder, APN, MS, CCRN, TNS - Advanced Practice
Nurse - Critical Care, Advocate Good Shepherd Hospital; John
T. Brown, RN - Registered Staff Nurse, Advocate Good Shepherd
Hospital; Patricia Moore, RN - Registered Nurse, Advocate Good
Shepherd Hospital; John J. Vesely Jr., RN, TNCC - Patient Care
Leader, Advocate Good Shepherd Hospital; Charisma R . Trinidad,
RN, BSN, CCRN - Patient Care Leader, Registered Nurse, Advocate
Good Shepherd Hospital
Issue: There are 1.7 million healthcare associated infections
(HAI’s) annually (Klevens, Edwards, & Richards, 2007). Since hand
antisepsis is known to reduce the incidence of HAI’s, the World
Health Organization (2006) introduced the “Five Moments of Hand
Hygiene”. The question now becomes how can this goal be met,
sustained, and easily surveyed for compliance. To achieve this depth
of hand hygiene our nursing quality and safety committee partnered
with industry to develop a personal hand hygiene system with an
automatic counting system. Following a review of the literature a
stretch goal of 8 hand hygiene events per hour was established. Since
compliance and sustainability is essential to any change process,
an adoption system was developed. The adoption system included
education, e-mails, personal inquiries, peer coaching, communication,
and celebrations/fun activities to achieve success. Results: Using
traditional soap and water and waterless antimicrobial hand gel at
the doorway, 71.7% of registered nurses and technicians that worked
in the unit had a baseline hand hygiene practice measured at a rate
of 3.5 handwashes per hour. The hand hygiene rate increased to
8.8 per hour within the first month following the introduction of
the personal hand hygiene system which the staff attached to their
pocket. Compliance was automatically counted electronically. Daily
compliance reports were displayed on a TV monitor on the unit for
staff, patients, and visitors to see. Staff were provided anonymous
numbers to track their own progress; however these numbers were
not shared with unit management. Sustainability was present 11
months later at a hand hygiene rate of 8.9 episodes per clinician
per hour. Lesson Learned: Traditional handwashing methods make
implementing and surveying the “Five Moments of Hand Hygiene”
difficult. Personal hand hygiene dispensers provided an additional
alternative to traditional methods and increased frequency of hand
washing near the patient’s environment. Automated surveillance
tools assisted in the collection of data with minimal personnel.
When introducing a new product and process, change theory
becomes important to achieve the goal. One approach to holding
staff accountable was through peer mentoring versus traditional top
down management. This approach was greatly appreciated by the staff
and relieved some anxiety about the introduction of this program.
Lessons Learned: Traditional handwashing methods make
implementing and surveying the “Five Moments of Hand Hygiene”
difficult. Personal hand hygiene dispensors provided an additional
alternative to traditional methods and increased frequency of hand
washing near the patient’s environment. Automated survellance tools
assisted in the collection of data with minimal personnel. When
introducing a new product and process, change theory becomes
important to achieve the goal. One approach to holding staff
accountable was through peer mentoring verus traditional top down
managment. This approach was greatly appreciated by the staff and
relieved some anxiety about the introduction of this program.
Impact of a Hospital wide policy on Clostridium
difficile testing using Cepheid System®
Elise E. Kumar, PHD, MS, MPH, CIC - ICP, Barnabas Health;
Kristin G. Fless, MD - Physician, Barnabas Health; Eileeen Yaney,
MS, CIC - Director of Infection Control, Barnabas Health; Mikhail
Litinski, MD - Physician, Barnabas Health; Fariborz Rezai, MD Physician, Barnabas Health; Paul Yodice, MD - Director of Critical
Care, Barnabas Health; Ellen Cianci, MT (ASCP), MS - Director
of Microbiology, Barnabas Health; Lauren Grimes, BS, CCRN Critical Care Nurse Manager, Barnabas Health
ISSUE: C. difficile is an anaerobic, spore-forming Bacillus that is
responsible for a spectrum of C. difficile –associated disease (CDAD),
including uncomplicated diarrhea, pseudomembranous colitis, and
toxic megacolon, which can, in some instances, lead to sepsis and even
death. A pilot study in our ICU found that the majority of specimens
sent for C. difficile testing were negative, however, repeated testing
and empiric treatment led to excess lengths of stay, increased cost of
care and over-treatment. We developed a new hospital wide policy
and procedure to ensure testing of appropriate specimens, curtail
unnecessary repeat testing and provide results in a timely manner.
PROJECT: Effective September 1, 2011, the Department of
Pathology at our hospital implemented real-time PCR (polymerase
chain reaction) methodology to determine the presence of C. difficile
toxin B gene in stool specimens. The test utilized the FDA-cleared
Cepheid® Xpert C. difficile Assay. Only patients with diarrhea or
with three (3) or more unformed stools per day were considered for
testing. Liquid or soft stool specimens taking the shape of container
were accepted for testing, otherwise specimen was rejected. One stool
specimen was considered adequate for testing because of the high
sensitivity (98.79%) and specificity (90.82%) of the assay. Repeat
testing was allowed if PCR was indeterminate, or if patient had a
relapse of diarrhea or diarrhea continued after 14 days of therapy.
If PCR assay was negative, repeat testing was allowed after 5 days.
The assay was performed by the laboratory twice a day, seven days a
week. We observed the number of specimens submitted for Cepheid®
testing, rejected specimens, and percentage of positive tests for four
months after the reduction initiative. RESULTS: Pre-Cepheid
testing was observed for four months during which 840 specimens
were submitted and 107 were rejected (12.7%). After introduction
of Cepheid® testing and hospital-wide policy implementation, 133
specimens tested positive (18.2 %) compared with 9.0% Pre-Cepheid
policy. Only 10.6% of specimens were repeatedly tested. Lessons
Learned: A change in C. difficile testing to the Cepheid ®Xpert
C. difficile assay along with a new hospital-wide policy governing
appropriate testing of specimens resulted in a higher percentage of
positive tests vs. our standard C. difficile toxin testing of three daily
consecutive specimens. A multidisciplinary team or Team Charter
drove the initiative and partnered to ensure adequate testing using the
Cepheid® PCR system as well as treatment of C. difficile. Education
must be presented multiple times in multiple ways to further limit
submission of inappropriate specimens. Our study did not look at
whether or not the 24 hour turnaround time of the Cepheid® PCR
test decreased utilization of anti-C. difficile therapy, but this would be
an exciting area for future study.
113
Reducing Transmission of Multi-Drug Resistant
Organisms in Procedural Areas
Janet L. Curtin, MT(ASCP), BS, CIC - Infection Prevention
Practitioner, Quality and Patient Safety, OhioHealth, Riverside
Methodist Hospital; Marcia L. Waibel, MT(ASCP), MBA, CIC Infection Prevention Practitioner, Riverside Methodist Hospital
Issue: Patients continue to acquire health care associated infections
at an alarming rate and estimated costs of approximately $8,832 per
infection. The Joint Commission’s 2010 National Patient Safety
Goal 07.03.01 requires the implementation of evidence-based
practices to prevent health care-associated infections due to multidrug resistant organisms (MDRO) in acute care hospitals. This
requirement applies to, but is not limited to, epidemiologically
important organisms such as MRSA, Clostridium difficile, VRE
and multi-drug resistant gram-negative bacteria. In addition, the
Fiscal Year 2010 Riverside Methodist Hospital Risk Assessment,
revealed that antibiotic resistant organisms were rated the highest
risk priority of the Infection Prevention Department. Riverside’s
healthcare associated infection rates for Clostridium difficile (C. diff)
and MRSA were above the average rates of comparative institutions
for calendar years 2008 and 2009, respectively. Project: A team
was assembled with representatives from fifteen procedural areas and
charged with reducing transmission of multi-drug resistant organisms
during patient transport. Project objectives included defining
expectations and communication to improve the internal practice of
contact isolation and designing metrics to measure effectiveness. The
key deliverable of the project was a visual cue to identify patients in
contact isolation. Process mapping of patient flow was performed to
identify process variation and opportunities for transmission, which
were then addressed through standardized interventions. Results:
The team developed an isolation transport packet that included
the following: • An inexpensive page protector with notebook
ring used to affix packet to bed/gurney during transport • Contact
Isolation signage, to be posted in the procedural bay until the area
has been cleaned properly • Solid color matching paper used to cover
isolation sign during transport Lessons Learned: Successful
interventions to reduce MDRO transmission opportunities are best
defined by front-line workers empowered by managers providing
project sponsorship and resource allocation for project success.
Standardizing practices to reduce variation in the transport of
contact isolation patients is key to consistent, safe patient care for
every patient, every time. Periodic process monitoring is necessary to
prevent normalized deviance from established standard practice.
It’s Contagious! CLABSI Prevention is Spreading
Jackie Smith, MSN - Infection Control Consultant, Vanderbilt
University Medical Center
Issue: Initiatives to reduce central line associated blood stream
infection (CLABSI) rates in the Pediatric Critical Care Unit
(PCCU) were reviewed in 2010. It soon became clear that the
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patients with central venous catheters (CVC) were not confined to
the PCCU. These CVC were accessed by other clinicians in many
areas of the hospital. For instance, CVC are being accessed in the
operating room, radiology, and cardiac catheter lab. In addition,
patients were transferred to acute care floors with their CVC in place.
No standardized care or protocol to care for these CVC had been
established; therefore CVC care varied from unit to unit and person
to person. A task force was formed that included nursing from all
areas of the hospital, infection control and prevention and quality
improvement, in which to develop standard procedures for the care
of CVC. Project: A multidisciplinary team was formed to look
at the maintenance care of CVC throughout a children’s hospital.
Several opportunities for improvement were identified; among these
were CVC dressing changes and accessing the CVC. The following
initiatives were developed: 1. Promote a new “Scrub the Hub”
campaign that included a systematic approach to scrubbing the hub.
The hospital also changed from alcohol wipes to chlorohexadine
wipes. 2. Develop standardized dressing change kits. Three size kits
were developed to capture the varying sizes of pediatric patients.
The kits also incorporated an appropriate sized chlorehexadine
impregnated dressing. 3. The Vascular Access Team (VAT) expanded
their role to include rounding daily on all in house PICC catheters
and troubleshooting central venous catheters in the PCCU. A future
initiative is to expand the troubleshooting role outside of the PCCU.
4. CLABSI event analyses (huddles) were being performed in the
PCCU. These multidisciplinary huddles reviewed the CLABSIs and
determined any commonalities. For instance, if the central venous
catheter had a sluggish blood return, it was noted that this increased
the risk for a CLABSI. These huddles were expanded to include
all hospital CLABSI events. 5. Bedside rounding tool templates
were developed that could be individualized to meet the needs of a
specific unit. These tools discussed catheter necessity and any issues
with that patient’s central venous catheter. Results: Following
the implementation of these initiatives, the CLABSI rates decreased
throughout the institution. In 2010 the numbers of CLABSIs were
54, for a rate of 2.4. The number of CLABSIs for 2011 totaled 17, for
a rate of 0.8. Lessons Learned: Collaboration from all areas
of the institution is necessary to develop a standardization of central
venous catheter care and foster a zero tolerance culture.
Infection Prevention Component of Process
Improvement Project to Reduce Regulated
Medical Waste
Christy M. Wisdom, BSN, RN, CIC, LSBB - Infection
Preventionist, Arkansas Children’s Hospital; Joe Knight Environmental Management Coordinator, Arkansas Children’s
Hospital; Jennifer Emerson, RN - RN III, Pediatric Intensive
Care Unit, Arkansas Children’s Hospital; Catherine Waters, BSN,
RN - Chief Quality Officer, Improvement U, Arkansas Children’s
Hospital; Kurtis Kuykendall, MBA - Director Process Improvement,
Arkansas Children’s Hospital; Aaron Lindberg - Director of
Environmental Services, Arkansas Children’s Hospital; Craig
Gilliam, BSMT, CIC - Director of Quality Development Infection
Prevention & Control, Arkansas Children’s Hospital
Issue: We describe a Performance Improvement approach to
solving issues related to Regulated Medical Waste (RMW). The
project identified variations in the process of RMW disposal and
clearly defined waste disposal practices. Streamlining the process
created significant disposal costs savings and standardization for
the facility. Project: We used methodology taught through our
internal process improvement program known as Improvement U.
This methodology is similar to LEAN Six Sigma but customized
to our facility. The team utilized the DMAIC method, define,
measure, analyze, improve and control and started in the Pediatric
Intensive Care Unit (PICU). Baseline data was collected by sorting
a minimum of 5 randomly selected containers of RMW from the
PICU. The contents of the containers were properly categorized,
wieghed in pounds and volume was measured in gallons. Baseline
data showed that only 16% met criteria for RMW. Three patient
rooms in the PICU were used for the PDSA (plan, do, study, and act)
cycles. Each PDSA was designed to be cumulative with an additonal
change added with each cycle. Each PDSA cycle was seven days and
waste was collected separately from both containers, RMW and
trash. RMW was collected, sorted and measured. Our contracted
vendor was able to track the PICU waste separately and provide a
waste generated per pound. Results: The best results were after
completion of the third PDSA cycle that included all three changes.
Staff became engaged in the process and the PICU exceeded the goal
of a 25% reduction in RMW. The interventions were celebrated by
the team and the PICU staff. Control measures were in place with a
tracking system for staff to monitor each department’s RMW each
month. Interventions were spread out department by department
throughtout the facility. We have an estimated savings of $118,000
annually, for the facility. This is based on a 32% reduction in the
waste generation, reduced labor by staff and decrease use of materials
and supplies. Lessons Learned: Develop a team to focus
on the project. Define your problem first and gather baseline data
before attempting solutions. Develop clear, concise and standardized
education materials. Standardize, the size of the containers, location,
education and guidelines. Assess best location of containers by
analyzing work flow. Provide frequent feedback to the staff, using
data driven charts. Celebrate victories by rewarding staff for positive
changes in behavior.
A Norovirus Cluster Reveals a Big Stink: A
Communication Failure Between Infection
Prevention and the Laboratory
Charlene Carriker, BSN, RN, CIC - Infection Prevention Nurse,
Duke University Health System; Pamela Isaacs, BSN, MHA, CIC Clinical Director, Duke University Health System
Issue: Laboratory tests are used by physicians to diagnose and
guide patient’s treatments. These results are also crucial to the
Infection Prevention Nurse (IPN) as a tool in identifying clusters and
preventing infection transmission. Project: In April 2010 the
IPN was notified of 4 cases of Norovirus in our 16 bed Pediatric Bone
Marrow Transplant Unit (PBMTU). The IPN’s investigation found
1 to be a community-acquired infection and the possible source case.
To prevent further transmission, Infection Prevention (IP) measures
were instituted immediately: Contact Isolation for symptomatic
patients, hand-washing with soap and water only, removing waterless
hand sanitizer from symptomatic patients’ rooms, environmental
cleaning with a bleach agent and discontinuing symptomatic patients’
participation in activities outside their room. The PBMTUs staff,
physicians and patient’s immediate family were also surveyed for
gastro-intestinal illness. After implementing immediate prevention
measures, there were no additional cases. While investigating, the
IPN discovered she had not received specimen results from reference
labs in her daily lab reviews. To better understand the process for
reporting reference lab results within the organization, the IPN
performed a specimen walk-round activity, reviewing each step in
the specimen send-out and reporting process. She found that tests
sent to reference labs had results communicated directly to the
ordering physician. Reference lab results were then entered into the
electronic medical record (EMR) in a lab section not accessed by IP’s
database, and not communicated to the IPN. A multi-disciplinary
team of physicians, IPNs and laboratory personnel met to address this
communication failure and identify a method to improve notification
to IP regarding specimens sent to reference labs. The team discovered
a failure of lab and IP databases to interface regarding these results,
indicating a need to identify an alternative method of notification.
The team collaboration resulted in the development of a daily
automated email to IP listing the specimens sent to reference labs.
Also, the lab renamed reference lab tests and results documented
in the EMR, allowing for easier access of results. Now IP could be
knowledgeable of ordered tests and could monitor for returned
results more efficiently. Results: While immediate interventions
curtailed additional Norovirus cases, the inadequate communication
process for notifying the IPN of specimen results was a significant
defect in our IP surveillance program. A multi-disciplinary approach
identified and solved the process failure using a relatively simple
communication system. With an improved communication process
and understanding of the reference lab processes, IP is informed of
tests sent to reference labs, can monitor results and can implement
prevention measures sooner for epidemiologically significant
pathogens. Lessons Learned: As laboratory technology
advances, the use of reference labs will increase. Communication
between the lab and IP regarding epidemiologically significant testing
and results is imperative in the prevention of infection.
The Development of a Process Improvement Tool:
The SWAT Approach to Surgical Site Infection
Analysis
Amy M. Dziewior, BSN, RN - Infection Control Consultant,
Vanderbilt University Medical Center; Lorrie G. Ingram, BSN, RN,
CIC - Infection Control and Prevention Consultant, Vanderbilt
University Medical Center
Issue: The Centers for Disease Control (CDC) estimates that
in the U.S., almost 2 million HAI (Hospital Acquired Infections)
occur annually. The cost for these infections adds between 4.5 and 11
billion dollars yearly to an overburdened healthcare system, with an
average extended hospital stay of 7-10 days. Surgical Site Infections
(SSIs) comprise nearly 20% of all HAIs. More importantly, HAIs
115
contribute to nearly 100,000 deaths annually. Of this number, an
estimated 8,000 deaths are secondary to SSIs. A great majority
of these are preventable. An important aspect of SSI reduction
and prevention has proven to be a “robust” surveillance program
with significant and timely feedback to surgeons, perioperative/
postoperative staff, administration, and other ancillary healthcare
providers. The Infection Preventionist’s role (along with related
staff and quality interface) using objective data collection methods,
consistently applied sound epidemiological definitions, and
surveillance methods that are standardized and easily replicated,
are all very important to a facility’s overall program integrity and
success. Project: Current research and studies have revealed that
facility programs that perform event analysis and case breakdown,
with the use of objective methods and tools that can identify, collect,
track, and analyze data elements (both by general and specific
surgery type) are more likely to gain meaningful and significant
insights with regards to trends and common occurrences that may
cause or predispose their patients to infection. This method/tool
also includes the consideration and collection of “risk adjusting”
elements. Thus, two of our surgical service line teams, who have
experienced an increase in SSI rates, developed a specific SWAT
(surgical wound analysis team) tool to assist in their analysis of cases.
Once an infection is identified by the IP (Infection Preventionist),
members of the SWAT are assigned a certain block of data elements
to collect/report via the tool. Elements are objectively abstracted via
the electronic medical record. Members have specific elements to
collect and make comments on, which may be discipline specific to
that members interface or function on the surgical healthcare team.
Results: The Cardiac Surgery SWAT, begun in 1995, was the
original model for the current process. The successes of this group
over this period of time include: increased participation with full
engagement by key members of the healthcare team and development
of a tool with specific elements for analysis related to risk factors,
evidence based care delivery throughout the surgical episode, and
variances to any standardized processes. Lessons Learned:
This group has evolved over the years due to the dynamic changes
in surveillance, care delivery, and the environment of care. Trend
analysis through the years has revealed that there may not be a specific
cause for any one SSI (although common factors may have been
identified), but that etiology is most likely multifactoral.
facility for a hospital-acquired CAUTI unless the condition was
documented as present on admission. As an acute care facility in a
large public hospital corporation in East Harlem, we were charged
with decreasing our CAUTI rate by 20%. In 2010 we had a total
of 27 hospital-acquired CAUTI’s for an overall hospital rate of 7.9
per 1000 catheter days. This rate triggered our Reason for Action.
There were 5 non-ICU CAUTI’s for a rate of 3.6 per 1000 catheter
days and 22 ICU CAUTI’s for a rate of 10.8 per 1000 catheter
days. Using the Breakthrough (LEAN) method, we systematically
implemented strategies to decrease our CAUTI rate in 2011. The
Breakthrough (LEAN) method improves processes and outcomes,
reduces cost, reduces cycle times and ultimately increases patient and
staff satisfaction. Our target state was 0 CAUTI. Project:The
metrics included all symptomatic CAUTI ‘s as defined by the CDC/
NHSN 2009 definition for CAUTI’s. CAUTI’s were monitored
on the non-ICU units and the ICU units. Interventions included:
revising the urinary catheter policy to reflect the best practice and
expectations of the nursing and physician staff, revised the CAUTI
bundle, competency checked the nursing staff on insertion and
maintainance of the urinary catheter, implemented a renew/review
need for the urinary catheter in the Electronic Medical Record
(EMR), standardized equipment and monitored the outcomes using
unit based champions and weekly prevalence data gathering. We
used the A3 tool that provided a structured approach to define and
understand the problem. The tool contains the following seven main
elements: reason for action, initial state, target state, gap analysis,
solution approach, rapid experiments and confirmed state. The nursing
staff and nursing education were the champions that drove the daily
practice, compliance and implementation of the “best practices”. The
Infection Control team monitored the CAUTI’s and supported the
nursing staff implementation of the project.Results:In 2011, the
overall reduction of CAUTI’s hospital wide was 44% compared to
the CAUTI rate in 2010. The greatest improvement was seen in the
ICU. A comparison of ICU CAUTI rates at baseline demonstrated
a decrease from 10.8 per 1000 catheter days in 2010 to 5.4 per 1000
catheter days post-intervention in 2011. This represents a 50%
reduction in the ICU. Lessons Learned: Implementing “best
practice”, working collaboratively and actively promoting infection
prevention demonstrates a positive impact on patient care and
satisfaction. Using the Breakthrough (LEAN) thinking method has
provided a framework for the staff to implement the right choices
creating processess that define the primary customer, the patient.
Decreasing Catheter Associated Urinary Tract
Infections (CAUTI) using the BREAKTHROUGH
(LEAN) Method
Kathi Mullaney, BSN,MPH,CIC - Associate Executive Director,
Peri-operative Services, Metropolitan Hospital Center
Issue:Urinary tract infections (UTI’s) are the most common
type of healthcare-associated infections (HAI’s), accounting for
more than 30% of infections reported by acute care hospitals.
Approximately 80% of all hospital-acquired Catheter Associated
UTI’s (CAUTI’s) are caused by instrumentation of the urianary
tract. CAUTI ‘s are one of the 10 hospital-acquired conditions “never
events” since they are preventable and should “never” happen. The
Centers for Medicare and Medicaid Services will not reimburse a
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Improving Antimicrobial Stewardship in the
Neonatal ICU with Computer Decision Support
Yu-hui Ferng, MPA - Project Manager, Columbia University School
of Nursing; Robert S. Hum, MD, MA - Assistant Professor of
Clinical Pediatrics, Columbia University; Morgan Stanley Children’s
Hospital of NewYork-Presbyterian; Patricia DeLaMora, MD Assistant Attending Pediatrician; Assistant Professor of Pediatrics,
Weill Cornell Medical Center; NewYork-Presbyterian; Sameer Patel,
MD, MPH - Assistant Professor in Pediatrics, Division of Pediatric
Infectious Diseases, Columbia University; Morgan Stanley Children’s
Hospital of NewYork-Presbyterian; Jennifer Duchon, MDCM,
MPH - Assistant Professor of Clinical Pediatrics; Attending
Neonatologist, Columbia University; Morgan Stanley Children’s
Hospital of NewYork-Presbyterian; Kenrick Cato, RN - Programmer,
Columbia University School of Nursing; Elaine L. Larson, RN,
PhD, CIC - Associate Dean for Research, Columbia University
School of Nursing; Lisa Saiman, MD MPH - Professor of Clinical
Pediatrics and Hospital Epidemiologist of Morgan Stanley Children’s
Hospital, Columbia University Department of Pediatrics
Background/Objectives: To improve antimicrobial
prescribing in the Neonatal ICU, we developed a Computerized
Decision Support (CDS) module embedded within our commercial
electronic medical record (EMR), Eclipsys XA. The module
(“LadyBug”) provided culture and susceptibility results obtained
during the entire NICU hospitalization; displayed selected
laboratory results identified by neonatal prescribers as clinically
important when considering both empiric and culture-based
antimicrobial treatment; and provided recommendations for therapy.
We present the preliminary results of an anonymous user survey.
Methods: LadyBug was implemented in July 2010 in two level
III study NICUs. The study team taught NICU staff, identified
as antimicrobial prescribers, how to use LadyBug’s features. From
November 2010 to June 2011, technical challenges resulted in
loss of the ability to provide culture-based antibiotic treatment
recommendations while other functionality remained intact.
Following the completion of multiple upgrades to the hospital
information technology system, full functionality was restored. An
18 item electronic survey was developed to identify the preferred
features of LadyBug, the barriers to use, the ease of use compared to
other hospital electronic data sources, and the potential impact of
the temporary loss of functionality. The first survey was administered
from July to September 2011 to NICU prescribers and a follow-up
survey will be administered at the end of the study period in April
2012. Results: Overall, 46 (28%) of 164 eligible participants
completed the survey. Participants included 12 NICU attending
physicians, 5 fellows, 18 residents, 2 house physicians, and 9 nurse
practitioners. Most respondents (63%) were aware of LadyBug.
The most preferred features were the summary of culture results
(77% of respondents) and the culture-based antibiotic treatment
recommendations for different types of infections (85%). Antibiotic
orders (42%), antibiotic levels (38%), and complete blood counts
(31%) were preferred by fewer respondents. Respondents reported
that LadyBug assisted in antibiotic decision-making (80%) and saved
time (60%) when compared to other electronic sources. However,
only 37% of respondents had used LadyBug during their last service
rotation. Additional features desired by respondents included
duration (80%) and dose (60%) of current antimicrobial therapy.
Conclusions: While we successfully implemented a CDS
module within a commercial EMR, we experienced unanticipated
technical challenges that temporarily limited functionality. While
most respondents were aware of LadyBug, fewer had used it during
their latest rotation. Nonetheless, the core features, summarized
culture results and antibiotic treatment recommendations, were
well received. The survey results suggested that these “value added
functions” potentially contributed to both improved decision-making
and time-savings. We speculate that loss of functionality of a core
feature may have reduced the usage and possibly the survey response
rate. Anticipating technical challenges and adding desired features
will be crucial in increasing usage and acceptance by prescribers.
Background/Objectives: The number of surgical
cases in National Obstetrics and Gynecology Hospital (NOGH)
is quite high, estimated at 16.000 – 18.000 cases/ year. (In 2011,
it was 18.207 cases, in which 6.618 cases were Planned Surgeries,
and 11.589 cases were Emergency Surgeries, with 29 complication
cases (0.16%), among which there were 9 cases of post-operative
infection. In order to enhance patient safety and minimize the
risk of complication, NOGH started applying W.H.O Surgical
Safety Checklist (SSC) since Oct 2011. Objectives: Collect and
summarize the comments on the Surgical Safety Checklist to make
it applicable, appropriate with an Ob-Gyn hospital. Evaluate safe
effectiveness and reduction of risk in surgery after 2 month SSC
application. Methods:Methods: Gather comments from 560
doctors and nurses related to the process of preparing the surgical
patients and surgeries. Summarize all the surgical complication in
total 3.102 surgical cases, conducted during 2 month application
of the SSC. Results: All comments supported the necessity of
the SSC application: 95.15% comments found the SSC appropriate
and applicable, while the other 4.85% found it complicated and
time-consuming. Suggestion to add information of neonatal doctor
– midwife with full neonatal intensive care equipments into “B”
item and checking the number of mother to match with the number
of newborn before bringing the newborn out of operating room
into “C” item. There was only one case with severe bleeding at preoperation and during operation, leading to coagulation disorder. This
complication made the patient hospitalize for post-operative 20 days.
It was an emergency operation as the admission was severe bleeding
central placenta previa. No post-operative infection cases found.
Conclusions: The SSC was highly effective and necessary. It
should be applied for all surgical cases. However, there should be
some minor modifications as stated above to make it more suitable
with local culture and characteristics of an Ob- Gyn hospital.
Evaluating the Primary Outcomes of W.H.O
Surgical Safety Checklist 2009 Application in an
Obstetrics and Gynecology Hospital of Vietnam
Hang Kim. Do - Head Nurse Of Operating Room, Vietnam
National OB-GYN hospital
A Process Improvement Project Decreases Blood
Culture Contamination Rates in the Emergency
Room
Maria C. Montero, MT(ASCP)SM, MPH, CIC - Manager,
Infection Prevention, Rush Copley Medical Center
Issue:Blood cultures are routinely collected in the emergency
room for infection diagnosis, source, organism identification, and
appropriate antibiotic treatment. Contaminated blood cultures
result in increased costs and adverse outcomes due to unnecessary
admission to the hospital, increased length of stay, unwarranted
antibiotic use, treatment side effects, and antimicrobial
resistance. Blood culture contamination rates collected in the
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emergency room remained above the national benchmark of 3%.
Project:Variations in blood culture collection techniques were
identified. The recommended procedure for application of the 2%
chlorhexidine gluconate/70% isopropyl alcohol (ChloraPrep®) skin
antiseptic was not always followed. Re-palpating the site after skin
preparation was routinely observed and tops of the bottles were
not disinfected before puncture. Many of the blood cultures were
collected during IV starts and 2 sets (4 bottles) were collected at the
same time. New policies were established to require two different
blood draws from two different sites. Collection of blood from the
peripheral line is not recommended. A dedicated blood culture
collection team was developed and education was conducted to
emphasize the importance of aseptic technique and the value of
proper blood collection. A 3.15% chlorhexidine gluconate/70%
isopropyl alcohol (Chlorascrub™) antiseptic swabstick for skin
preparation was implemented using a 30 second scrub and a 30
second dry time before blood culture collection. Re-palpating
the skin after antiseptic application was prohibited and tops of
the bottles were disinfected immediately prior to use. Education
with required yearly competency for peripheral and IV line blood
culture collection is required and must be repeated for any reported
contaminated blood culture. Results:Emergency room blood
culture contamination rates were above 7% at the beginning of
our project in 2002. Since implementing changes the rates remain
below 3%. Lessons Learned: Education and collaboration
in getting staff to recognize the importance of proper blood
collection technique for the patient and the hospital is essential for
practice compliance. Incremental changes were necessary to obtain
our goal. Appropriate use of an effective and easy to use product,
such as the 3.15% chlorhexidine gluconate/70% isopropyl alcohol
antiseptic swabstick improved compliance and outcomes. Patient
adverse events and hospital costs are avoided when blood culture
contamination is prevented.
Reaching Zero Central Line Associated Infections
by Improving Compliance to Aseptic Technique
Donna Matocha, RN, MSN, CNRN - IV Therapy Coordinator
/Clinical Educator ONP, Rush-Copley Medical Center; Maria
C. Montero, MT(ASCP)SM, MPH, CIC - Manager, Infection
Prevention, Rush Copley Medical Center
Issue: Central line associated bloodstream infections continued to
occur in our adult intensive care unit after implementing the Institute
for Healthcare Improvement’s Central Line Bundle despite our goal
of zero infections. Observations revealed breaks in aseptic technique
during skin preparation, line insertion, and port access. Project:
Infection Prevention and IV Therapy developed an intensive staff
education program that reinforced understanding of how aseptic
technique prevents contamination. Central Line insertion kits were
reconfigured to prevent breaks in asepsis. Skin antisepsis is performed
using non-sterile gloves and a ready to use swabstick containing 3.15%
chlorhexidine gluconate/70% isopropyl alcohol placed in an outside
fold of the kit. A sterile field is established using sterile full body
drapes. Hand hygiene is performed using a 65.9% alcohol handwipe
before sterile gloves and gown are donned. A chlorhexidine gluconate
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impregnated sponge is applied and covered with a semi-occlusive
dressing that effectively adheres to the skin for seven days. A central
line dressing change kit with a 3.15% chlorhexidine gluconate/70%
isopropyl alcohol swabstick was established because of its seven
day antimicrobial persistence. A port access kit was developed with
necessary supplies to reduce breaks in asepsis during port access.
Results: Our goal of zero Central Line Associated Infections
(CLABIs) in our adult intensive care unit was achieved in March,
2009, one infection in June, 2010, and zero infections in 2011.
Lessons Learned: Collaboration and commitment played a
role in implementing changes. Aseptic technique must be followed at
all times. A layered kit design with essential products in the right place
increases compliance. Easy to use efficacious products, such as the
3.15% Chlorhexidine gluconate/70% isopropyl alcohol solution for
skin preparation and dressing changes, the 65.9% alcohol handwipe,
the chlorhexidine gluconate sponge, and a dressing that adheres well to
the skin play an important role in infection prevention.
Quantitative Evaluation of Environmental Surface
Cleanliness in Pediatrics Intensive Care Unit
Yuxin Ma - Director, Infection Control Center, Fuwai Heart
Hospital & Cardiovascular Institute
Background/Objectives: The objective of the
present study was to quantitatively evaluate the environmental
surface cleanliness in the pediatrics intensive care unit (PICU) of
hospitals and to monitor the efficacy of the cleaning methods used.
Methods: 22 different kinds of environmental surfaces in PICU,
Fuwai Heart Hospital & Cardiovascular Institute were chosen based
on the hand contact frequency and contamination risk level. Their
cleanliness was evaluated using an ATP bioluminescence method.
Results: It was shown that the average ATP values of simple
respirator, physiological bedside monitor panel, infusion pump panel,
pressurized infusion bag ball and nurse’s table were >500 relative
light units (RLU) before cleaning, indicating high contamination
risk, while the RLUs of all environmental surfaces reduced to
<500 after cleaning. However, ATP values of physiological bedside
monitor panel, infusion pump panel, simple respirator and bedside
table showed a rapid increase after the cleaning and RLU readings
reached >500 4 h after cleaning. It is surprising to discover that the
average RLU of a blood-gas analyzer panel, screen and injection port
were >15000. Conclusions: It is concluded that in a PICU
the use of an ATP method could provide quantitative information
of cleaning efficacy and ATP trends, to allow identification of
environmental surfaces that require additional cleaning or cleaning
schedule amendments.
Collaborative To Decrease Central Line Associated
Blood Stream Infection (Clabsi) In A Neonatal Unit
(Nicu): An Urban Teaching Hospital Experience
Ona O. Fofah, MD, FAAP - Director, Division of Neonatology,
Department of Pediatrics, The University Hospital, Newark, NJ;
Leisha Nepomuceno, RNC - Staff Nurse, University Hospital,
UMDNJ Newark, NJ; Gloria Igwe, RNC, MSN, DNP - Nurse
Manager- Neonatal Intensive Care Unit, University Hospital,
UMDNJ, Newark, NJ; Willi Cruz, RN - Infection Control
Officer, University Hospital, UMDNJ, Newark, NJ; Beverly
Collins, RNC, MS - Director, Hospital Infection Control
Department, University Hospital- UMDNJ, Newark, NJ
Issue: CLABSI is an important cause of increased morbidity and
mortality in hospitalized patients. These infections are increasingly
recognized as preventable life-threatening adverse events, even
among newborn infants who may be more biologically at risk
than older children or adults. The avoidance of the use of central
lines (CL) as a primary prevention is often not feasible in sick
neonates. Available guidelines, secondary prevention techniques
and strategies are feasible in these neonates and when applied
may help decrease CLABSI rates in NICUs. The CLABSI rate
in the lowest birth weight category in our NICU was high when
compared to benchmark data with an average rate of 10.8/1000 CL
and umbilical catheter (UC) days. We set out to decrease this rate
through a multidisciplinary collaborative effort, use of potentially
better practices and quality improvement techniques. Project:
Our NICU is an open 24 bed level 3C perinatal center with annual
admission of 360 babies, 70 of whom weigh 1500gm or less. We
developed a comprehensive unit-based safety program (CUSP)
by creating a multidisciplinary core team consisting of leaders
from the Hospital infection Control Department, Physician and
Nursing groups. Other team members were Staff Nurses, Unit
Secretary, Resident physicians and Respiratory Therapists. Weekly
presentations at Critical Care committee, Staff meetings together
with monthly Resident education were initiated. Improvement in
hand hygiene (HH) techniques including the removal of jewelry
prior to hand washing by parents, visitors and staff were enforced
and monitored. Monthly compliance data were shared with staff.
Also developed, instituted and monitored are CL insertion and
maintenance forms; Use of barrier screens with a STOP sign
and procedure carts during insertion of CL; Use of devices such
as Swab Cap® port disinfectant; Enforcement of barriers e.g.
hats and masks by staff within 3 feet during procedures; Use of
Chlorhexidine for site preparation for CL insertion; Designated
CL insertion and maintenance team. Results: There was
sustained improvement in HH rates across all categories of staff.
The monthly compliance rates are best among Nurses (above 95%),
attending physicians above 90%. Rates among respiratory therapists,
consulting physicians and nursing assistants continue to improve
above 90%. Rates among Resident physicians remain lowest. The
PICC rate prior to intervention was 9.6/1000 CL days and UC
rate was 12.0/1000 UC days among the tiniest babies in our
unit. There have been no CLABSIs in our unit for the last 215
days. Lessons Learned: We learnt that collaboration,
coordination, communication, continuity and competence are
important in Teamwork and helpful in decreasing and preventing
infection. Also, that the principles outlined using the CUSP
model are effective in our NICU.
Attaining and Sustaining Hand Hygiene
Compliance. Patient/Family, Sr. Leadership to
Front-line Staff. A Winning Combination!
Nancy L. Osborn, RN, CIC - Manager of Infection Prevention and
Epidemiology, Medical Center of Central Georgia
Issue: Prevention of healthcare associated infections (HAI) is a
strategic priority at the Medical Center of Central Georgia (MCCG).
The relationship between Hand Hygiene and prevention of HAI
has been well documented and performance expectations clearly
defined in the CDC Guidelines for Hand Hygiene in Healthcare
Settings, World Health Organization Guidelines on Hand Hygiene
in Health Care and Joint Commission National Patient Safety Goals.
In 2010 we surveyed staff and managers and discovered a surprising
gap between Hand Hygiene practices and perception of compliance.
The majority of staff perceived Hand Hygiene compliance to be
>80%; in reality, based on 600 direct observation in 25 departments,
overall compliance was only 34%! Project: MCCG is a 637
bed, academic medical center, designated Level 1 Trauma Center
and Magnet hospital for nursing excellence. Goals * Improve Hand
Hygiene compliance from 34% to 65% in year one, increasing to,
and sustaining at, 85% following year. Note: data benchmarks
recommended by 3M Education Division consultation. * Utilize best
practices products, compliance monitoring, implementation and
sustainability strategies. * Assess risk factors for, and remove barriers
to, Hand Hygiene non-compliance. * Assure Administrative and
Governing Board priority of the PI project. Innovation * Utilization
of multiple methods of monitoring: mystery shopper observations,
patient interviews, product usage. * Partners In Hand Hygiene
program encourages patients, families and visitors to remind all staff
and visitors to wash their hands. Mystery Shopper visits patients for
perception of compliance. Patients rate staff (physicians included)
on compliance. * Weekly surveillance program is rigorous * Short
turnaround time and transparent dissemination of data within 2 days
to departments encourage immediate “job well done” or corrective
action. * Professional marketing of “speak up” buttons, flyers,
patient brochure, staff engagement.* * Individual unit “spin” on the
campaign; examples: Staff say.”ladybug” if a peer or physician out of
compliance. Results discussed in huddles, interdisciplinary rounds,
linked to HAI results. Peer mystery shopper assigned for a day - give
out cupons for “well done”. Meetings with key physicians to address
what would help improve hand hygiene compliance. Results:
Hand hygiene compliance improved to 65% within 5 months. Hand
hygiene compliance improvement continued, exceeding 90% at 6
months. 51% increase in product use. Sustained CLABSI, CAUTI,
VAP, Laminectomy SSI below benchmark. Outcomes correlated
119
with other evidenced-based practices and hand hygiene compliance.
Lessons Learned: Challenging (see October 2011) but
Important to keep the momentum going! Routine correlation between
patient data and staff compliance data. When we had special cause
variation in Oct. 2011, we discovered a modification in the patient
interview process by a new Mystery Shopper and a reduction in
observations due to Flu Campaign focus. Multidiciplinary committee
needs to meet regularly to re-evaluate the program. Physicians pay more
attention to patient perception data versus staff compliance results. Sr.
Leadership support is critical to success.
Standardizing Environmental Cleaning Procedures
And Measurement Across A 12-Hospital System.
Ellen W. Trovillion, RN, BSN, CIC - Infection Prevention
Consultant, BJC HealthCare; Jill M. Skyles, RN, BSN, MBA Vice President and Chief Nurse Executive, Barnes-Jewish St. Peters
Hospital; Diane Hopkins-Broyles, RN, MSN - Manager, Infection
Prevention, BJC HealthCare; Emily L. Ostmann, MPH - Performance
Research Analyst, BJC HealthCare; Aaron D. Rogers, MA - Project
Manager, BJC HealthCare; Hilary Babcock, MD, MPH - Assistant
Professor of Medicine, Infectious Diseases Division, Medical Director
Infection Prevention & Epidemiology Consortium, Med. Director
Occupational Health, Washington University in St. Louis, BarnesJewish Hospital, St. Louis Childrens’ Hospital; Keith F. Woeltje, MD,
PhD - Director, Clinical Advisory Group, BJC Center for Clinical
Excellence, BJC HealthCare, Washington University in St. Louis
Issue: Inadequate cleaning of surfaces and high risk objects (HRO)
120
in patient rooms can contribute to the transmission of organisms.
The Environmental Cleaning project developed a standardized
process for daily and discharge cleaning of patient rooms. 12
hospitals in the health system implemented the process with the
intent to reduce organism bio-burden. Project: Our team
consisted of a physician and nurse champion, housekeeping
managers/directors, staff housekeepers, infection preventionists,
and RNs. The team reviewed policies and mapped a current state.
A standard cleaning policy was developed incorporating 14 HRO
identified from the literature, a 7-step cleaning process and a
measurement method using a fluorescent marking system. Items
were considered either “clean” or “not clean” based on full or partial
removal of the marker. Housekeeping management was trained
one-on-one in the cleaning process and in the use of the marker for
monitoring 35 rooms per quarter. A spreadsheet was created, which
calculates cleaning compliance rates by room, by housekeeper and
by HRO. A toolkit was assembled to troubleshoot communication
gaps and to assist housekeeping staff in ensuring that all rooms were
cleaned daily. Results: Three hospitals piloted the project. 40
pre-and 40 post-measurements using the marker were obtained.
Post-measures were completed on the 7 HRO objects that
showed the greatest opportunity for improvement; data analysis
demonstrated improvement from 77% to 83%. The remaining
9 hospitals implemented the process during the last quarter of
2010. Pre- and post-intervention comparison revealed 17%
improvement in cleaning for all objects combined. The measures
were monitored by the project team for 2 quarters. Quarter 2 2011
“clean” percentage showed little change (81.6%) compared with the
post intervention measure (80.4%); however, Quarter 3 showed
a 10% increase in cleaning of the 14 HRO (91.8%). Lessons
Learned: A standardized cleaning policy, process and
measurement system is an effective way to improve cleaning. Use of
a fluorescent marker to assess room cleanliness resulted in improved
cleaning of objects and surfaces that may harbor organisms and
contribute to hospital-acquired infections. Exact reasons for the
increase in compliance between Quarter 2 and 3 are unknown, but
increased scrutiny and attention may have been given to the process
when initial results were below the goal of 90% clean on all 14
HROs. Monitoring and reporting results to Infection Prevention
and to the housekeeping management reporting chain can be
effective in maintaining continued interest in such a project.
Reducing Blood Culture Contamination in the
Emergency Department
Marie P. Hodgins, RN, BScN, CIC - Director, Infection Control
and Employee Health, Harlingen Medical Center; Deborah L.
Meeks, RN, MSN, CCRN - Director, Emergency Department,
Harlingen Medical Center
Issue: Our hospital’s Emergency Department had a blood
culture contamination rate ranging from 2-4 times the national
average. Contaminated blood cultures lead to increased length
of stay, increase cost and unnecessary antibiotic use with the
associated problems of pressure toward antimicrobial resistance
and increased risk of C. difficile associated disease. Project:
Our emergency department does not have the volume to justify a
dedicated phlebotomist, so in the interest of optimizing turn-around
time, the ED nurses and CNAs are responsible for phlebotomy.
This project was a joint effort of the Infection Preventionist, the
Emergency Department Director and the Emergency Department
Clinical Manager. We began by interviewing the staff and observing
current blood culture collection practices. Wide variation and
some alarmingly creative approaches were noted. Staff stated these
practices were intended to prevent an additional “stick” and to
save supplies and time. We created an inservice which focused on
the adverse impact of contaminated blood cultures, the rationale
for each recommended step in the process, and the opportunities
for contamination presented by current rogue practices. We
implemented an observation form to evaluate each individual’s
technique and provided real time feedback to individuals when a
sample they drew resulted with a contaminant. The rate did not
improve as expected. We observed again and determined that the
skin prep was rarely being performed correctly. We re-inserviced
with a real time demonstration of a full 30 second prep and full
30 second drydown. Individuals were observed in clinical practice
using the same observation checklist, but with emphasis on correct
duration of skin prep. This resulted in a dramatic improvement in
our contamination rate. Results were communicated and celebrated.
Results: Our monthly blood culture contamination rate ranged
from 6.6-8.6% in the four months prior to intervention. It actually
got worse immediately following the first inservice reaching 10%.
After the timing of the prep was addressed definitively, in dropped
down to a sustained at a rate of 2.1-3.3% in the last 6 months.
Lessons Learned: Careful planning and oversight is required
to facilitate change. Planning considerations include: -Understanding
what is motivating current behavior -Persuading individuals of the
value of the proposed change -Reviewing the literature to determine
which potential strategies are most likely to be impactful -Measuring
both processes and outcomes -Revising strategies as indicated
-Providing individualized, timely performance feedback, not just
aggregate results -Celebrating success
A Lean Surveillance Transformation
Health Network; Deborah Fry, MT(ASCP), MBA, CIC - Manager
Infection Control and Prevention, Lehigh Valley Health Network;
Terry Lynn. Burger, MBA, BSN, RN, CIC, NE-BC - Director
Infection Control and Prevention, Lehigh Valley Health Network
Issue: The demands facing Infection Preventionists today have
grown exponentially. They are challenged with increasing public
reporting requirements, more stringent regulatory requirements,
expanding scopes of practice (inpatient and outpatient), zero
tolerance for healthcare associated infections and mounting pressures
from value based pay for performance programs. Therefore it is
important to closely examine how Infection Preventionists structure
their daily activities to assure effective surveillance is achieved and
adequate time is available to invest in the multitude of other project
responsibilities. Project: The Infection Control and Prevention
department team members gathered for several sessions to identify
opportunities to improve patient safety and enhance their value to
patients. The objective of the activity was to create standard work
processes for surveillance and documentation and eliminate waste
in their daily routine. The team utilized several lean methodology
tools to streamline work flow. They followed a 6S approach to
organize their work spaces, completed a process map to illustrate
the mechanics of their daily work load and created an A3 analysis to
guide them through the activity. The format of the A3 included the
following: background, current conditions, ideal state, gap analysis,
proposed countermeasures, metrics and timelines and follow-up and
feed forward. Results: The current state demonstrated a lack of
standard work, redundancy in data entry, employee dissatisfaction,
lack of time for professional development, excessive travel, numerous
non-value added distracters, unused human potential and lack of
infection preventionist visibility. The goals of the ideal state was
to become more efficient, more organized, more standardized, to
decrease expenses, improve employee satisfaction, improve efficiency
and patient safety. A number of countermeasures were implemented.
Work processes were streamlined and standardized. All data entry
forms were made electronic. Additional staffing resources were
obtained. Electronic devices were purchased including individual
laptops, iphones and iPads. Work assignments were redistributed.
After the countermeasures were implemented waste was reduced
and employee satisfaction and workflow efficiency were immediately
improved. Since some of the countermeasures were recently
implemented the impact on healthcare associated infections and
patient safety is currently being evaluated. Lessons Learned:
Going to the Gemba is an expression utilized in lean methodology
which means going to where the work is done. This exercise illustrates
how critical it is to success. It is imperative to involve all members of
the team when a process improvement change is needed. Energy and
enthusiam drives results. The A3 and process map information helped
to justify and support all additional resources that were requested.
Infection Preventionists are finally getting the attention and support
they have always needed. Therefore it is necessary to assure those
resources are utilized in the most efficient and effective way. In a
financial atmosphere forecasting diminishing funding and pay for
performance driving reimbursement, it is essential that infection
control programs are designed to maximize efficiency to help achieve
the best outcomes for the organization and for the patient.
Mari Driscoll, RN, CIC - Infection Preventionist, Lehigh Valley
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Clinical Attributes of Non Ventilator-Associated
Hospital-Acquired Pneumonia
Successful Nurse-driven Improvement Team
Raises Postpartum Tdap Rates and Surpasses
Target Goal
Barbara Quinn, MSN, RN, ACNS-BC - Clinical Nurse Specialist,
Sutter Medical Center, Sacramento; Dian Baker, PhD, APRN-BC
- Associate Professor, School of Nursing, California State University
Sacramento; Carol Parise, PhD - Research Scientist, Sutter Health
Sacramento-Sierra Region
Objectives: To describe the incidence and risk factors of
patients with non ventilator-associated pneumonia (non-VAP
HAP). Background: Numerous studies have reported the incidence
and prevention of ventilator-associated pneumonia (VAP);
conversely, non-VAP HAP is an underreported and unstudied
area, with potential for measureable nurse-sensitive outcomes.
With the National Healthcare Safety Network focus on VAP,
hospitals are required to monitor VAP; however, there are currently
no requirements to monitor non-VAP HAP. The limited studies
available indicate that non-VAP HAP is an emerging factor in
prolonged hospital stays, patient morbidity, and increased cost of
$40,000 for each case. Understanding the incidence and determining
patients most at risk of this hospital-acquired infection is essential
to provide optimal patient care. Methods: Non -VAP HAP
data were obtained from a large, urban hospital’s electronic
integrated medical management system. Inclusion criteria for this
observational descriptive study were all adult discharges between
January 1, 2010 and December 31, 2010, coded pneumonia- not
present on admission and meeting the Centers for Disease Control
and Prevention’s (CDC’s) definition for HAP. Descriptive statistics
including means (SD) and percents were used to determine the age,
gender, length of stay, primary diagnosis for admission, common
risk factors, common chronic morbidities, and disposition upon
discharge. Results: A total of 24,482 patients comprising 94,247
patient days were eligible for study inclusion. 194 cases were coded
as HAP and 115 (59%) met the CDC definition. The infection rate
per 100 patients and per 1000 patient-days was found to be 0.47 and
1.22, respectively. The mean age of patients was 66 +14.45 and 54%
of the patients were male. The mean length of stay was 27 +30.48
days. Most HAP episodes were detected outside of the ICU (62%).
Cardiac disease was the most frequent primary diagnosis (18%),
followed by sepsis (14%) and cancer (10% ). The most common
risk factors for HAP were >6 medications (90%), central nervous
system depressants (78%), and acid blocking medications (76%).
Notable chronic co-morbidities were cardiac disease (37%), chronic
obstructive pulmonary disorder (30%), and diabetes (27%). The
most frequent disposition upon discharge was home (38%) and
other nursing facilities (34%); 28% of the HAP patients expired.
Conclusions: This study confirms that non-VAP HAP occurs
in a large, urban hospital and should be monitored. Coded databases
may not be the most accurate method of surveillance for this
hospital-acquired infection. HAP results in an extended length of
stay and occurrs most frequently in elderly, male patients with other
chronic conditions. Mortality among these patients is high, however,
most patients are discharged directly to home or to an extended care
facility. More research is needed to understand and design nursing
interventions to prevent non-VAP HAP iatrogenic disease.
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Tamara F. Persing, RN, BSN, MS, CIC - Director Infection
Prevention & Control, Geisinger Health System
Issue: The death of an infant from pertussis within the state
in 2010 raised the awareness of the healthsystem to improve
Tdap immunization rates. Postpartum Tdap immunization is
recommended by the Advisory Council for Immunization Practice
(ACIP) to reduce the risk of transmitting pertussis to their infants.
Initial attempts to immunize unvaccinated patients in 2009 at a large
teaching facility resulted in a 51% average rate. Prior efforts included
verbal education regarding Tdap at the initial perinatal visit and
immunization ordered at time of discharge. Project: In March
2010, the Postpartum Tdap Improvement Team was established to
improve immunization rates. This nurse-driven multidisciplinary
team was composed of front-line staff, perinatal educators, infection
preventionists, quality specialists, leadership sponsors and a prior
patient. Utilizing quality methodology, a team charter with a target
goal of 80% was developed that included defined process/outcome
measures with target dates. A unit data wall included baseline and
measurement graphs. Weekly team huddles and structured team
meetings were held to study the process redesign. Utilizing the
Plan, Do, Study, Act (PDSA) cycle changes, the team redesigned
the process of educating expectant parents/significant others in
the perinatal period, developed a written bi-lingual pamphlet, and
changed the timing of education from initial perinatal visit to the
3rd trimester by incorporating it into childbirth classes and perinatal
visits. Qualitative data collected indicated the educational timing and
pamphlets positively affected the mother’s decision to be immunized.
Inpatient and clinic staff education regarding Tdap was held
regularly. Visual reminders/posters were placed in all patient care
areas. Standardization of vaccine administration indicated a positive
change in vaccination rates. Standardization and automation of order
sets resulted in a decrease of missed orders, raising immunization
rates to a high of 91% in June 2011. Data was monitored weekly,
then monthly, to assess for process changes and outcomes. Missed
immunization opportunities were studied by the team. Reports
were sent to leadership for review and comment. Additionally, a
pilot program for immunizing fathers/significant others was trialed
as an offshoot of the initiative. Results: The postpartum Tdap
immunization rate increased from 49% (March 2009) to 91% ( June
2011) with rates remaining between 77% and above. Refusal rates
varied throughout the initiative from a high of 27% decreasing and
remaining below 14% with a low of 4%. Order standardization/
automation decreased missed doses from 23% to <5%. The
percentage of vaccine not ordered dropped from 19% to <6%. Of
note, an increase in outpatient immunized patients rose from <8%
to sustained >30% during the project. Lessons Learned: To
be an effective, successful improvement team requires collaboration,
diligence and engagement by all members. The value of the PDSA
cycle and measurement is critical to reaching target goals and
sustaining results.
Blood Culture Procedures and Results in a
Pediatric Hospital in La Paz, Bolivia: Opportunities
for Improving Efficiency and Decreasing Cost
Juan Pablo Rodriguez Auad, MD, MSc - Pediatric Infectious
Disease Physician, Hospital del Niño “Dr. Ovidio Aliaga Uria”;
Loreta I. Duran Arias, MSc - Head of Microbiology Laboratory,
Hospital del Niño “Dr. Ovidio Aliaga Uria”; Kyle M. Johnson, PhD,
Hospital
Background/Objectives: Bacteremias are serious
infections. Efficient use of blood cultures (BC) are quality indicators
for a healthcare service. We report on 20 months of BC data
and outline opportunities for improvement of this procedure.
Methods: The hospital, 174-beds, is a public pediatric hospital
in La Paz, Bolivia where 65 physicians and 165 nurses provide care.
As a tertiary care hospital, it has 11 units and treats children with
acute and chronic diseases, as well as cancer. In 2011, infection
was the most frequent reason for hospitalization (612/5559) and
death (22/139). We reviewed institutional BC policies, and current
practices, as well as laboratory methods for BC processing. We
examined microbiology reports and calculated frequencies and
percentages from available data. We obtained permission from
corresponding institutional authorities to review and report our
findings. Results: The principal indication for BC is fever
and suspicion of infection. Institutional BC policy recommends
collecting two samples with prior skin asepsis with 70% alcohol,
and before antimicrobial therapy. BCs are obtained by physicians
and sometimes by laboratory personnel. The BacT/ALERT PF BC
system is used, according manufacturer’s instructions, to process BCs.
In actual practice, one site is used for drawing the BC and there is
no technical oversight. We analyzed 1918 blood samples collected
from December, 2009 to July, 2011and identified 318 (17%) positive
BCs. The blood sample was considered contaminated in 27%
(85/318). Gram-negative Bacillus (GNB) was the most frequently
isolated group (46%), followed by Gram-positive cocci (GPC)
(33%) and fungus (10%). The most frequently isolated bacteria was
Staphylococcus aureus (21%, 67/318), 45% were methicillin-resistant.
Escherichia coli was the most common GNB (11.6%, 37/318), 43%
of those were positive for extended spectrum beta-lactamase enzyme.
The most frequent fungus was Candida albicans (5%, 16/318). The
average turnaround of positive samples was 3.76 days (Range= 1-14
days). Conclusions: We have found that positive culture rates
are lower than reported from sites in similar socioeconomic situations
to ours and we have a high rate of contamination. BC contamination
results in unnecessary admissions and antibiotic use. Better
understanding of the BC problem is our first step toward improving
this practice in our institution. We plan to improve current practices
by writing and disseminating BC policies and procedures. This will
be accomplished by: standardizing indications for ordering BCs; that
only trained providers draw BCs and promptly transport them to the
laboratory; ensure that the laboratory complies with standards; create
and use a diagnostic algorithm to determine if skin flora isolated are
true pathogens; and promptly communicate results to healthcare
providers. Through these organizational improvements, we are
confident that BC use in our patient care will result in less waste and
cost savings as well as reducing the workload for healthcare providers.
A Multi-faceted Approach to Increase and Sustain
Hand Hygiene Compliance in a Military Treatment
Facility
Michele A.T. Riboul, BSMT(ASCP), MS, CIC - Director Infection
Control, Wilford Hall Ambulatory Surgical Center; Hamidah
Franchette. El-Amin, LVN - Infection Control Surveillance Nurse,
Wilford Hall Ambulatory Surgical Center; Hilda P. Ben, RN,
BSN, CIC - Infection Control Specialist, Wilford Hall Ambulatory
Surgical Center
Issue: Despite substantial evidence that hand hygiene (HH) is
the MOST important infection control measure for preventing
healthcare associated infections (HAIs), adherence to HH by
healthcare workers (HCWs) remains low nationwide (between 40
to 50 percent). In 2004, a targeted assessment of HCWs compliance
with HH was conducted in our facility identifying a similar
compliance rate to the nation. In order to improve compliance,
the HH Program was created comprising of the Hand Hygiene
Compliance Team. Project: Our Program was based on the
Institute of Healthcare Improvement (IHI) “How–to Guide:
Improving Hand Hygiene”. The four IHI components to improve
compliance were implemented: 1) education of staff was conducted
through employee training and multi-component publicity
campaigns, 2) improvement of HH technique using several methods,
3) increase availability of alcohol-based hand rubs(ABHRs)
throughout the facility, 4) HH observations performed using Center
for Disease Control and Prevention (CDC) guidelines. Results:
1) Education of staff was conducted through orientation, annual
training and section specific training. Two multi-component
campaigns were implemented-first one in 2006, and the second in
2008. Campaigns included: HH posters, life size figure of facility
leader, HH pamphlets, quarterly HH articles, HH trophy, incentives
for patients/staff and HH surveys for the second campaign. Survey
results (2009-2011) reveal that staff awareness of the campaign
increased with each year and was above 90% and patient awareness
was above 80%. 2) Correct techniques for using an ABHR and
handwashing were discussed during educational sessions, 2 videotape
presentations, and using fluorescent dye-based training methods.
3) Pocket-size ABHRs were distributed and a survey of the facility
was conducted to maximize the availability of ABHR wall units in
patient care areas. 4) HH compliance checklist was created for use
by trained observers. Targeted areas were surveyed monthly with a
minimum of 30 opportunities for HH observed, immediate feedback
given, and compliance rates reported to leadership. Results:
24,840 observations were performed from 2006 to 2011, with
the most observations done in 2006 (5369) and the least in 2011
(2991). The facility goal was set at 90% compliance rate and was
reached in the latter part of 2008. The lowest overall compliance
rate was 77% in 2006/2007, and the highest compliance rate was
94% in 2011. Physicians/Respiratory Therapy technicians improved
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the most. Lessons Learned: All IHI components need to
be implemented simultaneously in order to improve compliance.
Patient participation and leadership support played a significant
role in achieving and sustaining our goal. HH observations were a
challenge due to the high turn-over of observers, missed assignments,
and limited areas that could be observed. Another challenge was the
continuous educational need of a transient employee population.
quarters, submissions had improved to an average of 72%. Lessons
Learned: Staff needed enough time to perform the actual
sterilizer maintenance. (Average of 30 minutes for weekly and up to
3 hours for monthly process). All staff that used the sterilizer needed
to be educated on how/when to use the biological indicator, (The
first load of every day the unit is run) how to perform maintenance,
and how to log the results. This took almost a year to see significant
improvement in reporting and compliance. Supervisors were required
to review the audit and address barriers or non-compliance. The
tool actually helped some sites make changes to staffing to assure
compliance. Audits are best submitted by excel format via email.
Initially this was done via interoffice mail or FAX. This led to missing
audits and inaccurate data. Although the measure of performance
is submission of the audit, the real value is in identifying areas of
concern such as lack of staff, lack of knowledge about policies and
supervisor awareness of compliance with this important infection
prevention and patient safety component. A future Quality
Assurance project could be developed to look at actual compliance
with all requirements.
A Quality Assurance Project to track Compliance
with Autoclave Maintenance and use of Biological
Indicators in Outpatient Physician Offices.
Laura L. Grant, RN - Infection Preventionist-Clinic, Aurora Health Care
Issue: Staff turnover or unclear expectations led to a lack of
autoclave maintenance and use of biological indicators in a 125+
physician office healthcare system. After instruction in proper
autoclave maintenance and use of biological indicators, there was
no way to measure if policies were being followed. Project: A
quarterly audit tool was developed. The percentage of returned audits
by market was measured. All sites that sterilized instruments in an
autoclave were required to track these actions: • Weekly autoclave
maintenance • Monthly autoclave maintenance • Review of each
load’s printer read-out • Use of a biological indicator in the first load
of every day the unit was operated • Failed biological indicators and
actions taken for failures Each site was required to assign a trained
staff member to keep the logs and fill out the audit 30 days after
the end of the quarter. All audits must be reviewed and initialed by
the site supervisor. This was done so the supervisor could identify
lapses in completion of actions as required per policy. All audits
are submitted to the clinic Infection Preventionist who shares the
data with leadership, infection control and quality committees.
Results: From the third quarter of 2009 to the third quarter
of 2011, 97 sites were required to submit data. Initial submissions
ranged from 0% to 100% with an average of 50%. At the end of 9
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Community Medical Center
Issue: In times of competing healthcare dollars, how does an
Infection Control department prove the benefit of expanding an
Active Surveillance Culture (ASC) program? A Methicillin-Resistant
Staphylococcus aureus (MRSA) Active Surveillance Culture (ASC)
Program was implemented on a Surgical Intensive Care Unit (SICU)
in a 500 bed community hospital for three years. The data collected
during this time demonstrated a significant difference of Healthcare
Acquired (HA) MRSA when compared to a similar unit that does
not utilize the ASC program. Project: Three years of comparison
data were analyzed to determine the benefits associated with a
reduction in HA-MRSA for the hospital. Research was conducted
into the cost and benefit of expanding the ASC program to other
units. However, the data alone was not sufficient to have the program
prioritized for expansion to other critical care units. Support and
validation was needed for the expansion to occur. The Association
for Professionals in Infection Prevention and Control (APIC)
provided the forum needed to achieve scientific credibility and to
substantiate moving the program forward. In 2011, an abstract (and
poster) depicting the benefits of the ASC program in the SICU was
submitted and accepted to APIC. Results: The poster illustrated
the significantly lower HA-MRSA associated with the ASC unit
(SICU) than the Medical Intensive Care Unit (MICU), the unit
without the ASC program p=.001 (CI 95%). The cost difference
associated with HA-MRSA between the SICU and MICU was
$884,175. In addition, the poster was submitted and presented at the
Data, Dollars, and Determination.....
Christine Filippone, DNP, ANP, CIC - Director Department
of Epidemiology/Infection Control, Community Medical
Center; Lisa M. Martinez, BSN, RN, CIC - Infection Control
Practitioner, Community Medical Center; Kelly Zabriskie, BS,
CIC - Infection Control Practitioner, Kimball Medical Center;
Mary Ann Wells, MPA, RN, CIC - Infection Control Practitioner,
125
Hospital’s Corporate Quality Fair. This provided the opportunity
to initiate communication with leaders on supporting the expansion
of the ASC program. Subsequently, the program was expanded to
the Medical Intensive Care Unit, providing those patients the same
benefit of early identification, isolation, and decolonization of MRSA
colonization. Lessons Learned: Valuable, sound data does not
benefit a hospital and its patients if it is not effectively communicated
to the healthcare team. This communication includes validation and
at times support of a prestigious national organization to bolster the
need for process change and improvement. Infection Preventionists
collect a large quantity of data, which alone does not benefit patient
care. Rates are reported at meetings however, when this data is peer
reviewed and supported it can help drive performance improvement
for the hospital. In today’s struggling economy, every healthcare
dollar is essential. It is important to demonstrate the benefit of
a program utilizing recognized forums to garner support and
validation.
Lessons Learned from 5-yrs of Central LineAssociated Bloodstream Infection Real-Time
Event Reviews
Nancy M. Hutchinson, RN, MSN, CIC - Nurse Epidemiologist,
Cincinnati Children’s Hospital Medical Center; Derek Wheeler,
MD - Associate Professor, University of CIncinnati College of
Medicine; MaryJo Giaccone, RN - Cincinnati Children’s Hospital
Medical Center; Beverly Connelly, MD - Director of the Infection
Control Program, Cincinnati Children’s Hospital Medical Center
Issue: Central line-associated bloodstream infection (CLABSI)
prevention for all patients has been a quality improvement inititative
at this facility since 2002. Subsequently, the practice of conducting
real-time event reviews following recognition of a CLABSI was
initiated with the aim of identifying additional interventions to
prevent these infections. Project: At the time a CLABSI is
suspected or confirmed, a standardized real-time event review
form is e-mailed to the medical and clinical leadership of the unit.
The form requests feedback from the direct patient care providers
regarding compliance with the CLABSI preventon bundle, barriers
to compliance, and risk factors that may have contributed to this
infection. In addition, days-between-infections are posted in
prominent locatons on the units to communicate infection data to
staff, reinforce the concept that infecton preventon is everyone’s
responsibility, and provide tangible measures of patient care quality.
The aim is to achieve zero tolerance for infectons and promote
adherence to best practices in the delivery of patient care. Results:
From January 1, 2007 through December 31, 2011 a total of 288
CLABSIs were identified. A review of returned real-time event
review forms indentified multiple risk factors that preceded an
infection. Included were lack of adherence with central line insertion
and maintenance bundles, mechanical problems (e.g. tear in central
line, occlusion, tip migration), misuse of medical devices, and patient
tampering with the central line. Observations were shared with
medical and clincial leadership and utilized to identify equipment,
training, and performance inadequacies to improve the central line
management process. Lessons Learned: Real-time event
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reviews involving direct patient care providers are an essential element
for identifying individual patient risk factors for CLABSI, promoting
ongoing quality improvement processes, and ensuring sustained
progress toward infection prevention.
Real-Time Event Reviews: A Useful Tool for the
Prompt Identification of System Failures
Nancy M. Hutchinson, RN, MSN, CIC - Nurse Epidemiologist,
Cincinnati Children’s Hospital Medical Center; Mary Lou Sorter,
RN, CIC - Senior Infection Control Practitioner, Cincinnati
Children’s Hospital Medical Center; Christine Voegele, RN
- Quality Outcomes Manager - Neonatal Intensive Care Unit,
Cincinnati Children’s Hospital Medical Center; Beth Haberman,
MD - Assistant Professor, Division of Neonatology and Pulmonary
Biology, Cincinnati Children’s Hospital Medical Center; Beverly
Connelly, MD - Director of the Infection Control Program,
Cincinnati Children’s Hospital Medical Center
Issue:Ventilator-associated pneumonia (VAP) is one of the most
common infections acquired by adults and children in intensive
care units. Recent publications report rates of VAP that range
from 1 to 4 cases per 1,000 ventilator days, but rates may exceed
10 cases per 1,000 ventilator days in some neonatal and surgical
patient populations. Project: In 2005, a multidisciplinary task
force was formed to develop a pediatric bundle designed to reduce
these infections. The VAP bundle elements were implemented in
2006 and included hand hygiene before and after contact with the
ventilator circuit; elevation of the head of the bed; oral care; circuit
maintenance, including every 2 hour checks to drain condensate;
procedures for management of oral suction devices; and daily
assessment of readiness to extubate. In addition, when a VAP was
suspected or confirmed Infection Control e-mailed a standardized
real-time event review form to the unit’s medical and clinical
leadership to notify them of the infection and request feedback from
direct care providers regarding bundle compliance and risk factors
that may have contributed to the infection. From 2003 through
2005, the CICU, NICU and PICU combined annual VAP rate was
5.1 infections per 1,000 ventilator days. Following implementation
of the bundle, the rate was reduced and sustained at 0.7 infections
per 1,000 ventilator days. However, in September 2011, 2 cases of
VAP were identified in the NICU for a unit rate of 5.5 infections per
1,000 ventilator days for the month. Results: The unexpected
increase in VAPs in the NICU prompted a thorough real-time event
review and analysis of findings. Analysis of the first VAP identified
failure to adhere to oral care as prescribed by the bundle. Further
investigation revealed that storeroom personnel had discontinued
routinely stocking mouth care kits in the nurse servers of ventilated
patients and therefore the visual cue of the need for oral care was no
longer evident. In addition, the infection occurred during a period
of high census and nursing staff had been called from other units.
A review of the just-in-time orientation provided to support staff
indicated the NICU VAP bundle was not included. Analysis of the
second infection identified an unusual suction device (i.e. intended
only for use during bronchoscopy) was attached to the ventilator
circuit upon the infant’s return from this procedure. While it was not
Poster Abstracts: Special Populations (Infections in the Immunocompromised Host, Pediatrics)
clear if the device had a role in the infection, lack of staff familiarity
with medical devices is problematic. These system issues have been
addressed and there have been no additional infectons. Lessons
Learned: Real-time event reviews are useful tools for prompt
identification of system failures and factors that may contribute to
healthcare-associated infections. This tool empowers direct patient
care providers to report events that occur at the bedside that may
not be otherwise shared. Reliability and sustainability are dependent
on identifying opportunities for improvement and integrating these
lessons learned into practice.
Colorado Clostridium difficile Infection Prevention
Collaborative
Tamara Hoxworth - Patient Safety Quality Improvement Specialist,
Colorado Dept. of Public Health & Environment
Issue: Clostridium difficile (CDI) is a leading pathogen in
hospital-acquired infections (HAI) in the U.S., causing diarrhea,
colitis and sepsis, often leading to prolonged hospitalization
and death.1 The Prevention Collaborative approach has been
successful in reducing other HAI, such as SSI 2 and CLABSI,3
and has the potential to be effective in reducing hospital-associated
CDI. Project: The Colorado Department of Public Health
(CDPHE) Patient Safety Program partnered with the Colorado
Hospital Association (CHA) and Denver Health & Hospitals
to implement a CDI prevention collaborative that began March
2010. Twenty facilities were targeted for enrollment and originally
enrolled; however, three facilities subsequently dropped out citing
workload burden. Seventeen facilities (14 hospitals, 3 Long- Term
Acute Care Hospitals) remained throughout the collaborative’s
duration (through December 2012). The collaborative enlisted
volunteers to work together to reduce health facility-acquired
CDI through data and idea sharing and collaborative learning.
Participants entered CDI event data into the National Healthcare
Safety Network (NHSN) and data for three process measures
(hand hygiene, environmental cleaning, gown & gloving practices)
into a secure website developed by CHA. Facilities also used the
CHA website to blog with other members on prevention problems,
approaches, and successes. Three face-to-face learning sessions
were conducted in March and October, 2010 and June, 2011 and
included presentations by experts on relevant infection prevention
topics, presentations of facility specific process and outcome
data, and presentations by participants on their own strategies for
success. Webinars or conference calls were held monthly to discuss
reporting and prevention issues and host presentations by expert
speakers on relevant topics. Results: The goal was to reduce the
Healthcare Onset (HO) and Healthcare Acquired-Community
Onset (HA-CO) CDI rates by at least 15% from baseline or to
zero. While Community Onset (CO) rates increased over the 20
month duration of the collaborative, quarterly HO CDI rates (per
10,000 patient days) declined by 14% from 6 to 5.2; HA-CO rates
declined by 24% from 3.1 to 2.4; the combined rate declined by
17% from 9.1 from 7.6. Lessons Learned: 1. The Prevention
Collaborative Approach may be an effective approach to reducing
health facility-associated CDI. 2. More frequent feedback of facility
data may be helpful. 2. Periodic recognition/awards for reporting
compliance may improve performance. 3. Data compilation by a
single oversight agency could expedite data analysis and reporting.
4. Data cleaning is necessary, requiring extensive data quality
checks. 5. Data management and reporting is resource intensive,
but critical. 6. Process measurement should be standardized using a
standardized audit tool. 7. Continual reminders to submit data are
needed to improve compliance with process measure reporting.
Special Populations (Infections
in the Immunocompromised
Host, Pediatrics)
Isolation Precaution Guidelines in NICU: Breast
Milk Storage
Amber Wood, RN, BSN, CPN - Infection Control Practitioner, The
Medical Center of Plano; Jessica Reese, RN - RN III, The Medical
Center of Plano
Issue: In our Neonatal Intensive Care Unit (NICU), a neonate
was found to have meningitis. The neonate’s mother was concerned
that she had transmitted an organism to her baby through breast
milk. To allay the mother’s concerns, an Infectious Disease (ID)
physician had the breast milk cultured. The breast milk cultured
positive for multi-drug resistant Acinetobacter baumannii, which was
not the same organism that caused the meningitis. The ID physician
classified the positive culture as colonization. Our institutions’
infection control policies did not address isola-tion of breast milk.
What is the best practice for isolation of breast milk? Project:
A literature review conducted by Infection Prevention and NICU
nurses to determine best practice for isolation of breast milk, which
showed that refrigeration of breast milk at 4ºC up to 96 hours did
not significantly alter breast milk integrity, including bacterial colony
counts, and thus, refrigeration would not destroy any organisms
present in the breast milk. Additionally, the literature showed that
common exposure of both the mother and the infant were not
predictive of infection in premature infants. The Infection Prevention
Coordinator placed the neonate in con-tact isolation under the
assumption that the baby could be colonized from the mother. Since
the breast milk was confirmed to be colonized with this emerging
multi-drug resistant organism (MDRO), Infection Prevention and
the NICU nurse also created a process to isolate the breast milk.
The breast milk was placed in a storage refrigerator and freezer,
which included labeling the containers of milk with the patient’s
identification label, placing the containers of milk in a biohazard
bag, and labeling the breast milk storage bin as contact isolation.
Separation of breast milk in the shared refrigerator from other breast
milk through distance and biohazard bags was maintained until the
neonate was discharged. The NICU physician allowed the neonate to
con-tinue to breastfeed and receive the expressed breast milk. Since
127
breast milk culture results were not predictive of infection when
evaluated prior to the occurrence of infection, the breast milk was not
routinely cultured during the infant’s stay in the NICU. Results:
The neonate did not develop any Acinetobacter baumanni infections.
No other cases of Acinetobacter baumanni were identified during
the neonate’s admission or in the month follow-ing discharge. Our
facility has adopted this technique of isolation for breast milk as
standard of care in NICU. Lessons Learned: Infection
Prevention needs evidence-based guidelines for storage of breast
milk for NICU patients in isolation. In the future, a research project
will be conducted to evaluate the risk for transmission of MRDO
organisms in breast milk storage refrigerators and freezers.
Relationship Between Wait-Time for Antibiotic
Initiation and Outcomes of Hospitalization Among
Children with Cancer Admitted to an Oncology
Ward in a Hospital in the Philippines
Jeannette Kirby, RPh - Graduate Student, School of Public
Health, University of Memphis; Miguela Caniza, MD - Director
Children’s Research Hospital; Don Guimera, BSN, RN, CIC,
CCRP - International Epidemiology Coordinator, St. Jude Childrens
Research Hospital; Kyle M. Johnson, PhD, CCRP - Clinical
Research Associate II, St. Jude Children’s Research Hospital;
Vikki Nolan, DSc, MPH - Assistant Professor of Epidemiology
and Biostatistics, University of Memphis; Fawaz Mzayek, MD,
MPH, PhD - Assistant Professor of Epidemiology and Biostatistics,
University of Memphis; George Relyea, MS - Assistant Professor at
the School of Public Health, University of Memphis; Mae Dolendo,
MD - Pediatric-Oncology Medical Director, Davao Partner Site, St.
Jude Children’s Research Hospital; Czarina Mae Castillo-Deluao,
RN - Registered Nurse and Infection Control Preventionist, Davao
Partner Site, St. Jude Children’s Research Hospital
Background/Objectives: Timely antibiotic
administration in children with cancer within an optimal 1- hour is
considered good clinical practice. In this study, we ascertained the
antibiotic wait-time (AWT) and identified factors associated with
healthcare access and delivery, and evaluated outcomes of AWT
of the first dose of antibiotic given. Methods: We reviewed
retrospectively 220 medical records of patients admitted to this
pediatric oncology unit between January 2011 and June 2011.
We took note of patient demographics, patient hospital course,
and antibiotic treatment and administration details. Through a
cross sectional survey questionnaire, administered to 36 healthcare
providers, we assessed factors associated with the healthcare delivery
systems (HDS) that included the institutional capacity (human and
non-human resources) and institutional response (standard-of-care
practices). Results: We found that average AWT was 2.5 days.
Access to HDS for known and non-referred patients was shorter
than for unknown and referred patients averaging 2.25 days versus
27 days for known patients vs. unknown patients (hazard ratio: 0.52,
p<.1), and 2.7 days versus 6.94 days for non -referred vs. referred
(hazard ratio: 1.59, p<.05). Fewer siblings were also favorable as
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reflected in a hazard ratio of 0.91, p=0.059 for number of siblings
(low vs. high) We also found that the outcome measurement length
of hospital stay (LOS) was on average 11.1 days for known patients
versus 14.8 days for new patients, p<.1 while referred patients
averaged 14.7 days vs. 11.4 days for non-referred patients, p<.1.
Outcome measurement LOS was reduced for neutropenic patients
(ANC<500) who received antibiotic therapy within 12 hours postadmission, p<.1. The survey among healthcare providers noted that
only 59% of nurses recognized fever as an oncologic emergency and
notified the physician in <15 minutes. The perception of antibiotics
availability varied among nurses (49%), Physicians (40%) and
pharmacists (73%). Conclusions: Patients admitted to this
pediatric oncology unit wait much longer than the optimal 1-hour
window for antibiotic treatment. This long wait-time increases their
risk for infection progression and consequently longer hospital stay.
In turn, a longer hospital stay increases the risk for hospital acquired
infections to the patient itself and makes the patient a source for the
continued transmission of pathogens to the other patients. It is these
considerations that underline the importance for a shorter wait-time
to antibiotic treatment for febrile neutropenic patients.
Epidemiological Patterns and Characteristics
Associated with Clostridium difficle Infection at the
Largest Freestanding Pediatric Hospital
Tjin Koy, MT(ASCP), MPH, CIC - Infection Preventionist, Texas
Children’s Hospital, Houston, TX; Amy Hankins, MSN, RN Infection Preventionist, Texas Children’s Hospital; Jonathan Crews,
MD - Infectious Disease Fellows, Baylor College of Medicine; Jeffrey
Starke, MD - Medical Director of Infection Control, Baylor College
of Medicine
Background/Objectives: While varied literature exists
regarding the epidemiology of Clostridium difficile infection (CDI)
in adults, data describing the occurrence of this disease in the
pediatric population is limited. Objectives: To describe the incidence
and clinical characteristics of confirmed CDI cases seen at Texas
Children’s Hospital (TCH). Methods: Children with confirmed
CDI cases at TCH between March 1, 2011 to September 30, 2011
were identified through a microbiology database. Medical records
were reviewed to collect information regarding demographics,
potential risk factors, symptoms, and co-morbidities. Rep-PCR
method was utilized to test the specimens. Results: 124 patients
with CDI were identified. The ages ranged from 1 month to 21 years
old (mean = 8 years). The percentage of males was higher (60%) than
females (40%). Sixty-two percent of the patients resided in Harris
County. Hispanics comprised 42% of cases, followed by Whites
(36%), African-Americans (13%), and Others (9%). In addition
to diarrhea (87%), additional symptoms observed were abdominal
pain (31%), fever (23%) and vomiting (20%). Ninety-five out of
124 cases (77%) had an underlying co-morbidity associated with
CDI. Malignancy was the leading co-morbidity (37%), followed by
gastrointestinal (28%), immunodeficiency other than malignancy
(19%), transplantation (9%) and pulmonary (7%). Potential risk
factors associated with CDI include previous hospitalization (65%)
and use of antibiotics in the last 30 days (65%). 1 patient died
during the study period. Fifteen patients (12%) were admitted to the
Pediatric Intensive Care Unit, 43 (35%) were seen as an outpatient,
and 66 (53%) were admitted to non-ICU units. The average length
of hospital-stay was 12 days. Ninety-four cases (76%) tested positive
for both toxins A and B. Toxin A was exclusively identified in 19%
of cases and toxin B was identified in 5% of cases. Thirty-nine cases
(31%) were classified as healthcare facility-associated infection
while 85 cases (69%) were classified as community-associated
infection. Conclusions:Clostridium difficile is an important
and frequently encountered organism in the pediatric population.
Most children with CDI at our children’s hospital have underlying
co-morbidities and have been hospitalized and/or have received
antibiotics in the previous 30 days. Community-associated infection
exceeds healthcare facility-associated infections at our hospital.
Sustaining Zero Central Line-Associated Blood
Stream Infections in Pediatric Intensive Care Unit:
A Light at the End of the Tunnel?
Tjin Koy, MT(ASCP), MPH, CIC - Infection Preventionist, Texas
Children’s Hospital, Houston, TX; Angela C. Morgan, MS, RN,
CCRN - PICU Nurse Practitioner, Texas Children’s Hospital;
Jeanine Graf, MD - Chief of Medical Staff in PICU, Baylor College
of Medicine
Issue: Eradicating Central Line-Associated Blood Stream Infection
(CLABSI) in the 31-bed Pediatric Intensive Care Unit (PICU) has
been the goal of our institution for many years. Despite following
the evidence-based insertion bundles and maintenance bundles,
maintaining the zero CLABSI rates seemed like an impossible target.
Recently, the PICU team has discovered the successful approaches to
sustain the zero CLABSI rates for 260 days. Project: Dispelling
the excuse that “our patient populationis sicker” was the first major
step in recognizing the problem. A non-punitive eporting system was
used by the staff to report any breach in infection control protocol
regarding the care of central lines. The report was reviewed by the
director/physician of the affected department and the action plan
was documented. Based on the suggestion of the nursing staff, a Cap
Change Kit and Dressing Change Kit were trialed and successfully
implemented in the unit. The physician leadership ensured that all
PICU physicians received a formal in-service regarding central line
insertion and maintenance. A four-hour mandatory interactive (
hands-on) training session is conducted annually for all the nursing
staff. Our institution is very fortunate to have a deicated Vascular
Access Team who will assist in dressing change and other central
line related issue in a timely manner. Root Cause Analysis (RCA)
“Lite” was conducted every time CLABSI was detected. Due to
the non-punitive nature of this process, the staff is very vocal and
contributes to many new ideas during this process. The introduction
of a closed medication system to reduce manipulating/accessing
the central line was introduced in summer 2011. The new product
called Site-Scrub®, which increases the compliance with “scrub the
hub” policy, was also trialed in summer 2011 and was well received
by the staff. This product was made widely available and visible in
the PICU. Results: PICU CLABSI rates have decreased 35%
in calendar year 2011 compared to 2010. As of January 10, 2012,
the number of days since the last CLABSI infection was 260 days.
Lessons Learned: Education alone did not have a strong
impact in sustaining zero CLABSI rates in PICU. Support from
senior leadership and physicians contribute to the success of this
program. Nursing staff “buys-in” and sense of ownership have been a
critical factor for the success of the program. Changes should not be
feared, including changes in product or policy. Success should always
be recognized and celebrated with the staff.
Outpatient Adult Hematopoietic Stem Cell
Transplant Visits: Respiratory Season Interventions
Ellen C. Dougherty, RN, BSN, MA, CIC - Infection Control
Practitioner, Memorial Sloan-Kettering Cancer Center; Janet
A. Eagan, RN, BSN, MPH, CIC - Infection Control Manager,
Memorial Sloan-Kettering Cancer Center; Ann Jakubowski, MD,
PhD, Board Certified in Internal Medicine, Hematology and
Medical Oncology - Clinical Director of MSKCC’s Adult Bone
Marrow Transplant Outpatient Unit, Memorial Sloan-Kettering
Cancer Center; Greg Mason, BA - Supervisor, Adult Outpatient
Bone Marrow Transplant Clinic, Memorial Sloan-Kettering
Cancer Center; Lisa Gosman, BA - Administrator - Outpatient
Clinics, Memorial Sloan-Kettering Cancer Center; Mini Kamboj,
MD, Board Certified in Internal Medicine and Infectious Disease
- Associate Medical Director, Infection Control, Memorial SloanKettering Cancer Center
Issue: Respiratory virus (RV) infections among transplant
recipients occur most commonly when patients have returned
to the community. Many are diagnosed with RV infections
during Outpatient Adult Bone Marrow Transplant (OPABMT)
clinic visits. Patients evaluated in the OPABMT clinic include
potential transplant candidates, early post-transplant recipients
and long-term survivors. The mean number of patients seen daily
in the OPABMT clinic is 45. In the last three respiratory seasons
(November-April 2008-2011) 105 patients were diagnosed with a
RV. The most frequent viruses were: RSV (n=45), influenza (n=26),
and parainfluenza (n=25). Previously, all patients, irrespective of
respiratory symptoms, registered at a reception desk located within
the waiting area of the clinic. Reporting respiratory symptoms
was passive; patients were instructed to report them at time of
check-in. Signs were posted to reinforce this. Any patient reporting
respiratory symptoms was given a mask. During the 2010-2011
season, sixteen patients were diagnosed with influenza during an
OPABMT visit. 10/16 patients wore masks while in the waiting
area. The six patients who were not wearing masks exposed staff and
other patients. Oseltamivir prophylaxis was recommended to those
exposed. Project: In the summer of 2011 a group of medical,
nursing and administrative leaders in the adult BMT service and
Infection Control agreed that masks should be worn by patients and
visitors in the clinic. They also created a system to evaluate patients
and visitors before entry to the clinic. An active screening process
was implemented wherein patients and visitors are now screened at
a reception desk outside the clinic. A clinic assistant confirms each
patient’s appointment, and then asks if the patient or accompanying
129
visitor(s) has a fever, cough, or sore throat. Patients or visitors who
respond “yes” to any question are given a mask and gloves to wear
and are directed to a separate waiting area outside the clinic. A
nurse comes to that area and performs an assessment. The patient is
then brought directly to an exam room for a physician evaluation.
Sick visitors remain outside the clinic. Patients who answer “no” to
questions about respiratory symptoms also receive a mask and gloves
and are directed to wait within the actual OPABMT clinic. Staff
were educated on these practice changes at team meetings this fall.
Results: We will evaluate all cases of RV for exposures in the
coming respiratory season and also review the number of tests sent to
see if these increase. To date, one case of influenza A was diagnosed.
The patient was appropriately triaged. No exposures occurred.
Lessons Learned: Patients and visitors are highly supportive
and understanding of the program. OPABMT patients are in various
stages of dealing with a transplant and are willing to take precautions
to assure the best outcome for all in the clinic.
in 2010 when mandatory masking for staff declining to receive
vaccine was enforced. Similarly, from 2009 to 2011 physician
Influenza vaccination rates increased from 61% to 83% coverage.
The same masking requirement applied to physicians as well. During
this time period there were 6 patient deaths related to community
acquired Influenza at our facility, of which one was a Hematology/
Oncology patient. Lessons Learned: Inpatient admissions
represent an opportunity for vaccination of pediatric patients.
Influenza vaccination of high risk patients, including Hematology/
Oncology patients should be a priority. Improved inpatient Influenza
vaccination rates at our facility seemed to be linked to improved staff
and physician vaccination rates and heightened staff and patient/
family awareness, due to the introduction of the new Influenza
(H1N1) strain, after the death of a Hematology/Oncology patient
and mandatory masking for those staff and physicians declining
to receive vaccine. Live attenuated Influenza vaccine seems to
be infrequently administered to pediatric inpatients due to staff
unfamiliarity with this vaccine and discomfort with using a live
product on the inpatient service. Although the number of vaccines
administered increased substantially by 2011, this was still a small
percentage of inpatients and is unadjusted for patients who had
received Influenza vaccine prior to admission. Standing protocols,
electronic medical record reminders and linkage to computerized
vaccine registries should help in this regard and may further reduce
missed opportunities.
Influenza Immunization of Medical/Surgical and
Hematology/Oncology Pediatric Inpatients
Wendi Gornick, MS, CIC - Infection Prevention & Epidemiology
Manager, CHOC Children’s Hospital, Orange, CA; Bijal Patel, BS,
MHA - Infection Prevention Analyst, CHOC Children’s Hospital,
Orange, CA; Jasjit Singh, MD - Medical Director of Infection
Prevention & Epidemiology, Department of Pediatrics, Division of
Infectious Disease, CHOC Children’s Hospital, Orange, CA.
Issue: Inpatient hospitalizations represent potential opportunities
for vaccination, especially for high risk pediatric patients. Missed
opportunities, particularly for Influenza vaccination are of great
concern. Project: We performed a retrospective analysis of our
inpatient Influenza vaccine administration from 2007 to 2011 for
Medical/Surgical patients and Hematology/Oncology patients. We
compared this data with our staff and physician Influenza vaccination
rates over the same time period. Results: For patients greater
than 6 months of age, inpatient Influenza vaccination administration
increased from 116 to 289 doses (149% increase) in Medical/Surgical
floors and from 1 to 73 doses (720% increase) on the Hematology/
Oncology floor. Medical/Surgical patient Influenza vaccination
peaked in 2010 at 475 doses and Hematology/Oncology Influenza
vaccination peaked in 2011 with 73 doses. Over this same time
period, inpatient admissions rose by 14% on the Medical/Surgical
floors and 27% on the Hematology/Oncology floor. The five year
total inpatient Influenza vaccines administered in these two patient
populations were 1,385 doses of which only 37 (2.7%) doses were
live attenuated Influenza vaccine all of which were given to Medical/
Surgical patients. Staff Influenza vaccination rates increased over
this time period as well; from 60% to 98% coverage, most notably
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Breaking the Bloodstream Infection Connection:
Utilizing a Swab containing Chlorhexidine
Gluconate (3.15%) and Isopropyl Alcohol (70%),
Chlorascrub™
Deb Hillman, BSN, RN, OCN - BMT Clinical Educator,
Franciscan St. Francis Health
Issue: The 17 bed Bone Marrow Transplant unit at our hospital
admits hematology patients for routine and critical care. Most
patients have central venous catheters that may increase their risk of
developing bloodstream infections (BSIs). Recommended practice
guidelines to prevent infections were implemented, but infection
rates were higher than expected. An evidence-based intervention
was needed to help decrease the rate of infection. Project: The
central line insertion bundle and a transparent dressing following
recommended practice were already in place when our project
began. We realized that many patients are admitted with previously
placed and various types of central venous catheters, but we followed
published standard definitions for documentation of a hospitalacquired BSI. Improving bloodstream infection rates is always an
objective in the immunocompromised bone marrow transplant/
hematology population. The first intervention began by adding
a chlorhexidine-impregnated sponge to our dressing protocol.
Bloodstream infection rates improved, but our objective is to target
zero. Observation of practice identified that central line access hub
cleaning with an alcohol swab was inconsistently performed without
a standard scrub time. Literature review of current Centers for
Disease Control guidelines suggested that using a Chlorhexidine
Gluconate (CHG) product to clean the hub may be beneficial. A
swab with 3.15% chlorhexidine gluconeate/70% isopropyl alcohol
was selected to scrub the hub. Education was provided for use of the
swab that directed staff to apply pressure and friction in a circular
motion for ten seconds, then allow to dry for at least 30 seconds prior
to access of the hub or lumen. Patients in the unit were encouraged
to help count during the process. All alcohol swabs were taken out of
the patient rooms to ensure compliance. Results: Bloodstream
infection rates were significantly reduced after implementation of the
new practice for hub cleansing. We were able to obtain zero infections
for several months. Lessons Learned: Following published
practice guidelines plays an important role in preventing bloodstream
infections. Implementing an effective product, such as the 3.15%
Chlorhexidine Gluconate/70% alcohol swab for hub cleansing can
reduce central line associated blood stream infections.
blood cultures in the NICU. Results: During the first phase,
October 2006 through August 2007, we were unable to reduce
peripheral blood culture contamination rates. On the contrary, our
contamination rate increased from 5.19% to 6.30% of all peripheral
blood cultures drawn. Once the task of drawing blood cultures was
assigned to nursing instead of the phlebotomists, in mid-September
2007, the contamination rate immediately decreased. By September
2008, blood culture contamination rate in our NICU had decreased
by 53% from the baseline first phase (5.19%) to the second phase
(2.46%). Lessons Learned: At our institution, designating
a dedicated group of highly skilled neonatal nurses reduced the
contamination rate of peripheral blood cultures drawn on patients
in the NICU. We believe that this was the result of limiting the
variability in the skills of personnel drawing peripheral blood
cultures, as the skills of NICU nurses are more homogenous in
comparison to the phlebotomy team. Our project was successful by
having the front line staff engaged from the beginning, which enabled
us to identify specific problem areas.
Improving the Quality of Care by Reducing
Contamination When Drawing Blood Cultures in
the Neonatal Intensive Care Unit
JoEllen L. Harris, RN, CIC - Infection Preventionist, All
Children’s Hospital; Stacey Stone, MD - Attending Neonatologist,
All Children’s Hospital; Carine Stromquist, MD - Attending
Neonatologist, All Childrens Hospital; David M. Berman, DO Pediatric Infectious Disease Consultant, All Children’s Hospital;
Rajan Wadhawan, MD - Physician, All Children’s Hospital; Tracy
L. Hullett, RN - RN- Neonatal Intensive Care Nurse, All Childrens
Hospital; Valarie J. Snyder, BSN - neonatal staff nurse in NICU, All
Childrens Hospital; Lori Sammel, RN - Neonatal Intensive Care
Nurse-Charge Nurse, All Children’s Hospital
Issue: Most coagulase-negative staphylococci positive blood
cultures are considered contaminants in adult populations. Neonates
are more susceptible to infections caused by these organisms and
most positive blood cultures are considered to be actual infections,
with the patient receiving antimicrobial treatment. In September,
2006, we identified a possible increase in false positive peripheral
blood cultures. We did not monitor blood culture contamination
rates at that time and were unable confirm our suspicion. Our
Level 3 Neonatal Intensive Care Unit (NICU) initiated a quality
assurance project in order to establish a baseline contamination rate
and reduce peripheral blood culture contamination. Project:
We established a working group consisting of Infection Prevention,
Nursing, Neonatology, Laboratory Medicine and Infectious
Diseases in September, 2006. The purpose of this group was to
address the issue of blood culture contamination and to develop
and implement measures aimed at reducing contamination of
peripheral blood cultures in the NICU. This included establishing a
baseline peripheral blood culture contamination rate and a process
to monitor contamination rates on an ongoing basis. During the first
phase (September 2006 through August 2007) the interventions
were primarily focused on improving blood culture technique for
the phlebotomy team. The second phase interventions (October
2007- September 2008) were focused primarily on establishing a
small group of NICU nurses to takeover obtaining all the peripheral
Race and Ethnic Disparities in Hospitalizations with
Community-Acquired Infections
Christie Y. Jeon, ScD - Postdoctoral Research Scientist, Columbia
University School of Nursing; Matthew Neidell, PhD - Associate
Professor, Health Policy and Management, Mailman School of
131
Public Health, Columbia University; Denis Nash, PhD - Associate
Professor, CUNY School of Public Health, Hunter College; Elaine
L. Larson, RN, PhD, CIC - Associate Dean for Research, Columbia
Background/Objectives: Infections that require
hospitalization are costly and potentially life-threatening. Studies
show that rates of infections, such as sepsis and pneumonia, differ by
race and ethnicity. The disparity could be attributed to differences
in quality and access to care and/or pre-existing comorbidities that
are influenced by the larger socioeconomic and cultural context.
Objective: We compared the prevalence of community-acquired
infections (bloodstream infections (BSI), urinary tract infections
(UTI), pneumonia (PNEU)) by race/ethnicity and determined
the contribution of socioeconomic and comorbid factors to the
disparity in infection. Methods: Study setting: We conducted
a retrospective study of patients who were discharged from January
2006 to December 2008 from a large tertiary hospital that serves a
diverse population in upper Manhattan. Analyses were conducted
on 64,997 inpatients whose race/ethnic category was specified
and for whom data on age, sex, comorbid factors (diabetes, renal
failure, malignancy, transplant history, Charlson score), ZIP code
of residence, insurance status and emergency room referral were
available in the electronic health records. Methods: We used the
standard infection definitions as delineated by CDC’s National
Healthcare Safety Network and modified the definitions where
clinical symptoms were indicated. An infection that was confirmed
by culture within 3 days of admission was considered communityacquired. Prevalence of infections was compared between nonHispanic whites, non-Hispanic blacks and Hispanics by logistic
regression, with sequential adjustment for age, sex, comorbid
factors, neighborhood median household income, insurance status,
and emergency room referral. Results: The crude analysis
showed that non-Hispanic black and Hispanic inpatients were
more likely to be admitted with BSI (OR blacks=2.33, 95%CI
(1.93,2.80); OR Hispanics=1.89 (1.58,2.27)), UTI (OR blacks=2.37
(2.11,2.66), OR Hispanics=2.19 (1.96,2.45)), and pneumonia
(OR blacks=1.79 (1.32,2.44), OR Hispanics=1.35 (0.99,1.83))
compared to non-Hispanic whites. Adjusting for the covariates
attenuated the associations for BSI (OR blacks=0.95 (0.76,1.19), OR
Hispanics=0.84 (0.67,1.04)), UTI (OR blacks=1.01 (0.87,1.17),
OR Hispanics=0.92 (0.80,1.05)), and PNEU (OR blacks=0.73
(0.50,1.07), OR Hispanics=0.61 (0.42,0.89)). The largest reduction
132
in association resulted from adjustment for neighborhood median
household income, independent of comorbid factors. Adjustment for
emergency room referral led to further reductions in the disparity.
(See Figure for results on BSI). Conclusions: Discussion:
Marked differences exist in the prevalence of community-acquired
BSI, UTI and PNEU present on admission between non-Hispanic
whites, non-Hispanic blacks and Hispanics. The reduction in
disparity resulting from controlling for neighborhood income level
indicates that socioeconomic and cultural context could lead to
race/ethnic differences in infection risk independent of underlying
comorbid factors. Furthermore, the attenuation of the association
observed with adjustment for emergency room referral suggests that
blacks and Hispanics may be at greater risk of infection that require
hospitalization due to lack of primary care.
Epidemiology of Nosocomial Infections in Selected
Neonatal Intensive Care Units in Children Hospital
No1, South Vietnam
Nguyen Thi Thanh . Ha - Chief of INFECTIN CONTROL
DEPARTMENT, Children Hospital No1
Background/Objectives: This study aimed to determine
the epidemiology of nosocomial infections (NIs), common
microorganisms and cost. Patients included in the study were taken
from a newborn intensive care unit (NICU), in Children hospital
No.1. Methods: A prospective cohort study was performed.
The subjects were 892 neonates who were admitted to the NICU,
survived longer than 48 hours after transferred to another unit,
between Jan. 1. 2008 to Sep. 30, 2008. NIs were identified according
to the NNIS definition. Data were analyzed with descriptive statistics
by Stata 10. Results: Cumulative incidence rate for NIs was 12,4
NIs of 100 admissions, with a total of 111 infections for 892 patients.
The most common infections were pneumonia (50%), bloodstream
infection (31%), and Surgical site infection (10%). Major pathogens
were Gram-negative such as Klebsiella 87 (36,5%), Acinetobacter
spp 49 (20,5%). The factors associated with NI was also associated
with a significantly increased risk of definite infection (OR > 1.19,
95% CI > 1 and p< 0,05): birth weight, > 7 days of hospitalized,
CVC, mechanical ventilation, surgical. hospital stay (25 days for
Ni and 16 days for non Ni) and fiscal costs (19,9 million VN Đ for
NI and 6,5 million VND for non NI) of these infections are high.
Conclusions: Nosocomial infection is a serious problem for
neonates who are admitted for intensive care. Since it is associated
with increases in morbidity, both hospital stay and fiscal costs of
these infections are high. we need strategies for the prevention and
treatment of nosocomial infection.
Poster Abstracts: Specialized Settings (Ambulatory Care, Behavioral Health,
Long-Term Care, Home Care)
Gender Differences in Risk of Bloodstream
Infection
Bevin Cohen, MPH - Project Coordinator, Columbia University
School of Nursing; Yoon Jeong Choi, RN, MSN - Doctoral Student,
Columbia University School of Nursing; Sandra R. Hyman, RN,
MPA, CIC - Infection Prevention Specialist, NewYork-Presbyterian
Columbia University Medical Center, Associate in Medicine,
Division of Infectious Diseases Columbia University; E. Yoko
Furuya, MD, MSc - Medical Director, Infection Prevention &
Control, NewYork-Presbyterian Hospital; Matthew Neidell, PhD Associate Professor, Department of Health Policy and Management,
Mailman School of Public Health, Columbia University; Elaine L.
Larson, RN, PhD, CIC - Associate Dean for Research, Columbia
Background/Objectives: Previous studies suggest
that men are at higher risk for bloodstream infections (BSIs), but
findings are inconsistent and limited by small sample sizes and
inability to control for possible confounders. High body mass index
(BMI) increases risk of infection, so gender differences in obesity
prevalence may explain differences in infection risk. The purpose
of this study was to examine the association between gender and
incidence of BSI in a large cohort while controlling for a variety of
clinical and demographic risk factors, including BMI. Methods:
All patients >18 years discharged from one tertiary care and one
community hospital in New York City from 2006-2008 were
included in a database that captured electronically available clinical
and administrative data for each patient (N=89,347). Patients
who developed BSIs were identified using a previously validated
computerized algorithm based on the Centers for Disease Control
and Prevention (CDC) National Healthcare Safety Network
definitions. Logistic regression was used to test the association
between gender and BSI, controlling for a wide range of clinical
and demographic characteristics. Data on height and weight were
available for all patients who underwent a surgical procedure at the
tertiary care hospital (N=20,861). BMI was calculated for these
patients and categorized as underweight, normal weight, overweight,
or obese, according to CDC definitions. Relative risk (RR) of BSI
for females vs. males was calculated within each BMI category.
Results: Odds of BSI were significantly lower for women than
men in the crude analysis (odds ratio=0.73; p<0.01), and this
difference remained significant after controlling for admitting
and discharge diagnoses, preexisting conditions (e.g. diabetes,
malignancies), hospital interventions (e.g. intubation, surgery),
medications, device and catheter days, length of stay and intensive
care unit stay, costs incurred, and month/year of admission (odds
ratio=0.77; p<0.01). Obesity was more prevalent in women than
in men (29% vs. 25%) but overweight was more prevalent in men
than in women (40% vs. 30%). Men had significantly greater risk
of BSI within each category of BMI; RRs ranged from 0.37 to 0.63
(all p<0.01) and gender differences did not change linearly as BMI
increased. Conclusions: The association between gender and
BSI is robust and unlikely to be due to confounding.
Specialized Settings (Ambulatory
Care, Behavioral Health, Long Term
Care, Home care)
Seasonal Influenza Vaccine Compliance Among
Hospital and Non-Hospital-Based Healthcare
Workers
Terri Rebmann, PhD, RN, CIC; Kate Wright, EDD - Director,
Heartland Center for Public Health Preparedness, Saint Louis
University, School of Public Health; John Anthony - Emergency
Preparedness Manager, St Louis County Health Department;
Richard Knaup - Manager, Communicable Disease Control Services,
St Louis County Health Department; Eleanor Peters - Epidemiology
Specialist, St. Louis County Department of Health
Background/Objectives: Influenza vaccination among
non-hospital healthcare workers (HCW) is imperative, but only
limited data are available on factors affecting their compliance.
The objective of this study was to examine factors influencing
hospital and non-hospital HCWs’ influenza vaccine compliance
with the 2010/2011, 2009/2010, and H1N1 influenza vaccines.
Methods: A vaccine compliance questionnaire in the form of
online and paper surveys was administered to HCWs working in all
healthcare settings in St Louis, MO in March - June, 2011. McNemar
tests were used to compare compliance rates across the three types
of vaccine; a non-parametric test was chosen because the outcome
variable is dichotomous and it is a matched sample (same HCWs
over different time periods). Hierarchical logistic regression, stratified
by hospital vs. non-hospital work setting, was used to determine
a predictive model for 2010/2011 seasonal influenza vaccination
compliance. Good model fit, indicated by a nonsignificant chi square
value, was calculated with the Hosmer and Lemeshow goodnessof-fit test. Results: In all, 3,188 HCWs completed the survey;
half of which (n = 1,719) reported no hospital work time. HCW
compliance was highest for the 2010/2011 seasonal influenza
vaccine (78.9%, n = 2,514), followed by uptake of the 2009/2010
seasonal influenza vaccine (74.9%, n = 2,383), and lowest for the
H1N1 influenza vaccine (63.3%, n = 2,017); these differences in
compliance were highly statistically significant (p < .001) for all three
comparisons (2010/2011 vs. H1N1, 2010/2011 vs. 2009/2010, and
2009/2010 vs. H1N1). In logistic regression stratified by hospital
versus non-hospital setting, and controlling for demographics and
past behavior, the determinants of 2010/2011 seasonal influenza
vaccination among non-hospital-based HCWs included having a
mandatory vaccination policy (odds ratio [OR], 21 [95% confidence
interval {CI}, 6.7 - 64.4]), perceived importance (OR 7.6 [CI: 4.3 13.3]), no fear of vaccine side effects (OR 4 [CI: 2.3 - 7.1]), free and
on-site access (OR 3.3 [CI: 1.9 - 5.7]), and perceived susceptibility
to influenza (OR 2.4 [CI: 1.3 - 4.2]). Determinants of hospital-based
HCW vaccine compliance included having a mandatory vaccination
policy (OR 32 [CI: 8.4 - 118.7]), belief that HCWs should be
vaccinated every year (OR 4.3 [CI: .11 - .50]), occupational health
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encouragement (OR 2.9 [CI: 1.3 - 6.7]), perceived importance of
vaccination (OR 2.9 [CI: 1.1 - 7.6]), on-site access (OR 2.9 [CI: 1.1
- 7.3]), and no fear of vaccine side effects (OR 2 [CI: 1.1 - 3.7]). The
final models correctly classified 78% of the non-hospital respondents
and 68% of the hospital-based workers. Conclusions:
Non-hospital-based vs. hospital HCWs’ reasons for vaccine uptake
differed. Targeted interventions should be aimed at workers in these
settings to increase their vaccine compliance, including implementing
a mandatory vaccination policy.
for proper work habits. 2. Monthly team meetings with a forum to
address ASC management. 3. Bug Bytes news letter. 4. Daily safety
calls. Lessons Learned: The monthly meetings have allowed
great working relationships to develop resulting in the sharing of
information. Site visits continue quarterly and aim for continous
readiness for inspections. “Bug Bytes” and the safety calls are two
more effective communication tools.
Infection Prevention Communication Within a
Health Sytem’s Ambulatory Surgery Centers
Barbara Doerflein, BSMT (ASCP), CIC - Infection Preventionist,
Novant Health, Charlotte, NC
Issue: Ambulatory surgery became a separate department within
our health system in the fall of 2010. The vice presidents of clinical
operations and business development established a team which
included the nine ambulatory surgery center (ASC) administrators,
a business analyst, a director of operations, and representatives from
anesthesia, IT, regulatory, human resources, finance and infection
prevention. January, 2011 was when the work began to learn the
business of ambulatory surgery and meet the infection prevention
needs of our centers. Infection prevention was seen as an important
focus with the recent outbreaks of bloodborne pathogens in
ambulatory settings in the last few years. A critical need was effective
communication. Project: Initially, communication involved
visiting all the ASCs and meeting with the adminstrators and the on
site person(s) responsible for infection prevention. This provided
an opportunity to inspect the center using the CMS survey tool,
review policies and procedures, and observe staff for good infection
prevention work habits. Monthly team meetings took place either
in person or by conference call and provided a forum to present new
initiatives or educate administrators about subjects such as record
keeping, surgical site infection surveillance, or disinfection. These
meetings allowed for the sharing of information and networking.
Another communication device employed was the development
of a newsletter called “Bug Bytes” which was sent out as an email
attachment. The first edition was an update on issues that had
been identified that needed addressing such as contact precautions
being implemented on patients that were known MRSA or VRE
colonized patients and continuing education such as the “One and
Only Campaign “ from the CDC. Other editions have explored
sugical site infection surveillance , an anesthesia infection prevention
checklist, and sharps safety in the ASC. The administrators share
these newsletters with staff. Our health system puts great emphasis
on patient safety in the hospital and has a daily safety call that
includes a representive, usually the department manager, from each
unit and service. This has also been adopted by the ASCs with each
administrator reporting on his or her center, any safety issues or great
service events of note. Infection Prevention is a part of this call and
it is a quick way to find out if there are issues that need addressing.
Results: Four communication methods evolved over the course
of the year: 1. Site visits to inspect the physical plant and observe staff
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What Is Wrong with Using a Dishwasher to Clean
My Instruments?
Linda S. Roach, BSMT, CIC - Infection Prevention, Novant
Medical Group
Issue: In 2010 a physician office group comprised of 300+ practices
added an Infection Prevention Consultant position. One of the
first opportunities discussed was the need to identify the number of
practices that performed reprocessing and to assess their compliance
with recognized standards. An initial survey was distributed and 111
offices responded that they either sterilized or high level disinfected
instruments. On-site visits were scheduled with each practice to
assess their space and processes. While it quickly became obvious that
many office settings are not appropriately set-up for reprocessing, it
was further evident that staff needed training as related to high level
disinfection and sterilization. Employees performing this function
were typically given verbal instructions covering the basic process
with few written procedures. The consultant also found that in offices
using endocavitary probes or CPAP masks, the vendor representative
was the person who provided instruction on disinfection, which
was not always in compliance with the manufacturer’s instructions.
Knowledge deficits were identified in aseptic technique, instrument
decontamination, and sterilization process monitoring. As an adjunct
to the observations, the consultant serves as faculty for the North
Carolina Infection Prevention Course for Outpatient Settings and
receives many questions regarding reprocessing from attendees.
Project: To address identified knowledge deficits, the Infection
Prevention Consultant developed two self learning activities (SLA)
for office employees. The first SLA dealt with decontamination. It
included discussion on the importance of decontamination, basic
decontamination steps and the proper use of personal protective
equipment. The second education tool focused on the sterilization
process. The principles of steam sterilization were covered along
with the types of process monitoring recommended. Information
on packaging, loading the sterilizer and maintenance were provided.
Links to corporate policies were included. Each activity included
a post-test and evaluation. Materials were emailed to practice
managers and clinical leads with a 30 day window to complete the
activities. Results: Following the initial assessments and SLA
offering, subsequent visits have revealed improved understanding
of decontamination and sterilization processes. Staff question
appropriateness of processes and seek confirmation that they are in
compliance. The SLAs were also favorably received by employees.
The SLA evaluation included the question “I am satisfied with this
self-directed learning activity”. For the Decontamination SLA,
66% of respondents Strongly Agreed and 34% Agreed with the
statements and for the Sterilization SLA 75% Strongly Agreed while
25% Agreed. Lessons Learned: Many physician office staff
members have significant knowledge deficits concerning reprocessing
procedures. Educational materials appropriate to the office setting
created an opportunity for improving processes and were well
received by employees. Additionally, the SLAs have been converted
to an on-line module available through a corporate intranet site to
facilitate availability and tracking completion.
Effectiveness of a Comprehensive Hand Hygiene
Program for Reduction of Infection Rates in a
Long-Term Care Facility: Lessons Learned
Steven J. Schweon, RN, MPH, MSN, CIC, HEM - Infection
Preventionist, Pleasant Valley Manor Nursing Home; Sarah
Edmonds, MS in Biology - Clinical Scientist, GOJO Industries,
Inc.; Jane M. Kirk, MSN, RN, CIC - Clinical Manager, GOJO
Industries; Douglas Y. Rowland, PhD - Consultant, D Y Rowland
Associates
Background/Objectives: Hand hygiene has been
recognized as the most important intervention for preventing the
transmission of pathogens in health care settings. Alcohol-based
hand rubs (ABHRs) play a key role in reducing the transmission
of pathogens and preventing infections in acute care settings,
especially as part of a comprehensive hand hygiene program. ABHRs
are associated with reduced hospital-associated infection (HAI)
rates, including respiratory tract infections, and those caused by
methicillin-resistant Staphylococcus aureus (MRSA). However,
their use and impact in long-term care facilities (LTCFs), where the
residents have increasingly higher acuity levels due to changing health
care delivery systems, has been virtually unstudied.
TABLES and Figures. Effectiveness of a Comprehensive HH Program
for Reduction of Infection Rates in a LTCF.docx
Methods: Infection surveillance data, including those meeting
McGeer et al. and the Pennsylvania Patient Safety Authority’s
reportable surveillance definitions, for lower respiratory tract
infections (LRTIs) and skin and soft tissue infections (SSTIs), as well
as hospitalization data were collected in a 174-bed skilled nursing
LTCF for 22 months (May 2009 and February 2011). In March
2010, a comprehensive hand hygiene program including increased
product availability (touch-free dispensers, alcohol based sanitizing
wipes, 2 oz. personal carriage bottles), education for health care
personnel (HCP) and residents, posters promoting hand hygiene, a
resident hand hygiene program, a monthly hand hygiene champion,
and an observation tool to monitor compliance, was implemented.
Results: Pennsylvania reportable infection rates for LRTIs were
reduced from 0.97 to 0.53 infections per 1,000 resident-days (P =
0.01) following the intervention; a statistically significant decline.
McGeer LRTI (non-pneumonia) also demonstrated a statistically
significant reduction. Pennsylvania reportable infection rates for
SSTIs were reduced from 0.30 to 0.25 infections per 1,000 residentdays (P = 0.65). There was a reduction with McGeer SSTIs that failed
to attain statistical significance. A 54% hand hygiene compliance
rate was observed among HCP. No statistically significant changes in
hospitalization rates due to LRTI and SSTI were observed during the
study period. Conclusions: This study demonstrates that the
use of ABHRs, as part of a comprehensive hand hygiene program for
HCP and residents, can decrease infection rates in LTCFs.
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Keeping our Eyes on TASS: Our Experience in the
Ambulatory Care Setting
Strengthening Healthcare-Associated Infection
Prevention Efforts in Rural, Small, and Critical
Access Hospitals in California through
Collaboration
Veronica Rose, RN, CNOR - Infection Prevention and Control
Coordinator, Saint Barnabas Ambulatory Care Center
Issue: Toxic Anterior Segment Syndrome (TASS) is an early postoperative complication of anterior chamber cataract surgery. TASS
is an inflammatory process causing decreased vision. It is reported
clusters range from a few cases to over 20 occurrences several times a
year in the USA. Investigations have demonstrated several causes for
TASS which include; abnormalities in the ph. or ionic composition
of irrigation solutions, ophthalmic viscoelastic devices, intraocular
medications, powdered gloves, or even the finish of an intraocular
lens. TASS has also been cited by many sources as occurring from
toxic residues on such as on improperly rinsed instrumentation or
soaked in enzymatic detergents along with improper use of ultrasonic
units. Project: 1/7/2010 to 2/4/2010. 4 cases of TASS were
reported from 2 physicians. A team was assembled to evaluate current
practices. The team included; Infection Control, Nurse Executive,
Operating Room Manager, and Sterile processing Manager. Review
of sterilizers cleaning demonstrated no servicing for one week before
trays sterilized, all loads met parameters for sterilization, no closed
container/short cycle loads were used for any instruments utilized
in these cases. Our research on TASS lead to the following changes.
1. Modification of OR post procedural cleaning/rinsing practice.
Incorporate two basins of sterile water on back table for intraprocedural rinsing and a second basin for post procedural rinsing
with copious flushing. 2. Propose purchase of a separate ultrasonic
unit for only ophthalmic instruments. 3. Utilize filtered needles
for drawing medication. This practice decreases the possibility of
microscopic shards from entering with ampule opening and changing
to preservative free medications when available, i.e. epinephrine.
4. Evaluate all cleaning practices in sterile processing. 5/5/2010
and 11/17/2010. 2 more cases reported after above changes. Team
reassembled: Sterile processing Manager introduced to team a rinsing
system from a company. We contacted the company obtained a loaner
which flushes cannulated instruments with an enzymatic cleaning
solution as well as distilled water and air. After a trial of the Quick
Rinse System, we purchased 3 units; one unit for use in the Operating
Room for immediate use after manual rinsing post procedure. The
Second and third units were placed in the sterile process department
one in decontamination and the other in the sterile prep area. The
Staff continues to follow the previous steps along with using the
Quick Rinse Unit. Results: 11/17/10 -2012 There have been
no further incidences of TASS. The Quick Rinse system has been
successful in cleaning ophthalmic instrumentations along with all the
lumened instruments utilized in our Operating Room. Lessons
Learned: Review with the Operating & sterile processing staff the
importance of following all steps of decontamination and sterilization.
Meticulous removal of all viscoelastic, cleaning products and other
potential toxins is imperative for successful patient outcomes.
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Ian Kramer, MS - Health Policy Analyst, Office of Healthcare
Quality/Office of the Asssistant Secretary for Health/U.S.
Department of Health & Human Services
Nadine Simons, MS, RN - Regional Health Administrator, US
Deptartment of Health & Human Services - Office of the Assistant
Secretary for Health
Rani Jeeva, MPH - Team Leader, Healthcare-Associated Infections
Initiative, US Dept of Health & Human Services/Office of the
Assistant Secretary for Health/Office of Healthcare Quality
Lynn Janssen, MS, CIC - Coordinator, HAI Liaison Program,
California Department of Public Health, Center for Health Care
Quality
Issue: Healthcare-associated infections (HAIs) are a significant
cause of preventable injury and death. California recognized HAIs
as a significant public health issue and initiated assistance with HAI
prevention strategies through the California Department of Public
Health (CDPH) in the mid 1990’s. One obstacle faced is the large
number of rural, small, and critical access (RSCA) hospitals spread
over an extensive geographical area (>163,000 square miles). Of
California’s 427 hospitals, approximately one-third have less than
100 beds, 72 are designated rural hospitals, and 28 are critical access
hospitals (CAH). Due to many factors, including limited financial
and staffing resources and limited collaboration opportunities due
to geographic isolation, these hospitals may need assistance and
training to aid in HAI prevention efforts within their facilities.
Project: Through a project conducted by the U.S. Department
of Health and Human Services Office of the Regional Health
Administrator for Region IX (as part of a Regional HAI Prevention
program in the Office of Healthcare Quality) in collaboration with
CDPH, current HAI prevention infrastructure was expanded to
enable a targeted focus on assessing the needs of and providing
additional support to RSCA hospitals. The project, which began
in late 2010, initiated outreach (1-on-1 consultations) to RSCA
hospitals. In March 2011, in association with the Hospital Council
of Northern and Central California, six focus groups were convened
via teleconference with RSCA hospitals in California to perform
a needs assessment and determine interest in a statewide HAI
Prevention Collaborative(s).Results: 71 healthcare providers
from 51 hospitals took part in the focus group discussions. The
size of participating hospitals ranged from 10 to 153 beds plus one
600+ bed hospital from a predominantly rural county. Excluding
the 600+ bed hospital, the median hospital size was 46 beds; 35
(69%) hospitals identified as rural, of which 15 (43%) identified
as CAH. 22 (43%) hospitals described past experiences with HAI
prevention interventions, with the most common infection or care
process target being central line-associated bloodstream infections.
11 (50%) of those hospitals with past experience stated they were
still “working on” one or more targets that required improvement.
A majority of respondents favored participating in a RSCA-focused
HAI prevention collaborative.Lessons Learned: Less than
half of participating hospitals reported recent experience with a
HAI prevention initiative and 50% of those who have experience
state further improvement is needed. Even without experience
many hospitals expressed interest in further participation in a rural
collaborative HAI prevention network. In 2011 CDPH began the
California RSCA Hospital HAI Prevention Collaborative. Three
projects were launched based on the results of the focus groups:
Clostridium difficile prevention and antimicrobial stewardship, HAI
prevention best practices for California’s smallest hospitals, and
catheter-associated urinary tract Infection prevention through the
national “On the CUSP: Stop CAUTI” initiative.
incidence of MRSA; although, rates of transmission increased from
the initial 6-month study (0.56 to 0.88, per 1000 patient days)
this still represented an 82% overall reduction in incidence over a
33-month period (p<0.001, chi-square analysis). Conclusions:
Many health care institutions contend with endemic rates of MRSA
colonization. Few studies have been conducted investigating
sustainable control measures to prevent MRSA transmission among
elderly residents in chronic care facilities or nursing home settings. To
our knowledge, this is the first extended study highlighting the utility
of daily CHG bathing, as a standard of care in a geriatric setting, that
has resulted in a sustained significant decrease in MRSA incidence.
Sustained Reduction in Methicillin-Resistant Staphylococcus aureus
Incidence in a Geriatric Setting by Implementing Daily Bathing with
2% Chlorhexidine Gluconate Cloths
Jane E. Van Toen, BSc, MLT, CIC - Infection Prevention and Control
Practitioner, Baycrest; Heather L. Candon, MSc, CIC - Infection
Prevention and Control Practitioner, Baycrest; Chingiz Amitov,
MPH, CIC - Director, Infection Prevention and Control, Baycrest
Background/Objectives: We previously described a
reduction in the Methicillin-Resistant Staphylococcus aureus (MRSA)
transmission rate, from 4.99 to 0.56 per 1000 patient-days, in an
MRSA-endemic geriatric setting after the six-month implementation
of daily baths with disposable 2% chlorhexidine gluconate (CHG)
cloths. Daily CHG bathing was then continued as a standard of care
over an extended period of time and we report on the long-term
sustainability of this intervention. Methods: Previously, an
interrupted time-series design indicated daily CHG bathing cloths
(Sage Products Inc.) reduced MRSA transmission in an Acute-Care
and Transition (ACT) unit in a geriatric facility. The ACT unit is
an alternative to preventing an admission to an acute care hospital
for elderly patients with subacute or chronic disabilities requiring
assessment and treatment interventions. Patients on the study unit
had an average age of 87 years, with all patients being > 65 years.
Pre-intervention there were 169 admissions and post-intervention
1339 admissions. We continued to monitor MRSA transmission over
a 33-month period on the ACT unit. To assess MRSA transmission,
swabs were collected within 48 hours of admission, and on discharge.
MRSA-positive patients were placed on contact precautions.
The main outcome measure was the number of ACT-acquired
MRSA cases post-intervention. We considered p values <.05 to be
statistically significant. MRSA acquisition rates during the two study
periods were compared using a chi-square test. The t test was used to
compare demographic data pre- and post-intervention. Results:
Time periods for comparison were six months pre-intervention,
followed by a one-month washout when staff received training,
and 33-months post-intervention. Patient length of stay, MRSA
colonization pressure and patient demographics was comparable
in both time periods. Swab-collection compliance was 95% for
both pre- and post-intervention. We found continuing the practice
of daily CHG bathing as a standard of care sustained the reduced
Possible Rabies Exposure in a Community Living
Center: Considerations and Decisions for PostExposure Prophylaxis
Elicia A. Greene, RN, MSN, CIC, CPHQ - Assistant Chief,
Infection Prevention and Control, Central Texas Veterans Health
Care System
Issue: Appropriate management of persons potentially exposed
to rabies requires prompt evaluation with several factors for
considerations. The risk of infection (type of exposure, type of animal,
availability and rabies vaccination status of the animal involved in the
exposure, etc.) and the efficacy and risk of prophylactic treatment.
Bats are considered high risk. The animal was not available for
testing, thus post exposure prophylaxis (PEP) was recommended.
Specifically, the guidance footnoted, “In incidents involving bats,
PEP may be appropriate even in the absence of demonstrable bite,
scratch, or mucous membrane exposure in situations in which there
is reasonable probability that such exposure may have occurred
(e.g., sleeping individual awakes to find a bat in the room, etc.).”
Project: Geographically, our health care facility is located on the
migration route of bats. During a Friday morning report, the nurse
manager of a community living center unit on our campus reported
that two of her night shift staff members “killed a bat in a resident’s
room”. After further investigation, the bat was initially seen the day
before in the hallway and spotted flying into the resident’s room. The
resident was removed from the room. An exhaustive search did not
reveal the bat. The resident was placed back into his room. Close to
morning, the bat was discovered on the floor of the resident’s room
and was subsequently captured and released by the nursing staff
rather than killed as initially reported. The resident was an 89-yearold, demented, total care resident, who was unable to communicate if
there was contact between him and the bat. Due to the unavailability
of the bat and after further consultation with the Chief, Infectious
Disease and the Zoonosis Control Specialist at Department of
State Health Services (DSHS), post exposure prophylaxis was
recommended. Results: The resident’s provider was notified
of the recommended PEP guidelines and the resident’s next of kin
was contacted for disclosure and consent. Pharmacy obtained the
Human Rabies Immune Globulin (HRIG) and Rabies Vaccine. The
dosing schedule of the vaccine is day 0, 3, 7, and 14 and the HRIG is
a onetime dose based on weight. The resident tolerated the vaccine
series well. Lessons Learned: Staff released bat, thus unable
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Poster Abstracts: Staff Training/Competency/Compliance
to determine rabies status. All involved staff was educated on how
to handle encounters with bats and the importance of retention of
the bat for testing was emphasized. The Pest Control and Safety
Specialists completed a physical assessment of the area, to include
the roof, and concluded that the bat entered the building through
a skylight located in the dining area on the unit. Engineering staff
concurred and caulked the skylight.
Staff Training/Competency/
Compliance
Increasing Nurses’ Hand Hygiene Adherence in
Acute Care Settings
Trudy Marie-Kueker. Howard, DNP, MS, RN - University of
Minnesota
Issue: Hand hygiene is one of the most critical infection prevention
strategies against healthcare associated infections. Hand hygiene
by healthcare workers remains dismal, ranging from 5% to 81%
with an average of 40% nationally. Mortality associated with health
care related infections is 90,000 annually in the United States.
Strategies to increase adherence are crucial to reduce morbidity
and mortality. Hand hygiene is influenced by behaviors, attitudes,
beliefs, values, and pre-conceived barriers (Pittet, 2004; Whitby,
et al., 2007; O’Boyle, et al., 2001; Kretzer, et al). Worldwide 1.4
million people suffer complications due to infections acquired
while hospitalized ( Jarvis, et el., 1996; Stone, et al., 2002, & Raju,
1999). The Joint Commissions National Patient Safety Goal 7 is
to “Reduce the risk of health care associated infections” (The Joint
Commission, 2008). Behavioral models have varying degrees of
success in increasing and sustaining adherence (Aragon, et al., 2006;
Bischoff, et al., 2000; Creedon, Curry, et al., 2001; 2005; Erasmus,
et al., 2009; Gould, et al., 2007; Larson, et al., 1997; Larson, et al.,
2000; Lausten, et al., 2008; Mertz, et al.. 2010; O’Boyle, et al., 2001;
Pittet, 2004; Sax, et al., 2007; Whitby, et al., 2006). Studies that
apply behavioral interventions have been reviewed (Aboelela, et al.,
2007). No significant increases in H.H. was found in the literature.
The Social Cognitive Theory and Wheatley’s Change Theory
supported behavioral change in this project. Project: This project
was completed in an acute care hospital. Twenty-nine nursing staff
participated. Five educational interventions were implemented over
3 months. interventions included an educational video, Easter Egg
fortunes which included hand hygiene “tidbits” on guidelines and
recommendations (and chocolate); collaboration with staff to culture
routine objects in the environment, and viewing of results in staff
meeting; APIC brochures on hand hygiene; and Joint Commission
hand hygiene buttons. Hand hygiene adherence did not increase,
it decreased on post observations. CNA staff was enthusiastic as
the project unfolded and actively participated in the agar culturing.
Results: Hand hygiene decreased from 64.3% in pre-intervention
observations to 42.6% in post observations. Behaviors associated
with an increase in adherence did not improve significantly. RNs
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perceived their adherence significantly (p = 0.013), CNAs did not
(p = 0.408); CNAs increased adherence in post observations after
patient contact (p = 0.008). This suggests interventions had an affect
on CNAs but not RNs. One intervention, “Ask me if I’ve washed
my hands” buttons, only two individuals wore the buttons. This
suggests hand hygiene adherence is perceived by staff as not a priority.
Lessons Learned: 1. Interventions designed to increase
hand hygiene adherence need to be implemented over a longer
time frame. Ongoing, uninterrupted feedback may be necessary. 2.
Nursing unit culture needs to be understood and addressed prior to
implementation of interventions to increase hand hygiene. 3. Prior to
increasing hand hygiene adherence, nursing staff behaviors, attitudes,
values and beliefs on hand hygiene need to be understood. These
behaviors affect the sustainability of hand hygiene adherence. 4. A
culture which encourages active verbal feedback among healthcare
workers (HCWs) on hand hygiene adherence is critically needed.
Bath Basins: Who Knows Where Evil Lurks
Renee L. Smith, MT(ASCP) - Infection Control Coordinator,
PinnacleHealth System; Lisa Snedeker, MT(ASCP) - Infection
Control Coordinator, PinnacleHealth System; Kimberly Rivera,
MT(ASCP) - Infection Control Manager, PinnacleHealth
System; Tina Willier, MSN, RNC-NIC - NICU Nurse Manager,
PinnacleHealth System; Mary Lou Mortimer - Staff Development
Instructor, PinnacleHealth System
Issue: Upon discovering that there was no written process in
place for the storage and cleaning of bath basins, it was decided that
this topic would become the focus for the August 2011 monthly
Infection Control Department’s Nursing newsletter. This edition
included recommendations for disinfecting and storing bath basins.
In response to the newsletter, the Nurse Manager of the Neonatal
Intensive Care Unit (NICU) contacted Infection Control requesting
to culture bath basins. Coincidentally, Nursing was planning to
implement an Incontinence Care Process which included a procedure
for bath basin disinfection. The new process was introduced to
Nursing Leadership in October 2011 with a go-live date of November
1, 2011. This study would determine if bath basins in the NICU
were colonized with bacteria that could potentially lead to hospital
associated infections. Project: This project was conducted in a
thirty-two bed Level 3 NICU. Current practice in the NICU was
to use a single bath basin for the duration of the baby’s admission, or
until the baby was big enough for a larger bath, and the basin was no
longer necessary. The basins were rinsed after each use, dried with a
paper towel, and placed in a drawer by the isolette. The basins were
then used to store various personal care items including, but not
limited to, body wash, tape measures, combs, sleeper outfits, wash
cloths, etc. A total of thirty bath basins were cultured over a fourweek period. Basins were tested if the baby had been in the NICU for
at least one week. The Microbiology Laboratory performed empirical
identification for all organisms, and also tested for MethicillinResistant Staphylococcus aureus (MRSA) and Vancomycin Resistant
Enterococcus (VRE). Results: Nineteen of the thirty basins (63%)
that were cultured grew one or more types of bacteria. 84% (16/19)
of the basins grew normal skin flora including coagulase negative
Staphylococcus, Corynebacterium species, Bacillus species, and alpha
hemolytic Streptococcus. MRSA was isolated from one of the basins
(5%) and gram negative bacteria including Pseudomonas aeruginosa
and Escherichia coli were isolated from 11% of the basins that grew.
Lessons Learned: This study demonstrated that improperly
disinfected bath basins in the NICU are a potential reservoir to a
variety of pathogenic bacteria that could lead to hospital associated
infections.
Improving Hand Hygiene Practice through
Utilization of Automated Hand Hygiene Monitoring
and Feedback Technology
Candie B. Northey, RN, BSN, CIC - Assistant CNO, Director
Infection Prevention, Critical Care & Education, Andalusia Regional
Hospital - Lifepoint Hospitals
Background/Objectives: Healthcare regulatory agencies
identify effective hand hygiene as the single most important way
to reduce infection risk, yet high levels of sustained hand hygiene
compliance remain elusive in healthcare facilities. A 2010 Infection
Control and Hospital Epidemiology study systematically reviewed 96
empirical studies on hand hygiene adherence and found the median
for hand hygiene compliance was found to be only 40%, with 72%
139
of the studies reporting compliance rates of 50% or
less. This study describes the use of an automated
hand hygiene monitoring to improve hand hygiene
performance and positively affect patient perception
of caregiver behavior. Methods: Researchers
conducted a prospective case study of the effects
of electronic surveillance technology on hand
hygiene activity using soap and sanitizer dispenser
counts and patient satisfaction survey results. The
hand hygiene monitoring technology consisted of
a wireless network, active communication display
units adjacent to dispensers, radio frequency
identification (RFID) tags, and existing sanitizer
and soap dispensers. Personal RFID tags worn
by healthcare workers were used to measure the
number of times caregivers engaged in hand hygiene
activities. The system recognized the healthcare
worker in the patient room, the time spent in the
room, hand hygiene solution dispenses and whether
soap or sanitizer was used. Patient perception of
hand hygiene activity associated with use of this
system was measured by the frequency of the patient
response of “always” on the patient satisfaction
survey tool question, “How often did the patient
care staff wash their hands or use an alcohol hand
rub before providing patient care?” Results:
At the end of the six month data collection period,
researchers noted an 82.6% increase in both soap
and alcohol based hand sanitizer dispenses when
stratified by admission. Patient satisfaction survey
results where the patient responded “always”
increased by 9% overall. Conclusions: The
implementation of an electronic hand hygiene
monitoring device resulted in an increase in hand
hygiene compliance and soap and sanitizer usage.
This confirms numerous studies that indicate
that while hand hygiene education is important,
compliance improves to a greater degree when
personnel are monitored.
140
Use of an Electronic Survey Instrument to Determine
Barriers to Certification in Infection Control
Anne C. Maher, MS, M(ASCP), CIC - Infection Preventionist, APIC-Northern
New Jersey; Nancy Kerr, RN, BSN, CIC - President, APIC-NNJ; Laura Anderson
RN, MSN, CIC - APIC-NNJ; Norma Atienza, RN, BSN, MPA, CIC - APICNNJ; Jane Badaracco, RN, BSN, CIC - APIC-NNJ; Vicki DeChirico, RN, MSN,
CIC - APIC-NNJ; Mary Ann Kellar, RN, MA, CHES, CIC - APIC-NNJ; Judith
Leschek, RN, BSN, CIC - APIC-NNJ; Romeo P. Mamon Jr., RN, BSN - Infection
Prevention Practitioner, Atlantic Health System
Issue: One of our chapter goals for 2011 was to increase certification among our
membership. To determine how to best assist members to achieve and/or maintain
certification, the APIC-NNJ Board decided to query the membership. A survey was
designed to identify barriers to certification for our members, their preferences for
overcoming these barriers, and ascertain the value of certification to our members
and their employers. Project: The board of directors collaborated on appropriate
questions to include in the survey. Refer to Figure 1. The survey was then formatted
on an electronic survey instrument (Survey Monkey) and was made available to
chapter members for a four week period. Responses were then collected and collated.
The crosstab and filter features of the electronic survey instrument
were used to sort responses by healthcare setting, certification status
and years of experience in infection prevention practice. A spreadsheet
with all responses, as well as each question’s collated responses and
graphs were downloaded. Results: Seventy of 191 members
responded yielding a 37% response rate. Refer to Figure 2. The most
frequent reported barriers to certification were cost of the test and
fear of tests (48.4% each). Although a large number of respondents
(36.8% and 32.3% respectively) also reported lack of familiarity
with test content and lack of experience as barriers (refer to Table 1).
Less experienced IPs (Infection Preventionists) tended to cite lack
of experience more frequently. Respondents from areas other than
acute care expressed concern that the certification exam covers areas
of healthcare outside their current practice setting. This survey also
indicated that fewer IPs are certified in healthcare settings with no
regulatory requirements for certification. Most respondents (79.7%)
indicated that study groups and educational sessions (71.2%) would
assist them in overcoming barriers to certification (refer to Table 2).
Among certified IPs there was a marked preference for the SARE
(Self-Achievement Re-Certification Exam) format for re-certification
despite comments on the difficulty of the SARE. Almost 96% of
respondents indicated that they considered certification beneficial
to the profession of infection prevention. However, less than 50% of
respondents are reimbursed for the cost of the exam, and only 32%
receive an incentive for CIC certification. Lessons Learned:
Our results indicate that despite perceived barriers to CIC
certification, the overwhelming majority of IPs who responded to this
survey believe certification is beneficial to the profession. Based on this
survey the chapter has developed educational sessions to assist more
members to become CIC certified and maintain certification. It is our
hope that may serve as a model for other chapters to conduct similar
surveys that validate our findings and/ or identify other barriers to
certification and methods to overcome these barriers
staff to experience an enjoyable
educational experience.
BACKGROUND: The
Infection Prevention (IP)
Team had an opportunity
to position a table in the
cafeteria during Infection
Prevention Week, October,
2011. We seized the valuable
occasion to reinforce infection
prevention concepts and
emphasize our culture of patient
safety, while strengthening
communication between the IP team, hospital staff, and students.
We were determined to connect with students and employees by
encouraging the asking of questions related to infection prevention
and participating in a thought-provoking raffle/quiz. For Infection
Prevention Week in October, 2011, an ungraded, anonymous
raffle/quiz was developed that consisted of 8 questions related to
infection prevention (IP). The objective was to provide education
while reinforcing IP concepts in an enjoyable and friendly approach,
and questions were selected that were interesting and challenging.
The raffle entry was at the top of the quiz and a total of six prizes
were distributed. Hundreds of boxes of hand sanitizer wipes were
distributed, as well as buttons, stickers, and pamphlets. Results:
The Cafeteria Quiz was a huge success as each raffle/quiz entry
initiated dialogue between staff and the IP team. This provided an
important glimpse into areas where education was appropriate due
to the high level of interest the questions generated. We received
numerous requests for the quiz to be e-mailed to unit managers for
the purposes of future education. The IP team also wore badges
that stated “I had my Flu Shot” and we reminded staff to have
Food for Thought: The Cafeteria Quiz; an
Educational and Engaging Approach to Reinforce
Infection Prevention Concepts during Infection
Prevention Week
Eileen Yaney, MT(ASCP) MS, CIC - Director, Infection prevention
and Control, Saint Barnabas Medical Center; Rochel Shapiro, RN,
MSN - Nurse Intern, Saint Barnabas Medical Center
Issue: Providing education can be challenging because students
and employees have very little free time, and we wanted students and
141
their influenza vaccinations and provided information about flu
vaccination. Additionally, staff truly liked the self-sticking hand
washing signs to adhere above sinks. More than 350 students and staff
entered the raffle contest, which required filling out the raffle quiz to
win prizes, and a total of six prizes awarded. Lessons Learned:
The cafeteria quiz was a resourceful method to initiate meaningful
communication between the IP team, students, and employees.
The opportunity to discuss infection prevention issues with IP
staff reinforced our organizational culture of safety and instilled
confidence in staff that the IP team is friendly and approachable. The
interactive cafeteria quiz encouraged critical thinking, teamwork, and
peer-learning.
catheterization or reinsertion of an IUC. It appears as though
the initiative is impacting CAUTI rates which have continued to
decrease (Figure 1) but IUC device days remain high (Figure 2).
Results of a Hospital-wide Initiative to Decrease
CAUTIs
Diane K. Newman, DNP FAAN - Adjunct Associate Professor of
Urology in Surgery, University of Pennsylvania
Background/Objectives: Hospital-associated infections
from indwelling urinary catheters (IUC) are a major cause of patient
mortality and morbidity and are considered preventable patient
safety issues. The CDC HIPAC evidence-based (EB) guideline on
prevention of catheter-associated urinary tract infections (CAUTIs)
recommends care practices to prevent CAUTIs. Objectives of this
study were to determine if components of an EB hospital-wide
patient care initiative on prevention of CAUTIS are being practiced
on a daily basis, to determine if the CAUTIs rates and device days
had decreased, and to determine staff knowledge of prevention
of CAUTIs. The underlying hypothesis was that there would be
differences in IUC nursing care practices to prevent CAUTIs
between patient units with low CAUTI rates as compared to those
with high CAUTI rates. Methods: Prospective descriptive
study of patients with IUCs on eight units (4 high CAUTIs, 4 low
CAUTIs) as noted in Chart 1, in a large academic center located
in Eastern United States and the registered nurses (RNs) providing
direct bedside patient care on these units. Methods included
direct observations of IUC systems, an online survey of RNs and
monitoring of CAUTI rates and device days. Results: A total
of 91 IUC observations were completed, yielding 637 components
of IUC system care. The results of these observations indicate that
on all eight units, the majority of RNs practice EB patient care,
are following components of the EB initiative, and no differences
were seen between units with high and low CAUTI rates. A total
of 301 nurses (58% response rate) completed the survey noting an
experienced group of clinical RNs as seen in Chart 2. Only 7.0%
answered all EB questions correctly. Differences in knowledge
depended on the number of years the RN had practiced. More
inexperienced RNs (new to practice) would not independently
make decisions about IUC removal (p=0.000) without an attending
physician’s order. More inexperienced RNs do not feel they have
enough control over their practice to make decisions about IUC
removal even though protocols are in place and resources are
available. A higher percentage of experienced (RNs > 5 years) RN’s
(p=0.040) did not know the amount of bladder volume necessitating
142
Hospital
Competence Based Orientation Program
Sandra R. Hyman, RN, MPA, CIC - Infection Prevention
Specialist, NewYork-Presbyterian Columbia University Medical
Center, Associate in Medicine, Division of Infectious Diseases
Columbia University; Louise Kertesz, ANP, MSN, CNOR
- Clinical Nurse Specialist, NewYork-Presbyterian Columbia
University Medical Center; Patrica Nelson, RN, MSN, CNOR
- Perioperative Clinical Nurse Educator, NewYork-Presyterian
Hospital Columbia Medical Center; Audrey Compton, MD,
MPH - Quality/Patient Safety Manager, NewYork-Presbyterian
Hospital Columbia University Medical Center; Vicki AlmarezFox, RN, MPA - Director, Milstein Perioperative Services,
NewYork-Presbyterian Hospital Columbia University Medical
Center; John C. Evanko, MD, MBA - Vice President, Medical
Director, Milstein Perioperative Services, Attending Dept of
Gynecologic Surgery, NewYork-Presbyterian Hospital and
Columbia University
Judy Prescott, RN, BSN, CIC - Director, Infection Prevention
and Control, Baylor Health Care System; Margaret L. Martin,
RN, MSN, BC, CIC - Infection Preventionist, Baylor Medical
Center at Southwest Fort Worth; Stephanie Kreiling, RN, BSN,
CIC - Manager, Infection Prevention and Control, Baylor All
Saints Medical Center; Brady Allen, RN, BSN, CIC - Manager,
Infection Prevention and Control, Baylor Regional Medical Center
at Grapevine
Issue: Verifying competence of the Infection Preventionist
(IP/IPs) can be challenging due to work complexity. The Joint
Commission (TJC) standards require verification of competence
of the IP through “ongoing education, training, experience and/
or certification”. A fourteen facility healthcare system wanted to
provide consistency of orientation of the IPs. A team was selected
from varying sizes and types of facilities to develop a consistent
competence based orientation program throughout the system.
Project: The objectives for the Competence Based Orientation
Program were: • Standardization of orientation for all system IPs. •
Individualization of orientation and competence verification based
on needs of the local hospital. • Initiation of a supportive orientation
program with a preceptor that encouraged retention of qualified
IPs. TJC Standards, APIC references, NHSN processes and current
practice was incorporated into the measurable outcomes. Modules
were developed that included complex areas of practice. Essential
elements and outcome language was used for competence based
assessment and orientation tools. Clear terms for orientation and
continuing education were differentiated for the IP so that system
standardization was improved. A pre-assessment tool was developed
with essential competencies for a new IP. A post assessment was
developed to reflect the status at completion. The orientation period
timeline was defined and guidelines for the program were developed
to standardize the essential elements. In the trial group, the new
IP was assigned a preceptor and the tools were used. Comparison
of the pre and post levels was done to measure progress of the
IPs. The pre assessment was compared with the post assessment
numbers and a percent of improvement was calculated. Results:
All new employees showed significant improvement. The greatest
improvement was observed in those with less experience. This tool
has been beneficial in the successful orientation process of new
IPs and provides consistent evaluation of competence. Lessons
Learned: Competence based statements assist the new IP to
achieve the outcomes expected. Minimal competencies for the IP
position establish a foundation for future growth with continuing
education. Frequency of preceptor review of the competence
tool assists in completion of the orientation. The ability to show
improvement from the start of orientation to the completion of
orientation is essential.
Engaging Staff to be Responsible for Surgical Site
Infection Prevention in a Large Academic Tertiary
Issue: Engaging Perioperative staff to practice and empower
others to prevent and control infection is a struggle in large
tertiary teaching institutions due to rotations of residents and
students, as well as having large numbers of employees, visitors
and vendors . Institutions are searching for creative ways to share
policies and proper practices while using a surgical conscience
and empowering others to assume responsibility. Our institution
consists of a 692-bed adult academic acute care facility and a
283-bed pediatric academic acute care facility. There are 38 adult
operating rooms (ORs) and 8 pediatric ORs. Project: Our
Perioperative Services resources include a perioperative infection
preventionist, clinical nurse specialists , designated educators
for individual services , surgical champions and a Surgical Site
Infection Prevention task force. All play a tremendous role in our
efforts. Education is given monthly to the adult OR nursing staff
and every 1-2 months to the children’s OR nursing staff. Methods
for teaching have consisted of games, fairs, teaching during routine
rounds, as well as posting and reporting of results of SCIP core
measures, observations and Standardized Infection Ratios (SIRs).
Surgical conscience initiatives are posted. A monthly newsletter,
published by staff, provides key infection prevention “hot topics”
as a supplement. Instruction is given to new residents in small
group settings in the OR or classroom with return demonstration.
Educators have been trained by the Perioperative IP with ongoing
assessment to ensure consistency. Multiple attendings and residents
have been designated infection prevention champions. Their role
might include providing inservices, or gathering staff for programs.
Attending support is essential for mandating attendance. All
new General Surgery medical students receive classroom training
followed by return demonstration of surgical hand preparation
and self and assisted gowning and gloving in the ORs. Infection
prevention multidisciplinary task forces exist to develop practice
guidelines and implementation that are unique to their services.
Guidelines have been developed for; Cardiac surgery, Neurosurgery,
Urology; Penile implant, and Ophthalmology. Results:
Success of interventions are evaluated by the use of SIRs that are
benchmarked with other hospitals in our State. SIRs are calculated
by procedure as well as surgeon. Currently, reported SIRs fall
within the expected national outcome. Program participant
evaluations are analyzed and observation of compliance results lead
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to interventions and education planning. As a result of Perioperative
IP visibility, surgeons have requested observations and suggestions to
reduce their patient infections. Lessons Learned: Education
methods must vary based on available time and preferred methods
for learning. The audience must be assessed to determine their needs.
Compliance is achieved not only through traditional SCIP and SIR
surveillance but by ongoing observations of process measures for
compliance.
When You Don’t Know, What You Don’t Know
(Healthcare-Associated Infection [HAI] Knowledge
in Ambulatory Surgery Centers [ASC])
Amber Taylor, MPH - Health Policy Analyst, US Dept. of Health
& Human Services/Office of the Asst. Secretary for Health/
Office of Healthcare Quality; Rani Jeeva, MPH - Team Leader,
Healthcare-Associated Infections Initiative, US Dept of Health
& Human Services/Office of the Assistant Secretary for Health/
Office of Healthcare Quality; April Velasco, PhD - Deputy Regional
Health Adminstrator/Region II, Office of the Assistant Secretary for
Health/U.S. Department of Health & Human Services; Jonathan N.
Tobin, PhD - President/CEO, Clinical Directors Network, Inc
Issue: Historically, substantial emphasis on preventing healthcareassociated infections (HAI) has been placed on hospitals and longterm care facilities. However, HAIs occur in Ambulatory Surgical
Centers (ASCs), and are occurring with increasing frequency,
especially as more surgical procedures are being performed outside
of the hospital setting. As such, many ASCs and their respective
clinicians need to ensure that they have adequate knowledge and
training to implement evidence-based practices to prevent HAIs
in their facilities. Project: The U.S. Department of Health
& Human Services (HHS) Office of the Assistant Secretary for
Health (OASH) Region II (New York, New Jersey, Puerto Rico
and the Virgin Islands) received funding from the OASH Office of
Healthcare Quality (OHQ) to educate healthcare professionals and
administrators working in ASCs on HAI prevention and control.
An onsite training was held in NYC for participants in the NY and
NJ metro area. Satellite locations also received the same training via
simulcast for those who were not able to travel to NY. An online
enduring CDE-accredited training webcast is available at www.
CDNetwork.org. A separate Spanish-language training was also
offered in Puerto Rico using the same curriculum design used for the
NYC training. OHQ promoted the training more widely through
listservs, twitter, blogs, and other social media. A half-day trainthe-trainer (TTT) session was held following the main training
for participants to train their ASC staff on infection control and
144
prevention. Pre- and post- tests were conducted to evaluate changes in
each participant’s knowledge of HAIs in ASCs. Results: A total
of 103 ASC staff attended day 1 and 68 attended day 2 (TTT) for
the unique participants. The majority of participants who completed
both pre and post questionnaires currently spend <25% of their
time doing infection control activities (37% spent only 0-5 hours on
infection prevention). Pre-test: 39% completely disagreed that they
felt confident in their ability to explain state regulations on infection
prevention to others in their ASC, as compared to 51% post-test.
Pre-test: 49% of participants completely agreed that they are aware
of how to implement an infection control program in their ASC, as
compared to 63% post-test. Though there was a lack of knowledge
about some infection control practices and guidelines, both pre and
post-test showed that 100% of respondents completely agree that it
is important to follow infection prevention guidelines. There were
significant improvements seen in the following knowledge areas:
hand hygiene, safe injection practices, sterilization and disinfection.
Lessons Learned: More educational opportunities and
training, especially TTTs, need to be carried out in ASCs to ensure
that patients are not harmed, as well as protecting the healthcare
providers from HAIs in ASCs.
followed by Alcohol Based Hand Rub (ABHR) product and so team
should improve compliance to ABHR products as recommended by
CDC (since 2002) and by WHO (2006 and 2009).
Hand Hygiene Compliance and Variables of
Interest at Neonate Intensive Care Unit in a
Brazilian Hospital
Luciana Rezende Barbosa, PhD - Scientist, USP - GOJO; Adelia
Santos - Medical Doctor, Rumel Santos Healthcare Training and
Consulting; Sergio Colacioppo - Pharmacist, Faculdade de Saúde
Pública USP; Maria Albertina Santiago Rego - Medical Doctor,
Faculdade de medicina UFMG
Background/Objectives: Several factors influence hand
hygiene (HH) compliance and different variables can be evaluated
to improve quality of care assessment, to focus on the best training,
to incentive for performance improvement, outbreak investigation
and infrastructure design. Objective of this study was to describe
compliance to HH associated with variables of interest in a direct
observation (DO) study in a Neonate Intensive Care Unit in a Public
University Hospital in Brazil. Methods: Direct Observation
was performed by 10 validated observers. Variables were associated
with type of opportunity, professional category, and product used.
Statistical analysis used software Stata and SPSS for Windows and
Chi-square test. Results: 7,324 opportunities were identified
during 255 1 hour DO periods from Dec 2008 to Mar 2009. General
compliance to HH was 50,2%. 1) Compliance according to the
type of opportunity and professional category - *Others mean other
Professional Category that non nurses and medical doctors, like
physiotherapist, laboratory technician, speech therapist, etc. 2) Type
of product used (if alcohol based hand rub product or soap and water
or both) for HH in each type of opportunity 3) Professional category
x product used. Conclusions: Results evaluation helped the
infection control team to focus on training according to the needs
related to the type of opportunity and professional category. Results
also indicated that healthcare workers use to use soap and water
Maintenance of Environmental Services Cleaning
and Disinfection in the ICU After a Performance
Improvement Project
Teresa A. Fitzgerald, BSN, RN, CIC - Infection Preventionist,
The Nebraska Medical Center; Lee A. Sholtz, MSN, RN, CIC
- Infection Preventionist, The Nebraska Medical Center; Nedra
Marion, MPA, RN, CIC - Manager, Infection Control and
Epidemilogy, The Nebraska Medical Center; Paul Turner, CHESP
- Director, Environmental Services, Sodexo and The Nebraska
Medical Center; Philip C.. Carling, MD - Director of Hospital
Epidemiology, Caritas Carney Hospital; Mark E . Rupp, MD Medical Director of Infection Control and Epidemiology, The
Nebraska Medical Center
Issue: Performance Improvement projects (PIP) directed toward
improving the performance of Environmental Service (EVS) Staff
can be successful. Sustainability of performance improvement
is best ensured with permanent systematic changes and ongoing
monitoring and feedback. If performance levels decrease, actions
should be taken to assess the cause of the decline and to redirect
efforts to restore performance levels. Project: In a collaborative
effort, Infection Control and Epidemiology (ICE) worked with
EVS staff on a PIP to achieve optimal cleaning and disinfection of
ICU rooms. EVS staff were provided with instruction on cleaning
high-touch surfaces using a training video and cleaning checklist.
ICE staff marked 15 high-touch items in approximately 45 ICU
rooms each month with an ultraviolet-tagged marking solution
145
(DAZO®, Ecolab, St. Paul, MN), and evaluated results (using ultra
violet light) after terminal room cleaning. Results were shared with
EVS staff in face-to-face meetings on a monthly basis for 6 months.
Cleaning performance increased from baseline of 52% to a sustained
level of 80-85%. A maintenance program was then instituted which
included surveillance of 30 ICU rooms/quarter and feedback on
a quarterly basis to EVS administration. Results: After three
quarterly maintenance reports to EVS administration, cleaning
performance had declined to 57-66%. In an effort to restore cleaning
performance, ICE began reporting data including the room number,
the date the room was marked, the date the room was read, and the
cleaning results for the 15 marked items to EVS supervisors on a
monthly basis. This allowed follow up with individual EVS staff on
their cleaning performance. Also, the number of rooms marked and
read per quarter was increased to 45. The next two quarters showed
an increase in performance to 74% and 71% respectively. With
results being less than anticipated, and below optimum, a return
to face-to-face reporting was instituted. Lessons Learned:
PIP can be effective in achieving desired results, but maintenance
requires ongoing vigilance. Although quarterly feedback to EVS
administration was initially thought to be adequate maintenance,
we found this method to be inadequate in maintaining cleaning
performance. With the reporting of data to staff supervisors, cleaning
performance was not restored to previously observed levels. Faceto-face monthly reporting with EVS front-line employees has been
reinstituted with hopes this collaborative approach will increase
cleaning performance to optimum levels.
to reduce healthcare associated infections. The World Health
Organization established direct observation of hand hygiene practices
as the “gold standard” to measure adherence rates. The goal of this
study was to systematically observe hand hygiene compliance in all
of Maine’s acute care hospitals to develop a baseline by which to
measure effectiveness of interventions. Project: Four external
observers were trained by Maine’s state public health department
to use standardized definitions and reporting format developed by
an advisory group based on Healthcare Infection Control Practices
Advisory Committee and Joint Commission recommendations.
Observers visited all 36 acute care hospitals in Maine between
May-Nov 2011. Observations of hand hygiene compliance were
performed on three units for each facility (emergency department,
medical-surgical unit, and intensive care unit) for two hours per
unit. If units had low census, observations could be conducted
facility-wide. Data from this initial round were immediately shared
with the IP. Interventions were instituted dependent on the initial
findings. Observations were repeated on the same units at each
facility approximately 12 weeks later. Hand hygiene compliance
was calculated as the number of instances where hand hygiene was
observed divided by the total number of hand hygiene observations.
Facilities or units with at least 30 observations in each round that had
either 90% or higher compliance in both rounds or had improvement
of at least 25% from the first to the second round were asked what
interventions had been done. A list of effective and ineffective
interventions was compiled. Results: External observations
showed overall hand hygiene compliance statewide was 59% the
first round and 76% the second round, compared to an internal,
self-reported rate of 89%. Statewide, compliance was lower before
contact with the patient or patient’s environment (52% first round,
62% second round) than compliance after contact with the patient or
patient’s environment (67% first round, 87% second round). Hand
hygiene compliance in physicians (43% first round, 60% second
round) was lower than for nurses (66% first round, 79% second
round). Twelve hospitals met criteria for high compliance or great
improvement, as well as seven hospitals’ emergency departments and
seven medical-surgical units. Self-reported effective interventions
included linking compliance to employee performance evaluations,
changing product used, placing reminders near alcohol dispensers,
and acknowledging both compliance and missed opportunities
Lessons Learned: There is still much variation in hand
hygiene compliance between facilities, within facilities, and by
different health disciplines. Interventions that successfully improved
or maintained high hand hygiene rates were collected from hospital
IPs and will be used to further raise hand hygiene compliance in
Maine acute care hospitals.
State Public Health Department Performs External
Observations of Hand Hygiene Compliance in All
Maine Acute Care Hospitals, 2011
Donna Dunton, RN, BSN, CIC - Director of Infection Prevention
and Control, Eastern Maine Medical Center; Stefanie DeVita, BSN,
RN, MPH - CDC/CSTE Applied Epidemiology Fellow, Maine
Center for Disease Control and Prevention
Issue: Hand hygiene is the most effective prevention method
146
Transforming Regulatory Guidelines to Infection
Prevention Guidance
Debra Apenhorst, MA, RN - Infection Practitioner, Mayo
Clinic; Rebecca C. Faller, MPH - Community Health Education
Specialist, Mayo Clinic; Jean Wentink, MPH, RN - Infection
Preventionist, Mayo Clinic in Rochester; Vicky Shultz, MSN,
RN - Infection Preventionist, Mayo Clinic; Brenda Hansen, RN
- Infection Preventionist, Mayo Clinic; Kimberly Aronhalt, MA,
RN - Infection Preventionist, Mayo Clinic; Linda Diez, RN, CIC Infection Preventionist, Mayo Clinic
Issue: Healthcare is ever evolving and to remain current and
compliant requires monitoring and strict adherence to regulatory
standards and practice guidelines. As healthcare delivery transitions
across the continuum, practice must evolve to meet the changing
needs of the patient care experience. Patients, payers and the
public demand safer, more cost effective care, of which infection
prevention is an integral component. With approximately 1.7
million healthcare associated infections (HAIs) occurring in the
United States and 99,000 resulting in a patient death each year,
federal, state and institutional objectives are focusing on HAI
reduction. These reduction efforts may start as regulatory mandates,
but are actualized via Infection Prevention and Control (IPAC)
guidance and healthcare worker execution at the bedside. IPAC
staff work alongside healthcare workers with the common goal
to prevent disease transmission. Understanding the enormity of
regulatory standards expected of healthcare workers, IPAC staff
review guidelines and professional agency recommendations to
create policies that guide best practices. IPAC staff understand that
policies alone cannot drive practice. To promote compliance with
best practices, IPAC transform select policies into simplified tools
to support healthcare worker’s complex and multifaceted practice.
Project: The intent of the project is to provide healthcare
workers tools in the form of algorithms that simplify evidence-based
regulatory guidelines relating to infection prevention across the
continuum of patient care. These algorithms are incorporated into
education, institutional policies and guidelines. Complex infection
prevention guidelines and regulatory requirements are more easily
incorporated into practice work flow when converted into algorithms
that facilitate critical thinking. To develop the algorithms, IPAC
reviews pertinent regulatory standards, frequently asked questions
from staff, and opportunities for improvement found during unit
consultations. Feedback on algorithms is sought from Nursing and
other Allied Health staff. Upon recommendations the algorithms
are revised and implemented into education and practice. Multiple
algorithms are available on the Infection Prevention and Control
web site as tools to assist healthcare workers in providing patient
care in a manner consistent with HAI prevention. Algorithms are
presented to the appropriate procedural guidelines committee for
inclusion into applicable policies. Results: Multiple algorithms
are available on the Infection Prevention and Control web site as
a tool to assist healthcare workers in providing patient care in a
manner consistent with HAI prevention. Algorithms are presented
to a procedural guidelines committee for inclusion into applicable
policies. Lessons Learned: The algorithms have been wellreceived by healthcare workers as a tool intended to simplify, guide
and standardize practice. Seeking feedback from healthcare workers is
critical to develop effective tools. There is a continued responsibility
for Infection Preventionists to interpret regulatory standards and
translate them to meet the needs of healthcare workers. Future work
may include the validation of tool utilization, evaluation of their
impact on practice, and development of tools for additional settings
across the healthcare continuum.
Using Electronic Counter Device to Monitor Hand
Hygiene Frequency at Neonate Intensive Care Unit
in a Brazilian Hospital
Luciana Rezende Barbosa, PhD - Scientist, USP - GOJO; Adelia
Santos - Medical Doctor, Rumel Santos Healthcare Training and
Consulting; Sergio Colacioppo - Pharmacist, faculdade de Saúde
Pública - USP; Maria Albertina Santiago Rego - Medical Doctor,
Faculdade de Medicina UFMG
Background/Objectives: Monitoring hand hygiene
compliance by direct observation is part of several multimodal
hand hygiene promotion programs but difficult to perform during
healthcare workers (HCW) routine. Electronic counter devices (EC)
are being largely used to monitor hand hygiene (HH) frequency in
several healthcare settings. Objective of this study was to describe
the frequency of HH at different locations in a Neonate Intensive
Care Unit in a Public University Hospital in Brazil. Methods:
28 EC were installed inside coded dispensers filled with either
alcohol based hand rub product (ABHR) or soap. Number of HH
performed was checked each 24 hours. Descriptive statistics were
developed using software Stata and SPSS for Windows. Results:
The cumulative number of usages of each dispenser from December
2008 through March 2009 was plotted on the Pareto Diagram below
where dispenser #6 (soap) was used 18,902 times and dispenser #
147
28 (alcohol) was used nearly 100 times. Dispenser # 6 was a soap
dispenser located on the sink at the entrance of the unit where
everyone needs to perform hand hygiene and the dispenser # 28
was an ABHR dispenser located at a clean area where they receive
clean materials and then soap is more used than ABHR product.
Conclusions: This study helped the infection control team
to identify what products (if ABHR product or soap + water) were
used more often and what dispensers’ location were more likely to
be used by the health care team. The information gathered helped
the development of training sessions and re-location of dispensers to
more popular spots.
administered to staff that were in attendance. Results are currently
pending; this survey is intended to identify areas of strength as well
as areas for improvement for future presentations. Observations of
staff during the aseptic compounding process were also performed,
and compliance was recognized. Specific behaviors that had been
identified prior to the presentations were not observed upon followup at one year. Lessons Learned: Combined efforts between
pharmacy leadership and infection prevention in the education
of pharmacy technicians could lead to higher compliance with
regulatory standards. Visual demonstration of potential microbial
transfer during the compounding process presented technicians with
the opportunity to become aware of their role in infection prevention
and patient safety.
Infection Prevention and Pharmacy Compounding
for Regulatory Compliance
Ashley M. Clark - Pharmacist, Riley Children’s Hospital Inpatient
Pharmacy at Indiana University Health; Brittany Crumpacker, RN,
BSN - Infection Preventionist, Riley Children’s Hospital at Indiana
University Health
Issue: The compounding of intravenous products by pharmacy
personnel is guided by a strict set of guidelines called USP797. These
guidelines are rather strenuous for pharmacy technicians, and in
some cases, were being considered as excessive and unnecessary by
members of the pharmacy staff. In an attempt to positively influence
both attitudes and behaviors within the department, a demonstration
with Glo Germ™ was prepared to educate on the importance of these
guidelines as they relate to infection prevention and patient safety.
Project: The compounding processes of pharmacy technicians
were observed in an IV room which complied with USP797
standards. Compounding behaviors that did not comply with
infection prevention practices were identified and recorded. Using
Glo Germ™ within the IV room, an experiment was designed in order
to demonstrate the possible contamination of sterile compounds
when non-compliant behaviors were practiced. Glo Germ™ is a
fine, white powder which is hard to identify with the human eye,
but is visible under blacklight. Glo Germ™ was placed on products
around the IV room, specifically keyboards, phones, and vials based
on practices which had been observed by compounding staff. With
normal lighting and an environment meeting USP797 standards,
one dose was prepared following USP797 guidelines while another
was prepared using the identified behaviors during observation.
After completion of compounding, the lights were turned off, and
a blacklight was placed to identify the transfer of Glo Germ™ during
compounding. Pictures were taken, and a PowerPoint was created and
presented to pharmacy staff in order to demonstrate the importance
of proper compounding practices. Results: USP797 requires
monthly and yearly media fills that reveal no microbial growth in
order to assess compliance with aseptic compounding guidelines.
While there is no historical data for comparison coupled with an
elevated staff turnover rate within the past year, only two individual
samples of the monthly required media fills came back positive
for microbial growth. This is suggestive of high compliance with
USP797 standards and aseptic compounding practices. As a followup to the effectiveness of the Glo Germ™ presentation, a survey was
148
The Small Group Role-Playing Educations
Improved Hand Hygiene Compliance in Intensive
Care Unit
Yukie Mishima - Subdirector of Department Of Infection Control,
Jikei University Hospital; Ayako Saito - Department Of Infection
Control, Jikei University Hospital; Taku Tamura - Department Of
Infection Control, Jikei University Hospital; Toshiaki Okutsu Department Of Infection Control, Jikei University Hospital; Yasushi
Nakazawa - Director Of Department Of Infection Control, Jikei
University Hospital; Seiji Hori - Department Of Infectious Disease
And Infection Control, Jikei University School Of Medicine
Background/Objectives: MRSA remains a significant
problem for Japanese hospitals. It is well known that hand hygiene is
a key strategy to control MRSA, but the compliance of staff remains
low. Since our hospital confronted same situation, we thought
that our educational method was not appropriate and effective on
improving compliance. Therefore our hospital innovated small
group educations contained the role-playing method reflected
daily consecutive care. Our objective was to assess the impact these
educational method to control MRSA in ICU. Methods:
This study is an observational study before and after intervention
at ICU (20 beds surgical and medical ICU), Jikei University
Hospital in Tokyo. From 2009, we provided frequent small group
educations to staff working at ICU. These educations contained
the role-playing method, based on a scenario of usual daily care.
Furthermore the optical effect using fluorescent material applied
them to make bacterial contamination understandable. To examine
the educational effect, we measured the product use of alcoholic
hand hygiene solution and the hand hygiene compliances studied by
direct observation method from 2008 to 2011. We also measured
the annual incidence rates of new patient colonized or infected
MRSA in ICU. Results: The annual consumption index of
alcohol hand solution increased about three times during four years
(11.52/1000paitent at 2008, 20.9 at 2009, 27.3 at 2010, 33.7 at
2011). The hand hygiene compliance measured by direct observation
remained 42.5% at 2008, 34.0% at 2009, but increased after 2010
(54.5% at 2010, and 50.4% at 2011). Inversely annual incidence
rates of new MRSA patient showed decline (3.42/1000 patient days,
3.76, 1.95, 0.43). Conclusions: Our educational interventions
using small-group and role-playing method improved hand hygiene
compliance and MRSA transmission was suppressed in ICU.
catheters, use of bladder scanners, and accurate documentation in
the electronic medical record. Practice team champions provided
one-to-one education to all staff members over the course of a year
to the participating units. The education initiative included; upfront
education to all staff members, data updates per infection control to
unit manager, education of new staff, and communication on progress
to staff via unit/floor-based newsletters and department specific
intranet. Each participating unit showed at least a 50% reduction
in healthcare associated UTI rates doubling the initial goal of 25%.
Nursing staff had a better overall understanding of their impact on
the reduction and prevention of healthcare associated urinary tract
infections. The back to basics approach proved to have the greatest
impact on staff education and improved patient outcomes.
Collaboration Impacting Patient Safety: Infection
Control and a Unit Based Performance Improvement
Team Reducing Healthcare Associated Urinary Tract
Infections
Lori Coddington, MSN, RN-BC - Infection preventionist, West
Virginia University Healthcare; Dianne L. DeAngelis, RN, ICP,
CIC - Infection Preventionist, West Virginia University Healthcare;
Samantha Richards, MSN, RN - Director, 8th Floor & Dialysis, West
Virginia University Healthcare; Freda White, MSN, RN - Nurse
Manager, 8NE, West Virginia University Healthcare; Kathy Nigh,
RN - Infection Preventionist, West Virginia University Hopitals;
Jackie Sanner, RN - Infection Preventionist, West Virginia University
Hospitals
Issue: Each year, more than 13,000 deaths are associated with Urinary
tract infections (UTIs) and account for more than 30% of health care
associated infections reported by acute care hospitals. Based on these
staggering numbers presented by Infection Control, one nursing practice
team took a hard look at its own health care associated infection rates to
determine the best strategies to combat these occurrences. Project:
The overarching goal of the floor based practice team was to partner
with the Infection Control Department and identify ways to reduce
its hospital acquired UTIs. A collaborative review of data along with
identification of areas of improvement and action plan development; the
team set UTI reduction goal to reduce by 25%. Results: Infection
Control and the floor based practice team completed a review of the 2010
health care associated infection rates. The review included two acute care
medical-surgical units (58 beds), observation unit (10 beds) and stepdown unit (24beds). Team findings revealed a noted increase for the year
in UTI rates indicating an immediate need to decrease this percentage
and improve patient outcomes. Lessons Learned: Ultimately
a back to basics approach was utilized to identify areas of improvement
and to develop goals. The teams approach included; education related to
specimen collection/handling, review of catheter insertion/maintenance,
use of securement devices, prompt removal of all indwelling foley
Development of Index for Compliance on Hand
Hygiene Using a Nursing Need Degree and Hand
Hygiene Product Usage
Yoshiko Nabetani, RN, CNIC - Subdirector, Head Nurse; Hanako
Misao, RN, PHN, RNM, PhD - Professor
Background/Objectives: There is no gold-standard
method for evaluation of hand hygiene (HH) practice. Most
existing studies of compliance on HH have used a direct observation
method. However, the direct observation method requires an
immense amount of time and effort for infection prevention
practitioners. Therefore, we developed an indirect index for
compliance on HH using the Japanese version of nursing need
degree and the total amount of HH product usage. All Japanese
hospitals evaluate the nursing need degree of all inpatients every
day for medical service fee. Using the scores of nursing need degree,
each patient was classified into one of the five levels of severity.
Methods: Data collection was conducted at a medical and a
surgical ward of the Japanese university hospital. The procedures
for developing the indirect index were as follows: 1) to count
the number of HH procedures required for opportunities of
treatment and care (including chest tube dressing and bed-bath);
2) to select 10 patients at each severity level, and count the number
of opportunities of medical treatment and care extracting from
electronic medical records; and 3) to observe all the opportunities of
medical treatment and care among 10 patients at each severity level,
and calculate the average of the required number of HH procedures
of each severity level per day (the denominator). The numerator
was the values that the total amount of the HH products divided a
single dose. We conducted the direct observation method and the
indirect method for six months, and compared the rates of HH
compliance. Results: The total numbers of the required HH of
each severity level for medical patients per day were as follows: level
I 4, level II 11, level III 22, level IV 38, and level V 52. The total
numbers required for each severity level for surgical patients were
as follows: level I 4, level II 14, level III 17, level IV 36, and level V
68. The moving average rates of compliance at medical ward by the
indirect index were 37.5%, 23.2%, 24.4%, 31.4%, 28.6%, at surgical
ward 26.2%, 29.6%, 26.0%, 32.2%, 33.2%. The moving average rates
of compliance at medical ward by a direct observation method from
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May to August were 12.8%, 7.9%, 8.0%, 11.3%, 20.2%, at surgical
ward 28.0%, 15.2%, 13.0%, 24.4%, 26.2%. Conclusions:
As compliance on HH by a direct observation method is not
representative of its practice for 24 hours, the indirect index could be
used as an alternative method for evaluating HH practice.
Development of an Introductory Disinfection/
Sterilization Class in the Physician Office Setting
Laura L. Grant, RN - Infection Preventionist-Clinic, Aurora Health Care
Issue: Disinfection and sterilization of instruments and equipment
is a key component of infection prevention. In the physician office
setting, staff education is not always organized or consistent and
policies related to this area are sometimes focused on hospital
settings or non-existent. Staff resources for infection prevention
and education are limited. Project: A large healthcare
organization in Wisconsin which includes over 125 clinics hired an
infection preventionist in 2008 to manage the infection prevention
program for the outpatient sites. One of the first risks identified
in a survey of supervisors was the need for policies and education
on disinfection and sterilization practices. Site tours identified
similar risk areas such as lack of Personal Protective Equipment,
improper cleaning/disinfection product use, unacceptable clean/
dirty utility areas, improper instrument packaging/indicators and
autoclave use and maintenance. A curriculum was developed and
in 2009, education was initiated via a region-based six hour class.
The initial classes included education on the above topics, staff
hands on demonstrations and competency check-offs. These initial
classes also included instruction on endoscope practices for those
who were responsible for cleaning and disinfection. In 2010, the
class was revised to eliminate the endoscope section to decrease the
time of the classes and offer more sessions. The typical schedule of
classes was to offer at least one session in each of 4 regions across the
state in the spring and fall. Each session had a four hour section in
the morning and afternoon. Results: From 2010 to November
2011, over 300 RN’s, LPN’s and Medical Assistants have attended
the introductory class on Disinfection/Sterilization. The trained
caregivers are expected to be mentors at their sites until more staff can
attend the classes. They have identified various concerns and practices
which affect infection prevention such as exam room cleaning, hand
hygiene, aseptic technique, sterilization of specialty instruments and
injection safety lapses. Lessons Learned: During evaluation of
the classes, frontline caregivers have shared these observations: • All
staff should be required to take the class as it is sometimes difficult to
implement best practices with other staff. • They wanted more hands
on training on packaging of instruments. • They could state at least
one action they learned and could share at their sites. The instructors
have adjusted the focus to meet these needs: • The curriculum must
remain flexible to accommodate caregiver questions/concerns. •
Offering shorter sections allows for more staff to attend the class,
leads to supervisor satisfaction and good use of resources. • Policies
must be developed to meet the objectives of the program. • Annual
education is offered on various topics identified by staff to support
current skills and introduce other infection prevention best practices.
150
It’s Everybody’s Problem: A Collaborative
Approach to Hand Hygiene
Safiyya Nazarali, BScN, RN - Infection Control Practitioner,
Woodstock Hospital; Natalie J. Goertz, BScN, CIC Manager of Infection Prevention and Control, Woodstock
Hospital; Kishori Naik, BSc. - Infection Control
Coordinator, Woodstcok Hospital
Issue: In Canada more than 8000 patients die from health
care associated infections a year. Hands of health care workers
are the most are the most common mode of transmission.
The number one way to prevent infection is to perform hand
hygiene by using alcohol based hand rub or soap and water.
In 2009/2010 our hospital hand hygiene rates were at an
overall rate of 42% compliance. In 2010/2011, hand hygiene
was picked as a quality indicator with a goal to increase
our rate to 80% compliance. Project: Our aim was to
increase compliance rates but also implement a sustainable
hand hygiene program. In planning our initiatives we spoke
with other hospitals with successful hand hygiene programs
prior to developing our plan. Results: Successful hand
hygiene programs encourage involvement and ownership
from frontline staff. Unit auditors or ‘Germinators’ were
implemented. Staffs from inpatient units were trained to
observe and collect hand hygiene data. Binders were created
and left on each unit with reference material and this was a
place that ‘Germinators’ could drop off completed observation
sheets for IPAC to pick up. During IPAC week a matching
game was put together where staff had to match a various
leaders of our hospital with their hand hygiene message. Our
goal was to engage staff and show that that hand hygiene
impacts all departments. In addition, using case studies that
had actual outcomes of morbidity and mortality helped staff
to understand that infections do kill and that infections can
be prevented by hand hygiene. On Global Hand Hygiene day
we offered staff a chance to win 6 hours of free house cleaning
if they allowed IPAC to observe them for a few minutes and
provide on the spot feedback. This was well received by staff,
creating an environment where feedback was acceptable.
New pamphlets were implemented encouraging patients to
ask if their health care worker had performed hand hygiene.
Finally, our program tried to use positive deviance principals.
During audits, we highlighted staff that were “caught” with
excellent practice and were given a coffee/muffin voucher. In
addition, IPAC recognized one staff member per quarter as an
IPAC star. An article was written for the hospital newsletter
recognizing their contributions to positive outcomes for our
program. Lessons Learned: Our rates have shown that
staff involvement and ownership of hand hygiene rates does in
fact impact practice. Although our work is not done and hand
hygiene is a continuous battle, through our various initiatives,
by being visibly present, using positive reinforcement and
education we were able to see an increase in our hand hygiene
compliance, from 42% to 75%.
Poster Abstracts: Surveillance
Surveillance
A Ticket To Ride: A Colloborative Approach
to Infection Control Initiatives for a Hospital
Relocation
Natalie J. Goertz, BScN, CIC - Manager of Infection Prevention
and Control, Woodstock Hospital; Kishori Naik, BSc. - Infection
Control Coordinator, Woodstcok Hospital; Safiyya Nazarali, BScN,
RN - Infection Control Practitioner, Woodstock Hospital
Issue: Hospital relocation is a large undertaking for all involved,
yet there are few resources available to provide guidelines for proper
Infection Prevention and Control (IPAC) initiatives and patient
safety check points. Project: Numerous multidisciplinary teams
were formed 18 months prior to moving to the new hospital building.
A systematic approach was used to ensure IPAC input was included
in the planning of patients and equipment being moved. A clear plan
and schedule was developed with teams to address specific cleaning
and transfer roles. Various hospitals, which previously experienced
relocations, were polled, and their learnings were incorporated into
the move plan for our hospital. Infection Control orientation was
provided for all hospital staff and additional training programs were
provided to transport, cleaning and nursing staff. Results: A
global orientation was created to retrain staff on IPAC practice and
provide education to new policies and procedures pertaining to their
new environment. Case studies of hospital acquired infections were
used to futher impact staff on the importance of adhering to IPAC
policies and protocols. In addition, training sessions were created
for nurses and those transporting patients to increase awareness
of IPAC practice on move day. Results from our polls to various
hospitals found that use personal protective equipment (PPE) was
confusing for staff on move day. Subsequently when it was indicated
for isolation patients, supplies had already been depleted. To limit
confusion a “ticket to ride” poster was created and hung on the
outside of isolated patient doors identifying appropriate PPE for
both the transporter and the patient. On move day, after the final
roaster was made, IPAC placed the posters on the designated doors
and remained present for support on the unit the last patient had
been moved. Two separate staging areas were created for cleaning
stretchers/wheelchairs and various equipment. Clean and dirty areas
were clearly identified so equipment was not cross contaminated.
Three “Clean Teams” were created, one to clean patient transport
equipment, the second cleaning equipment prior to it entering our
new building and the third team was assigned to clean immediately
vacated spaces. Training sessions were created and implemented one
month prior to the move day. In addition, on the day of the move,
reference tools such as posters and IPAC personnel were available
for staff. Lessons Learned: Prior to relocating a hospital,
multidisciplinary teams are essential to foresee obstacles and planning
appropriate measures to mitigate potential problems. Training
sessions played a key role to prepare staff and alleviate anxiety.
Reference tools, such as the “ticket to ride” and posters for the clean
teams, were important for staff to refer too during the move. Finally,
it was essential to have multiple Infection Control Practitioners on
site to provide support.
Streamlined Emergency Department PostDischarge Surveillance Reduces Rehospitalizations
Lisa M. Pope, RN, BSN, MSN - TJC/Infection Prevention/EHS
Coordinator, Spectrum Health Reed City Hospital
Background/Objectives: This presentation looks into the
daily surveillance of positive cultures in the emergency department
setting. Previous to this program the inconsistency in which positive
cultures was addressed and antibiotic stewardship was seen showed
a large number of patients being placed on the incorrect antibiotic
for their positive culture result as well as the lack of follow up by
the hospital post discharge. it also addresses re-hospitalizations
related to these unaddressed issues. Methods: The setting was in
Reed City emergency department. The use of infection preventions
electronic surveillance program by both IP and nursing staff has
increased our compliance in addressing 100% of our post-discharged
patients positive culture results preventing a record number of rehospitalizations. it has built a new team work mentality, improved
patient safety, improved the health and wellness of the community
and the relationship with our consumers, and had a significant
financial impact on the hospital. Results: The outcome for this
project is 100% compliance with all discharged patients and the
addressing of their positive cultures that have resulted in a decrease
in infection related re-hospitalization from 19% down to 13%
since January 2011, and a annual cost savings of $438,000 for rehospitalizations that could have been avoided. Conclusions:
Cost savings of $438,000 for avoided rehospitalizations, 100%
compliance with antibiotic stewardship, improved teamwork
between nursing and physician practices, decrease in infection related
re-hospitalizations from 19% down to 13%.
151
Healthcare Associated Legionellosis Prevention
Within a Large Acute Care Center
Communication of Mrsa Status upon Transfers of
Ltcf Residents to an Acute Care Hospital
Jacqueline P. Butler, CIC - 2, CIC; 3, MLT (ASCP); Director, SH
Infection Prevention & Control, Sentara Healthcare
Zoran Pikula - ICP, North York General Hospital; Wil Ng, MHSc
- Epidemiologist, NYGH; David Kim - IS specialist, NYGH; Diane
White - Manager of IPAC, NYGH; Kevin Katz - Medical director of
IPAC; ID specialist, NYGH; University of Toronto
Issue: An estimated 8,000 to 18,000 cases of legionnaire’s disease
occur in the United States each year, 25-45% of which are health care
associated. Hospital surveys have detected Legionella contamination
of the water supply in 12-70% of hospitals. Transmission to patients
is felt to occur by inhalation of aerosols or ingesting contaminated
potable water containing Legionella and has been more closely
correlated with the number of sites testing positive rather than
the quantitative cultures; >30% of sites with positive cultures has
been associated with hospital acquired cases. (marking of resource
bibliography to be added at time of presentation). Project:
In November 1995, there were two cases of healthcare associated
Legionella pneumophila infections and one probable case of atypical
Legionella infection in a 525-bed tertiary care Level I Trauma Center.
The hospital complex consisted of patient care areas constructed from
1956 to 1993. In response to these cases, and in conjunction with
recommendations made to the facility Epidemiologist by CDC, an
intensive preventive program was initiated in December 1995. The
preventive program included monthly superheating (> 70 degrees C
measured at the outlet with a 10 minute flush) of the entire hospital
water system and monthly surveillance cultures. The entire hot water
system was inspected for “dead enders”, removal of all aerators from
faucets and emptying/cleaning of water tanks. In 2000, the local
city’s actions of switching the city water system from chlorination to
chloramination led to several years of eradication of Legionella from
the hospital potable water system. Results: Comparison of Water
Culture Results from Different Prevention Methods: Methods/ %
of positive cultures for Legionella species: Superheating (12/19959/2000) 51.1% (342/669) Superheating + monochloramination
(10/2000-2010) 0% (0 /560). We conclude that municipal
chloramination is a highly effective method of eliminating Legionella
from cultures of potable water in health care facilities. Lessons
Learned: After the change from chlorination to chloramination
from 10/2000 - December 2010, there were no positive cultures for
Legionella from the hospital potable water supply (0 of 560 cultures).
After cooling tower cultures were negative in 2001 and 2003, cultures
were discontinued. On resumption of cooling tower cultures in 2010,
4 of 8 cooling towers had cultures positive for Legionella with colony
counts ranging from 5 to 1,140 cfu identified. Despite draining and
mechanically cleaning all affected cooling towers and treatment with
stabilized bromine for 24 hours with repeat flushing and institution
of a dual alternating biocide program (oxidizing and non-oxidizing),
intermittent positive cultures were found in the cooling towers. We
conclude that municipal chloramination is a highly effective method
of eliminating Legionella from cultures of potable water in health
care facilities. However, even with the increased residual activity and
efficacy in biofilms of chloramines, Legionella can persist in cooling
towers requiring continued vigilance.
152
Issue: Acute care facilities face challenges with MRSA positive
residents transferred from Long Term Care Facilities (LTCFs),
particularly if their MRSA status is not known on admission. In
2004 and 2005 our admission screening data showed a high rate of
MRSA colonization among residents transferred from LTCF ‘A’
(35%). As a result, we implemented empiric contact precautions to
prevent transmission to other patients, similar to measures in place
for high risk direct transfers from out-of-country healthcare facilities.
In addition, MRSA PCR testing within 24 hours of transfer was
implemented for all LTC transfers and efforts were made to improve
communication of MRSA status during the transfer process to our
facility. We describe our experience over the last 5 years. Project:
Admission and screening data available on LTCF resident transfers
from January 2006 to December 2010 were reviewed. We determined
the incidence of unknown MRSA cases among residents transferred to
our acute care facility from any LTCF. We defined unknown MRSA
cases as those cases not identified on the transfer forms. MRSA
positive cases whose status was communicated upon transfer were
not considered ‘at risk’, and therefore not included in the analysis.
LTCF residents transferred to NYGH were tested by MRSA PCR
and confirmed by culture. MRSA admission screening data for the
general patient population (April-July 2008) were also analyzed
for comparison reasons. Results: Over the study period, 3049
residents from various LTCFs in Ontario were transferred to our
hospital. The number of these transfers increased steadily from 501
residents in 2006 to 768 residents in 2010 (53% increase) indicating
an increased burden for our ER and inpatient units. We identified 373
unknown MRSA cases among them (12%). We found a significant
decrease in the percentage of unknown resident MRSA cases
detected upon admission to our hospital from LTCF ‘A’, from 56%
in 2006 to 24% in 2010 (p<0.001). In addition, the percentage of
unknown MRSA positive cases among the residents transferred from
all LTCFs decreased significantly from 16% in 2006 to 9% in 2010
(p<0.001). This rate, however, is still higher than overall admission
MRSA prevalence in all patients without a known history of MRSA
colonization (1.4%). Lessons Learned: LTCF transfers to
acute care facilities can lead to unwanted MRSA exposures if MRSA
status is not well communicated upon transfer. Communication of the
status of known MRSA positive residents helps to avoid undesirable
MRSA exposures. Effective communication between sectors is
required and improvement is possible.
instruments. Methods: Surgical instruments used in this study
In Situ Detection of Residual Protein
Contamination on Surgical Instruments for
On-The-Spot Monitoring of Decontamination
Procedures
Helen C. Baxter - Senior Research Fellow, University of
Edinburgh; Robert L. Baxter - Professor, University of Edinburgh
Background/Objectives: Current methods for
detection of residual contamination on reprocessed surgical
instruments can no longer be considered adequate for quality
control in modern hospital decontamination units. Visual
inspection by trained operatives results in rejection of instruments
with surface protein loadings of >0.1 ug/mm2. Chemical
‘swabbing’ methods are less effective. We have developed a fast
and quantitative method for analysis of surface-bound protein on
reprocessed surgical instruments. This involves derivatization of
surface-bound protein molecules with a fluorescent reagent and
epifluorescence surface scanning (EFSCAN). This technique gives
a quantitative map of sub-nanogramme/mm2 concentrations
of proteins bound to instrument surfaces in a few minutes.
Objectives of the Study a) Determining the ‘current status’ of
residual contamination on reprocessed surgical instruments
using reprocessed instruments. b) Configuring the EFSCAN
instrumentation to give a pass/fail code for reprocessed
were cleaned by conventional procedures by Hospital Sterile Service
Departments. Labelling of residual contamination was carried out
by immersing the instrument in a (0.1%) solution of fluorescein
isothiocyanate (FITC) in carbonate buffer and rinsing with water.
EFSCAN was carried out using a custom-built scanner. Excitation
of the sample was at 468 nm and the fluorescence was detected
collinearly with the excitation. FITC-Bovine serum albumin (BSA),
153
dried onto stainless steel discs, was used for calibration. The limit
of detection was <10 pg/mm2.Results: A major problem in the
area of surgical instrument reprocessing is the definition of ‘clean’.
Figure 1 shows a typical SEM and elemental analysis of a reprocessed
surgical instrument, measured during a UK survey in 2004. This
instrument had passed visual inspection and chemical swab tests
but SEM examination showed it to have significant surface protein
contamination (ca 100 ng/mm2). This result was fairly typical
(reprocessed instruments normally have 50-120 ng/mm2 protein) but
this type of analysis of an instrument takes several hours. Our recently
developed EFSCAN technique gives fast and reliable quantitation
of residual protein contamination on instrument surfaces. The
layout of the scanner is shown in Figure 2. Using this technology we
have conducted a survey of reprocessed surgical instruments taken
from Scottish hospitals over the past six months. A typical scan of
a reprocessed instrument is shown in Figure 3. Sample results for
42 instruments are shown in Figure 4 and Table 1. Gratifyingly, our
results show much lower levels of contamination than the UK survey
of 2004 . Conclusions: We are now developing this technique
as a method of quality control – where instruments can be validated
on a pass/fail (green/red) system. This is exemplified in Table 1 for a
hypothetical pass/fail threshold of 1.5 ng/mm.
Multicenter Study of Hand Carriage of Potential
Pathogens by Neonatal ICU Providers
Yu-hui Ferng, MPA - Project Manager, Columbia University
School of Nursing; Sarah Clock, PhD - Project Coordinator &
Laboratory Supervisor, Columbia University Medical Center;
Jennifer Wong-McLoughlin, RN - Research Nurse, Columbia
University School of Nursing; Patricia DeLaMora, MD - Assistant
Attending Pediatrician; Assistant Professor of Pediatrics, Weill
Cornell Medical Center; NewYork-Presbyterian; Jeffrey Perlman,
MB, ChB - Professor of Pediatrics; Director of the Divison of
Newborn Medicine, Weill Cornell Medical Center; Kelly Gray,
RN - Neonatal Clinical Research Coordinator, Christiana Care
Health System; David Paul, MD - Associate Professor of Pediatrics;
Attending Neonatologist, Christiana Care Health System; Thomas
Jefferson University School of Medicine; Priya Prasad, MPH
- Research Associate, The Children’s Hospital of Philadelphia;
Lauren Miller, BA - Research Assistant, The Children’s Hospital of
Philadelphia; Julie Fierro, BA - Research Technician, The Children’s
Hospital of Philadelphia; Theoklis Zaoutis, MD, MSCE - Associate
Professor of Pediatrics and Epidemiology; Associate Chief, The
Children’s Hospital of Philadelphia; Setareh Tabibi, BA - Laboratory
Technician, Columbia University; Luis Alba, BS - Data Manager,
Columbia University; Susan Whittier, PhD, ABMM - Assistant
Professor of Clinical Pathology; Associate Director, Clinical
Microbiology Service, Columbia University; NewYork-Presbyterian;
Elaine L. Larson, RN, PhD, CIC - Associate Dean for Research,
Columbia University School of Nursing; Lisa Saiman, MD, MPH
- Professor of Clinical Pediatrics and Hospital Epidemiologist
of Morgan Stanley Children’s Hospital, Columbia University
Department of Pediatrics
Background/Objectives: Hand carriage of potential
bacterial pathogens by neonatal ICU (NICU) healthcare providers
is well documented and can be associated with infant colonization/
infection and outbreaks. We compared the rates and types of hand
flora among NICU providers in four level III NICUs. Methods:
We performed 4 surveillance efforts in each NICU from April 2010
to November 2011 and obtained cultures from the dominant hand
of 50 providers in each study NICU using the glove-juice method
(Larson E, et al. Arch Pediatr Adolesc Med 2005; 159:377-83).
Eligible participants included those providers with direct patient
contact whose primary clinical responsibility was in the study
NICUs (e.g., neonatology attending physicians and fellows, nurses,
nurse practitioners, respiratory therapists). Names of participants
were not collected and participants could be cultured during more
than one surveillance effort. Cultures were processed in a central
microbiology laboratory. Results: In all, 800 hand cultures
were obtained: 78% from nurses and 94% from women. Most
participants (mean 79%, range per effort: 68-90%) reported they
had performed hand hygiene within 15 minutes of obtaining hand
cultures. The proportion of cultures with normal flora and/or other
microorganisms during the four surveillance efforts is shown (Table).
The majority of cultures (99%) grew normal skin flora (defined as
coagulase negative staphylococci [CoNS] and/or diphtheroids).
The rate of recovery of normal flora was similar between sites and
surveillance efforts. Six cultures grew methicillin-resistant S. aureus
154
and one culture grew vancomycin-resistant enterococci. Among the
14 gram-negative bacilli detected, none were resistant to gentamicin,
ceftriaxone or meropenem. The proportion of cultures with specific
microorganisms was similar among the study NICUs during each
individual surveillance effort and also within individual NICUs
over time. However, when results from all of the surveillance efforts
were aggregated, the proportion of cultures positive for S. aureus
or streptococcal species differed among the NICUs (both P=.001).
Conclusions: In this multicenter study, few NICU providers
harbored potentially pathogenic flora (with the exception of CoNS)
and none harbored resistant gram-negative bacilli. Differences
in hand flora for some microorganisms, most notably S. aureus,
were noted among the different NICUs. We speculate that recent
performance of hand hygiene by participants removed potentially
pathogenic flora.
Survey to Determine Compliance with Center for
Disease Control Recommendation for Vaccination
of Adolescents
Christine Kettunen, PhD, MSN, RN, CIC - Director of Nursing
& Epidemiology, Ashtabula County Health Department; Rebecca
Robinson, RN - Public Health Nurse, Ashtabula County Health
Department; Katie McIntrye, RN - Public Health Nurse, Ashtabula
County Health Department; Cindy Anderson, BSN, RN - School
Nurse, Geneva Area City Schools
Issue: The Center for Disease Control & Prevention (CDC)
& the Advisory Committee on Immunization Practices (ACIP)
recommend that adolescents receive vaccination for protection
against tetanus, diphtheria, pertusis (Tdap), meningococcal
meningitis (MCV4), human papillomavirus (HPV), and influenza
(flu). Information released from the CDC in August 2011
demonstrated that approximately 30 - 50 percent of adolescents
are missing at least one of the recommended critical vaccines for
ages 11-12. Project: The county health department in a large
rural county developed a questionnaire to determine if parents
of adolescents are being provided with information from their
health care providers on the CDC recommendation for adolescent
vaccines and if so are their adolescents receiving the recommended
vaccines. The vaccinations on the questionnaire included Tdap,
MCV4, HPV, and flu. The questionnaire also provided a section
requesting parents to circle or write in the reasons for not having
their child receive one or more of the vaccination if the child hadn’t
received all recommended vaccinations. The questionnaire was sent
home with all seventh grade students in one of the larger school
districts in the county. The questionnaire was piloted with seven
sets of parents prior to mass distribution in the school district. A
letter explaining the current recommendations was included with
the questionnaire that was sent home to the parents. Students were
asked to return the questionnaire to the school by a specific date.
Results: 162 students were provided with questionnaires to take
home to parents. The questionnaire requested some demographic
information; however, names were not requested. All students who
returned questionnaires were asked to place the questionnaire in an
enevlope so they could remain anonymous. Students who returned
questionnaires could place their name in a separate envelope for a
chance to win a $25 gift card. 86 students returned questionnaries.
On returned questionnaires 70% of parents reported being aware of
the current recommendations for adolescent vaccines. 30% reported
not being aware prior to the information that was sent home.
Questionnaire results showed that adolescents had received some
of the recommended vaccines even if parents reported not being
aware of the recommendations. Approximately 78% of students had
received the Tdap vaccination, 46% received the MCV4 vaccination,
24% received at least one HPV vaccination, and 20% received
the 2011/2012 influenza vaccine. Lessons Learned: Most
parents are aware of the recommendations for Tdap vaccine and
their children have been immunized. Tdap vaccination became a
requirement for 7th grade entry in 2009. The primary reason parents
reported for not having children immunized with Tdap was that the
child had received Td vaccine within the past 5 years; therefore, the
vaccine wasn’t required for 7th grade entry. Parents are less aware
of the MCV4 recommendation as unawareness was reported as the
primary reason children were not immunized. Many parents reported
being aware of the HPV vaccine but choose not to have their child
receive the vaccine. Approximately 30% of parents cited vaccine
safety concerns as the primary reason for not having their child
receive HPV vaccine followed by the recommendation of their health
care provider to wait until the child is older or becomes sexually
active as the second most reported reason. The primary reason
reported for adolescents not receiving flu vaccine is parental belief
that the vaccine is unimportant followed by vaccine safety concerns
as the second most reported reason. Many parents have not been
educated on all of the CDC vaccine recommendations. Most parents
reported they would discuss MCV4 vaccine with their provider
since receiving the information included with the questionnaire.
Follow up with providers in the community to determine reasons
for not providing information to parents on all vaccines would be
appropriate. Additionally it is important to determine the reason
some providers are recommending waiting on the HPV vaccine.
Initiation of a community wide campaign for educating parents
on the current adolescent vaccine recommendation should be
considered. More detailed information on the importance for
vaccinating against HPV and flu is necessary including information
on vaccine safety. Partnering with schools to get information home to
parents regarding vaccines may help improve vaccination rates among
adolescents. Maximizing Office Based Immunizations (MOBI) is a
quality improvement program provided for immunization providers.
The program is an immunization education and training program
developed specifically for health care providers with the focus to
increase childhool immunization rates. Expanding the program to
include more focus on adolescent vaccines may be beneficial.
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Nurse Jackson- A Positive Deviance Success
Story
Tricia Hutton, RN - Infection Prevention and Control
Practitioner, Member of CHICA
Issue: To eliminate Healthcare Acquired Infections (HAIs) on a
LTC unit at Trillium using Positive Deviance. Project: Positive
Deviance (PD) is based on the notion that “in every community
there are certain individuals whose uncommon practices/behaviors
enable them to find better solutions than their neighbors who have
access to the same resources”. One PD technique is ‘Improvisation’.
At Trillium a group of staff, patients and families participated in
an Improvisation called “Beat It!”. This performance emphasized
poor Infection Prevention and Control (IPAC) practices of
“Nurse Jackson”. To Michael Jackson’s song “Beat It”, Nurse
Jackson enacted the spread of MRSA to another patient, staff and
surrounding environment. The exaggerated and humorous actions
of Nurse Jackson not only amused the audience but demonstrated
the seriousness of how easily the chain of transmission can be
broken. What’s most fascinating is that Nurse Jackson is neither
a male nor female; Nurse Jackson isn’t necessarily a nurse either.
The name Nurse Jackson has evolved into a ‘code word’ and/
or concept. As a result of the post-Improvisation discussion
amongst staff, patients and families, code word “Nurse Jackson”
has been established to identify gaps in IPAC standards and/or
practices. It promotes instant corrective actions by simply saying
‘Nurse Jackson’. It conveys a no-blame approach!” Results:
Nurse Jackson” has produced numerous positive outcomes. The
following are the findings of one year surveillance (May 2010-May
2011): • zero HAI rate (significant reduction in comparison to 5
HAI the year prior) • 3 months after code word “Nurse Jackson”
was initiated 31% indicated that they HAVE been called “Nurse
Jackson”, which resulted in heightening their awareness and
immediate improvement of IPAC practices. 8 months after 6%
indicated that they HAVE been called “Nurse Jackson”, signifying
a continued increase in heightened awareness and improvement
of IPAC practices. • Cultural shift from a closed culture to open
communication & collaboration. Continuous Discovery and
Action Dialogues (DADs) occur amongst staff which has resulted
in a significant improvement in creating a ‘no-blame’ culture. 8
months after introduction, 97% of staff surveyed indicated feeling
comfortable using “Nurse Jackson” to address IPAC matters.
Increase Inter-collaboration of staff “I feel I have a stronger voice
on the unit now and am a valuable contributor to the quality of
patient care delivery” –Sereena Johnson (Hospitality Associate,
Trillium) • 8 months after implementation, 100% of staff and
students surveyed agreed that the Nurse Jackson concept has/will
help to make Infection Prevention and Control a priority • PD
initiatives expanded hospital wide • Implementation of Education
Tool: Nurse Jackson Video presentation to students, new hires
and staff for educational in-services. • Senior Management
and Physician support and direct Involvement . Lessons
Learned: “Nurse Jackson” is a household name amongst staff,
some patients, families and Physicians. Involving frontline staff is
key in success and sustainablilty. Grassroots approach is key! We
love Positive Deviance!
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Utilizing an Electronic Surveillance System to
Automate Identification and Electronically Submit
LabID Event Data to the National Healthcare Safety
Network
Jennifer R. Peeples, MPH - Sr. Clinical Consultant-Infection
Prevention, Premier healthcare allicance; Kathy Roman - Manager,
Microbiology Laboratory, University Hospitals; Lisa Beno, RN,
MN, Alumnus CCRN - Director System Quality Initiatives,
University Hospitals; Pamela Parker, RN, BSN, MEd, CIC Director, Infection Control and Prevention, University Hospitals;
Julia Wendt, RN, BSN, CIC - Infection Control Nurse, University
Hospitals; Sarah A. Jadin, MPH, CIC - Sr. Clinical ConsultantInfection Prevention, Premier healthcare alliance
Issue: A large academic medical facility in the Midwest
participated in a state sponsored grant project that required
utilization of clinical document architecture (CDA) to electronically
submit methicillin-resistant Staphylococcus aureus (MRSA),
methicillin susceptible Staphylococcus aureus (MSSA), and C. difficile
Laboratory-Identified (LabID) events to the National Healthcare
Safety Network (NHSN). Project: The facility elected to employ
their electronic surveillance system (ESS) to meet the electronic
submission requirement. The ESS vendor developed functionality
that allowed the facility to automatically identify LabID events by
using the admission, discharge, and transfer (ADT) and laboratory
data sent from the facility to the ESS. The ADT and lab data was also
used to pre-populate LabID event forms within the ESS which were
made available to clinicians for review and modification. CDA files
containing the LabID event form data could then be generated for
subsequent import to the NHSN reporting application. Results:
The facility was able to successfully utilize the ESS to identify LabID
events, generate the events into a CDA file, and submit the LabID
events to the NHSN via electronic import. Lessons Learned:
The ESS contained all the data elements required to identify LabID
events and populate required fields on the event form, but there were
some challenges in implementing this functionality. Two aspects
of the LabID definition required development of complex logic in
the ESS to ensure each specimen was appropriately classified. The
first was the special case that classifies a specimen as a LabID event
if it is collected in an ED or outpatient location from a patient who
is admitted to an inpatient location on the same calendar day. The
second aspect requiring special logic is the application of the LabID
algorithm based on whether a facility is using the “by location” or
“facility-wide” reporting method. During development of the ESS
functionality, it was determined that values used by the NHSN for
body site and specimen type do not always align well with specimen
sources utilized by hospital laboratories resulting in several specimens
with a body site and specimen type of “unspecified”. Utilizing an ESS
to automatically identify LabID events, pre-populate event forms,
and generate files for subsequent upload to the NHSN results in time
savings by eliminating the need to manually identify LabID events
and enter event information into the NHSN reporting application.
In January 2013, the Centers for Medicare and Medicaid Services
(CMS) will require all healthcare facilities participating in the
Inpatient Prospective Payment System (IPPS) program to report
LabID MRSA bacteremia and C. difficile events via the NHSN.
Utilizing an ESS to identify and generate LabID events for electronic
import will reduce the burden on infection prevention staff in
fulfilling the reporting mandate.
Using an Electronic Surveillance System to
Generate Facility Specific Antibiogram Provides
an Accurate and Time Saving Tool for Clinical
Providers
Rhonda Mull, RN, BSN, MHA - Clinical Consultant-Infection
Prevention, Premier healthcare alliance; Sarah A. Jadin, MPH, CIC
- Sr. Clinical Consultant-Infection Prevention, Premier healthcare
alliance; Jennifer R. Peeples, Mph - Sr. Clinical ConsultantInfection Prevention, Premier healthcare alliance; Daisy Jackson,
Cic - Clinical Consultant - Infection Prevention, Premier healthcare
alliance; Pat Nimtz - Senior Manager Operations, Premier healthcare
alliance
Issue: A facility or community specific antibiogram is a tool
that is utilized to provide patients with appropriate antimicrobial
coverage for infections. This reduces the cost of health care and
improves patient outcomes by earlier intervention with the
appropriate treatment. Manually calculating the antibiogram is a
very time intensive process that involves many different departments
and individuals within a facility. We looked at the time spent on
antibiogram generation before and after the implementation of an
electronic surveillance system. Project: In 2008, a new process
was implemented at a greater than 400 bed facility in the New
England region of the US using an electronic surveillance system with
the ability to generate an antibiogram with customizable options. A
scheduled report was set up to generate the information 6 months
after submission of data began. The parameters of the report are
standardized to be in line with the Clinical and Laboratory Standards
Institute (CLSI) guidelines. Additionally, the electronic surveillance
system allows for stratification by specimen sources and locations.
Results: The new method of generating the antibiogram takes
approximately a quarter to a third of the time a manual process takes,
going from greater than 30 hours to less than 10 hours. Automating
the process provides the ability to generate an antibiogram quarterly
instead of yearly. The electronic surveillance system allowed for
stratification by specimen sources and locations, which most manual
processes do not allow for. Overall, using an electronic surveillance
system to generate an antibiogram provides more accurate
information as it relies on electronic calculations and diminishes
the human error factor. Lessons Learned: The benefits of
utilizing an electronic surveillance system to generate an antibiogram
is saving time and allowing timely intervention of the best treatment
options for identified infections. This leads to cost savings for the
facility in addition to improved patient care. Automating the process
provides the ability to generate an antibiogram quarterly instead
of yearly. A timelier antibiogram is more actionable and identifies
changes, patterns or developing trends in real-time as well as current
provider utilization. An important factor in correctly interpreting the
antibiogram data is understanding which drugs are being suppressed.
Overall, using an electronic surveillance system to generate an
157
antibiogram provides more accurate information as it relies on
electronic calculations and diminishes the human error factor.
Apples to Apples: A Model for Standardizing
Surveillance Throughout a Healthcare System
after Implementation of an Electronic Surveillance
System
Katie Wickman, MS, RN - Infection Preventionist, Advocate Illinois
Masonic Medical Center; Linda Stein, MPH, RN, CIC - Manager
of Epidemiology & Infection Control, Advocate Lutheran General
Hospital; Sinead Forkan-Kelly, BSEH, RN, CIC - Infection
Preventionist, Advocate Lutheran General Children’s Hospital;
Jean Watson, MT(ASCP), MPH, CIC - Infection Preventionist,
Advocate South Suburban Hospital; Karen Martin, MPH, RN, CIC
- Director of Epidemiology & Environmental Services, Advocate
Christ Medical Center; Katie Rivest, BS - Patient Safety Intelligence
Analyst, Advocate Health Care; Donna Currie, MSN, RN - Director
of Clinical Support Services, Advocate Health Care
Issue: The world of infection prevention is moving rapidly into
the electronic surveillance system (ESS) era. Benefits of ESSs have
been documented, and the Association for Professionals in Infection
Control and Epidemiology, Inc. advocates for their use. However,
after the implementation of an ESS, infection preventionists
(IPs) are left with questions about how best to use the system in
order to improve efficiency while maximizing utility. The issue is
compounded further when attempting to use the ESS to compare
hospital-associated infection (HAI) rates throughout a healthcare
system. While many articles discuss the resources needed to initially
implement an ESS, few articles discuss the process and challenges of
standardizing workflows after its implementation, especially across
a system. The IP team at a 10-hospital system created a model for
organization and standardization of the new ESS. Project:
Ten of 12 system hospitals simultaneously implemented an ESS in
July 2010. Experienced IPs with strong computer skills from 3 sites
were selected as ESS coordinators for the system. The coordinators
met regularly with a system administrator and the ESS program
manager to troubleshoot issues and create system-wide standard
processes and documentation expectations for the ESS. Workflows
based on National Healthcare Safety Network (NHSN) definitions
were developed for documentation of select HAIs and important
pathogens, and system-wide reports were developed based on
those workflows. After workflows were created, the coordinators
held classes for all system IPs that included ESS navigation,
documentation requirements, and case studies for each workflow.
The case studies tested both knowledge of the NHSN definitions
and documentation expectations in the ESS. Each hospital was
also assigned one coordinator through which to direct additional
questions, concerns, or enhancement requests related to the ESS.
Results: The ESS coordinator role provided a channel for IPs to
ask questions and provide feedback to a knowledgeable leader in an
organized fashion, allowing for timely responses and issue trending.
The team approach offered a centralized setting for communication
and troubleshooting with the ESS company. The standardization
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classes improved ESS proficiency and confidence among system IPs.
After standardization, HAI reports were abstracted directly from
the ESS by the program manager for benchmarking. Electronic
instead of manual data submission allowed for more timely and
robust HAI reports, and system stakeholders were able to view and
use the reports with greater confidence. Lessons Learned:
The effective introduction of an ESS to a hospital, and especially a
system, can be a timely and resource-intensive endeavor far beyond
its initial implementation. The creation of both a dedicated and
resourceful leadership team and an organized, standardized process
for surveillance and documentation are essential to mold the ESS into
a useable, reliable, efficient tool for the IP and system leader alike.
Dirty laundry? Evaluation of Clostridium difficile
contamination in the laundry at a long-term care
facility
Marguerite O’Donnell, RN, BSN, CIC - Infection Control Nurse,
Infection Control Department, Louis Stokes Cleveland VA Medical
Center; Jennifer Cadnum, BS - Research Assistant, Research Service,
Louis Stokes Cleveland VA Medical Center; Brett M. Sitzlar, BS
- Research Assistant, Louis Stokes Cleveland VA Medical Center;
Curtis J. Donskey, MD - Chair, Infection Control Committee, Louis
Stokes Cleveland VA Medical Center
Issue: Cultural transformation in the long-term care setting
encourages patient autonomy in activities of daily living. Because
residents of long-term care facilities may be colonized or infected with
healthcare-associated pathogens, there is a potential for transmission
of pathogens during activities of daily living such as washing clothes.
Our objective was to assess the frequency of contamination of patient
laundry facilities with Clostridium difficile and vancomycin-resistant
Enterococcus and evaluate the effectiveness of the washer for removal
of spores from contaminated clothing. Project: We performed
a point-prevalence culture survey of 4 patient laundry areas in a
long-term care facility that cares for patients receiving post-acute care
for rehabilitation or chronic care. The C. difficile infection (CDI)
incidence in the facility was 4 per 10,000 bed days of care. Clothing
of patients with CDI was cultured before and after washing and again
after drying. Before and after washing clothes from a CDI patient, the
inside and outside of the washer and dryer and the countertops were
cultured for C. difficile. Results: Of 19 sites cultured in the laundry
area during the point-prevalence study, 1 (5%) was contaminated
with C. difficile and 1 (5%) was contaminated with VRE. For 2 CDI
patients, 4 of 7 (57%) articles of clothing were contaminated with
C. difficile before washing versus 0 of 7 after washing. Nine sites
inside and outside the washer and dryer were negative after washing
the clothing of CDI patients. Lessons Learned: C. difficile
contamination was common on the clothing of residents with CDI.
However, contamination of the laundry area was relatively uncommon
and our data suggest that routine washing of contaminated clothing
may be effective in reducing levels of contamination. Further studies
are needed to evaluate the potential for transmission of C. difficile by
contaminated clothing.
Use of an Electronic Surveillance System to Further
Refine MDRO Isolation Categorization
Linda Nelson, RN - Infection Preventionist, Western Maryland
Health System; Brenda Gross, BSN, CIC - Infection Prevention
and Control Coordinator, Western Maryland Health System; Jamie
Karstetter, RN - Director Clinical Services, Western Maryland
Health System; Daisy Jackson, CIC - Clinical Consultant - Infection
Prevention, Premier healthcare alliance; Jennifer R. Peeples, MPH
- Sr. Clinical Consultant-Infection Prevention, Premier healthcare
allicance; Sarah A. Jadin, MPH, CIC - Sr. Clinical ConsultantInfection Prevention, Premier healthcare alliance
bacteremia elsewhere, when there are no confirmatory cultures. A
modified algorithm avoiding that subjectivity and at the same time
conserving resources had been deployed in a 660 bed metropolitan
acute care hospital. The resource intensive and process of intensive
chart review was initiated in 2009 in the adult and pediatric critical
care units and extended house-wide in 2010, when the latter rate
denominator changed from patient days of experience to central line
catheter (CL) days. CLABSI rates classifying only culture confirmed
infections at an alternative site as secondary BSI were compared with
those that met additional clinical criteria of an infection and whether
Issue: Based on review by the Pharmacy and Therapeutics
Committee and Infectious Disease, the laboratory standards for
defining gram negative multidrug resistant organisms (MDRO)
were revised at a large regional acute care health system serving a
three state area. Hospital policy requires all patients with a history
of gram negative MDRO to be placed into isolation precautions.
Project: All patients with a gram negative MDRO lab result are
routinely flagged in the hospital’s electronic surveillance system (ESS)
using a function called “tagging”. A readmission alert for patients
with this particular tag is used to identify them on return visits in
order to assure that isolation precautions are being followed. This has
been the practice for 2 years. After the laboratory standards for gram
negative MDRO were revised, the readmission alert was used as a way
to trigger a review of the patient’s gram negative MDRO history by
the Infection Prevention Department. Patients not meeting the new
definition for gram negative MDRO had their tag removed and were
not placed in isolation. Results: As of December 31, 2011,151
patients had their tags removed from the ESS, eliminating the need
for isolation based on history. This represented a cost savings for the
hospital by preventing unnecessary isolation precautions and lead
to improved staff efficiencies. Lessons Learned: An ESS was
useful for managing patients with a history of MDRO in the face of
changing laboratory standards thereby preventing an unnecessary
isolation status. Without the ESS, it would have been difficult to
quickly identify and easily review the patients’ laboratory history.
Examining Processes for Identifying Central Line
Associated Bloodstream Infections and Variation in
a Large Acute Care Facility
Michele A. Carra, BS, MT ASCP, CIC - Infection Prevention
Database Coordinator, Mercy Medical Center; Jan M. Tippett,
MSc., CIC, MT ASCP (M) - Director of Infection Prevention,
Mercy Medical Center; Daniel H. Gervich, MD, FSHEA - Medical
Director of Infection Prevention and Healthcare Epidemiology,
Mercy Medical Center
Background/Objectives: It is well established that
variation in Central Line Bloodstream Infection (CLABSI) rates
may occur when applying NHSN criteria, which include the
subjective component of attempting to assign a primary source of the
159
the modified algorithm method was a viable surveillance option.
Methods: Positive blood cultures are received via electronic
surveillance and determined to be present on admission (POA),
contaminant or a hospital-acquired bloodstream infection (HA-BSI).
Patients designated as HA-BSI are then reviewed for the presence of
central lines and whether the infection is primary or secondary to an
infection at another site. Cases with matching positive cultures from
an alternative site were eliminated and cases which were either culture
negative or not collected were reviewed for clinical indications of
infection at another site. Results: The CLABSI sample sizes
for this 2 year study for 2010 and 2011 were 63 and 53 infections
respectively (Chart 1). When in-depth chart reviews were performed
to determine secondary infections, these numbers were reduced to 42
and 25 (33% and 53%) respectively for years 2010 and 2011. Rates
were reduced from 1.78 to 1.18/1000 CL days in 2010 and from
1.28 to 0.76/1000 CL days in 2011. There were 17 BSI during the 2
year study on our Oncology floor that would have been designated
CLABSI using the truncated algorithm inflating the 2 year rate from
1.17 to 2.70/1000 CL days (Charts 2 & 3). Conclusions:
Comparing outcome measures at these two points in the process for
CLABSI determination showed significant variation. The truncated
algorithm was more objective and efficient. However, the loss in
specificity greatly inflated the CLABSI rate in some service lines as
illustrated with our Oncology and Critical Care data. Completing
the process through the clinical review stage limits comparisons
because of variation in reviewer’s skills and subjectivity. With the
requirement for public reporting this study further illustrates some
of the difficulties associated with inter-institution comparison, as
outlined in the recent commentary by Weinstein et al ( J Am Med
Inform Assoc. 2010 Jan-Feb; 17(1):42-8); Fraser et al CID 2011:52
(12). et al ( J Am Med Inform Assoc. 2010 Jan-Feb; 17(1):42-8).
Issue: Coccidioidomycosis (commonly known as Valley Fever or
Cocci) is a fungal disease that lives in the soil in endemic areas such as
California, Arizona, New Mexico, Nevada and parts of Northwestern
Mexico. Persons become infected by inhaling the airborne spores
especially when soil has been disrupted (such as during construction,
agriculture, archeological exploration, after earthquakes, fires or dust
storms). Cocci is not spread person to person, it is not contagious. It
can infect animals as well as humans. Each year in San Luis Obispo,
California many cases of Cocci are identified. The following is an
overview of the disease and the findings and data collection obtained
from years of Coccidioidomycosis surveillance. Project: San Luis
Obispo is a relatively small county located between Los Angeles
and San Francisco. The population of San Luis Obispo County is
approximately 269,637. It is divided into the south and north county,
with the south county being more coastal in nature and north county
more arid. Both areas support agriculture, cattle ranching and are
most popular for their vineyards. Most Cocci cases occur in the
north county or derive from the prison population. San Luis Obispo
County houses the California Men’s Colony prison. The hospital that
serves the north county is Twin Cities Community Hospital (a Tenet
Hospital) located in Templeton. This hospital opened a dedicated
14-bed lockdown Medical Guard Unit in 2010 which serves the
prison population throughout the Central Valley endemic with
“Valley Fever”. Results: Residents of San Luis Obispo with signs
and symptoms are frequently tested for Cocci. Inmates presenting to
the Medical Guard Unit at Twin Cities Hospital with pneumonia
like symptoms are worked-up for Cocci and ruled-out for tuberculosis
as a differential diagnosis. The Twin Cities Infection Preventionist
works closely with the local Public Health Department to ensure all
cases are tracked and reported. Testing can be confirmed by serum
blood testing. A Cocci titer will test for antibody (past infection) and
precipitin (acute infection). Cocci fungus can also be grown from
infected cultures. Lessons Learned: Increased awareness is
needed about the prevalence of Coccidioidomycosis among clinicians
and providers. This is especially important when patients have visited
endemic areas and contracted illness. Limited intervention and
prevention is available to decrease this disease until a a viable vaccine
can be formulated and licensed for use. Cocci is currently treated with
antifungal drugs such as fluconazole. At the San Luis Obispo Public
Health Department Laboratory new PCR testing is being researched
and validated for future use.
Implementing an Active Surveillance Program
with Multi-Site Swabbing for Methicillin-Resistant
Staphylococcus aureus in a Community Hospital
The Incidence of Coccidioidomycosis In San Luis
Obispo, California
Jeannette L. Tosh, RN, CIC - Infection Preventionist, Twin Cities
Community Hospital / Tenet Corporation; Ann E. McDowell,
MPH - Epidemiologist, San Luis Obispo Public Health Department
160
Angela D. Dickson, RN, CIC - Infection Preventionist,
PeaceHealth, St John Medical Center
Issue: In many hospitals, nares only swabbing is the standard
for active surveillance culturing (ASC) for Methicillin-Resistant
Staphylococcus aureus (MRSA). The main goal of MRSA ASC is to
identify patients who are silently colonized and place them in contact
precautions thus reducing silent transmission to other patients. While
nares is noted to be the most common site of colonization, multiple
anatomic sites must be sampled to achieve sensitivity greater than
90% for MRSA detection and groin samples yield positive results
more consistently with community acquired MRSA (Lautenback,
E., Nachamkin, I., Hu, B., Fishman, N., Tolomeo, P., Prasad, P.,
Bilker, W., & Zaoutis, T., 2009). Should a MRSA ASC program
include additional testing sites to identify silent colonizers thus
ensuring proper identification and timely implementation of contact
precautions? Project: In response to our annual risk assessment
and mandatory state requirements, a MRSA ASC program was
developed and implemented within a community hospital. A
multidisciplinary team approach was used. Based on various literature
sources and local data indicating endemic rates of community
acquired MRSA, a multi-site swabbing approach was desired to
ensure high sensitivity of identification of patients who were silently
colonized with MRSA. The targeted populations were Intensive
Care Unit (ICU) admissions, total joint arthroplasties (TJA), and
fractured hips. The anatomic sites chosen for swabbing included
nares, throat, groin, and any wounds or percutaneous drains. Samples
were plated separately on CHROMagar selective plates for MRSA
rather than pooled together so site prevalence could be evaluated.
Turnaround time was 18-24 hours. Patients with a documented
history of MRSA were not swabbed but rather placed directly into
contact precautions. All other patients were swabbed and contact
precautions were initiated once positive test results received unless
evidence of infection triggered empiric isolation. Results: Data
for each population was collected on an excel spreadsheet from
January 1, 2010 through December 31, 2011. Compliance with
ASC was high: 98% for ICU, 98% for TJA, and 91% for fractured
hips. Overall MRSA prevalence for these three populations was
14% (390/2706). MRSA prevalence varied among the populations
studied likely due to the chronically ill nature of ICU and fractured
hips versus TJA (graph 1). Overall sites positive for MRSA other
than nares was 31% (50/163) indicating three out of ten patients
would be missed if nares site only was swabbed (graph 2). It was also
noted that 53% of patients who tested positive were also positive at
one or more sites. Lessons Learned: If we did not do multisite swabbing for MRSA we would miss 30% of our silent colonizers.
A multidisciplinary team approach was the key to implementation
success. Multi-site swabbing should be the standard in ASC programs
to ensure identification of all patients colonized with MRSA.
(NHSN). NHSN users reporting SSI data must adhere to the
NHSN definitions for reporting SSI data. In order to be considered
an NHSN operative procedure the incision must be closed. When
the skin incision edges do not meet because of wires or devices or
other objects extruding through the incision, or when “loosely closed”
the incision is not considered primarily closed and therefore is not
considered an operation. For many institutions the only method
of accurately determining the skin closure status is to read the
operative report of every HYST and COLO case before reporting
denominator data into NHSN; meaning many extra hours of work
for Infection Prevention (IP) staff. Project: In a large medical
school associated hospital the operative reports of 1,353 inpatient
HYST and COLO procedures, performed during 2010-2011, were
read to determine skin closure status. Results: Of the 441 COLO
procedures 52 (12%) did not meet the definition of an NHSN
operative procedure because the incision was not closed. Of the 912
HYST procedures only 1 case did not meet the definition of an
operative procedure (table 1.) Lessons Learned: Determining
the skin closure status for COLO and HYST cases is labor intensive
for institutions that are performing a high number of operations. For
HYST cases in our institution 99.9 percent of cases had complete
skin closure over a 2 year period. Therefore it may not be necessary
to read all operative reports for the HYST category. Conversely 12
percent of COLO operative incisions were not closed over a 2 year
period. Therefore, for our institution, COLO operative reports must
be reviewed to determine cases that should be excluded because the
skin edges do not meet. The number of denominator cases excluded
for the COLO category would affect the SSI rate generated by
NHSN which is reported to CMS. A computer generated report of
skin closure status would be the ideal solution in order to avoid the
labor intensive work of reading every operative report. The objective
for every institution should be to enter accurate denominator SSI
data to NHSN as efficiently as possible. Our institution is now
working with the operating room staff and our medical informatics
department in order to generate such a report.
Is it Necessary to Determine Skin Closure Status
for all Operative Procedures Prior to Entering SSI
Denominator Data into NHSN?
Catherine Statz, RN, BSN, PHN, MPH - Nurse Manager - Surgiclal
Wound Infection Surveillance, University of Minneaota; James
Glover, BS - Administrative Specialist, University of Minnestoa
Issue: The Center for Medicare and Medicaid Services (CMS)
requires reporting surgical site Infection (SSI) data for inpatient
abdominal hysterectomy (HYST) and colon (COLO) procedures
beginning with surgical procedures performed on January 1,
2012. Hospitals are to report via the Centers for Disease Control
and Prevention’s (CDC’s) National Healthcare Safety Network
Control of MRSA Colonization in a Teritiary NICU
Sarah A. Smathers, MPH, CIC - Infection Preventionist, Children’s
Hospital of Philadelphia; Cindy L. Hoegg, RN, CIC - Infection
161
Preventionist, Children’s Hospital of Philadelphia; Eileen Sherman,
MS, CIC - Manager, Infection Prevention and Control, Children’s
Hospital of Philadelphia; Lori Brittingham, RN, BSN - Registered
Nurse, Children’s Hospital of Philadelphia; Jacquelyn R. Evans,
MD, FRCP, FAAP - Medical Director, Newborn/Infant Intensive
Care Unit, Children’s Hospital of Philadelphia, University of
Pennsylvania; Susan Coffin, MD, MPH - Hospital Epidemiologist
and Medical Director of Infection Prevention and Control,
Children’s Hospital of Philadelphia, University of Pennsylvania
Issue: Methicillin-resistant Staphylococcus aureus (MRSA)
colonization in neonates increases the risk of hospital-acquired
infections. To identify transmission of MRSA in this high risk
population routine surveillance screens are performed. Project:
During routine point prevalence screen in a 76 bed tertiary newborn/
infant intensive care unit (NICU) 6 patients were identified as
newly colonized with MRSA. All patients were from the same
subunit of 12 beds and were cared for by the same nursing team.
All MRSA positive patients were placed on contact isolation and
nursing assignments were cohorted. Weekly screening was initiated
to identify ongoing MRSA transmission. The first weekly screen
found one additional MRSA colonized baby. The NICU subunit was
then closed to new admissions and all 7 MRSA isolates were sent for
pulse-field gel electrophoresis (PFGE). Hand hygiene observations
were increased and adherence to personal protective equipment
was monitored. Staff was interviewed to determine opportunities
for improvement in infection prevention protocols. Results:
No additional episodes of MRSA transmission were found during
weekly screens which continued until all positive patients had
been discharged (6 weeks). None of the newly identified MRSA
colonized patients developed infections. The unit was re-opened to
admissions after 2 weeks of negative screens. PFGE results suggested
a common source of transmission as 5 of 7 strains were identical
and 2 were related. Although this source was never definitively
identified it is thought that a baby, with a MRSA positive twin,
went unscreened and therefore was in the NICU for several months
unisolated. Independent observations highlighted several breaches in
hospital policies, leading to inadequate cleaning of the environment
and lack of adherence to basic infection prevention principles.
Recommendations were to 1) reduce clutter of extra patient
equipment and staff personal items so that environmental services
could perform a deep cleaning of all common areas and patient rooms
2) reinforce appropriate cleaning of common patient equipment
after each use 3) ensure that single patient use items were not being
cleaned and reused on different patients 4) reinforce hospital policy
with families to visit one another in the common areas such as the
family lounge instead of patient bedsides 5) change the admission
MRSA screening policy from infants 30 days or older to all infants
at admission or if in-born on day of life 7, and increase the frequency
of point prevalence surveys from every 6 months to every 2 months.
Ongoing monitoring of the NICU subunit for six months has shown
no additional episodes of transmission. Lessons Learned:
Unidentified MRSA colonization, along with environmental
contamination as a result of crowding and clutter were implicated in
the spread of MRSA in a NICU. Initiating strict cohorting, isolation,
environmental cleaning and increased surveillance resulted in
immediate disruption of transmission.
162
The Impact of Using Chlorhexadine Gluconate
Products in the Adult Critical Care Setting
Audrey Adams, RN, MPH, CIC - Director of Infection Prevention
and Control, Montefiore Medical Center
Sheron Wilson, RN, MPH, CIC - Infection Prevention Nurse,
Montefiore Medical Center
Issue: Prevention of device-associated infections in the critical
care setting has been a focus of regulatory agencies and the Centers
for Disease Control and Prevention. To address this, evidence
based practice in the form of “bundles” to prevent device associated
infections were implemented during the past six years in all critical
care units of our 3 division, 1,491 bed teaching hospital. These
bundles have contributed to lower infection rates. To further decrease
infection rates in the critical care setting, a pilot study to measure
the impact of using Chlorhexadine Gluconate (CHG) impregnated
bath cloths and the use of CHG for oral care of ventilator patients
was implemented in one of six adult ICUs. Project: The concept
of replacing the traditional wash basins and cloths with disposable
cleaning wipes and CHG impregnated bath cloths was presented
to the nursing staff. Training was given to staff on all shifts, and a
resource binder containing written guidelines and protocols was
provided. In addition, CHG was added to the oral care regimen of
ventilator patients, and the computerized order entry VAP bundle
was updated to include CHG oral care every 12 hours. To measure
the impact of these interventions, the routine six month infection
surveillance period, was extended by 3 months. The intervention
study period was October 2010 through March 2011. Results:
When compared to a non-intervention surveillance period in 2009
( July – December), the overall infection rate during the intervention
study period decreased from 20 per 1,000 patient days to 7.5 per
1,000 patient days, a statistically significant reduction of 63%
(P=.0002). There was also a significant decrease in the catheterassociated urinary tract infection (CAUTI) rate and ventilatorassociated pneumonia (VAP) rate, with reductions of 70% and
63%, respectively. The central line-associated blood stream infection
(CLABSI) rate and the “other” infection rate decreased by 67% and
42%, respectively. These reductions were not statistically significant.
Due to positive patient outcomes, a decision was made to implement
the use of CHG impregnated bath cloths in the remaining 5 adult
critical care units. CHG oral care had been previously implemented
in the units. Lessons Learned: Our findings demonstrated
statistically significant overall lower infection rates when reusable
bathing cloths and basins were replaced with disposable CHG
impregnated bath cloths. Statistically significant lower VAP rates
were identified with the addition of CHG to the oral care protocol.
Intervention strategies contributed to lower infection rates in all
major sites monitored. Use of a standardized process measuring tool
is necessary to monitor and sustain compliance with the intervention
strategies. Ongoing efforts to implement new infection prevention
strategies may improve patient outcomes in the critical care setting.
Epidemiology of Infections in a Pediatric Oncology
Service in Guatemala
Mario Melgar, MD - Infectious Diseases Physician, Unidad Nacional
de Oncología Pediátrica, Guatemala City, Guatemala; Nancy Gatica
- Infectious Diseases Fellow, Hospital Roosevelt, Guatemala City,
Guatemala; Marylin Ramirez - Preventionist, Unidad Nacional
de Oncología Pediátrica, Guatemala City, Guatemala; Federico
Antillon-Klussmann, MD - Director of Medicine, Unidad Nacional
de Oncología Pediátrica, Guatemala City, Guatemala; Don Guimera,
BSN, RN, CIC, CCRP - International Epidemiology Coordinator,
St. Jude Childrens Research Hospital; Kyle M. Johnson, PhD,
Hospital
Background/Objectives: Infection is an important
cause of morbidity and mortality in cancer. We aim to describe
the infection epidemiology and risk factors in children with
cancer in our unit. Methods: The Pediatric Oncology Service
(POS), 42 beds, is a semi-autonomous unit, and cares for 300
new patients yearly--about 50% of expected pediatric cancer in
Guatemala. The unit has 104 nurses and 35 physicians including
members of the infection prevention and control (IPC) program
(an infectologist and 2 nurses). During the study period (December
2009 to November 2010), 1944 children were admitted to the
service, baseline illnesses were 1187 (61%) acute lymphoblastic
leukemia (ALL), 113 (6%) acute myeloid leukemia (AML), 189
(10%) lymphomas, and 455 (23%) other malignancies. We followed
standard infection definitions, entered all data in EpiInfo™ and
used frequencies and percentages to report results. This study was
approved by the local research ethics committee. Results: We
recorded 540 infectious events in 263 children (global infection
rate 28%), being 265 (49%) healthcare associated infections (HAI)
and 275 (51%) community acquired infections (CAI). Mean age
was 8 years and 60 % were male. The underlying diseases of infected
children were as follows: 404 leukemia (352 ALL, 45 AML, 7 other),
26 lymphoma, 55 solid tumors, and 55 another type of malignancy.
The most common infectious events in CAI were fever of unknown
origin and neutropenia (FUO-N) (133, 48%), pneumonia (41, 15%)
and acute diarrhea (16, 9%); and the most common HAI where
phlebitis (169, 64%), pneumonia (24, 9%) and FUO-N (19, 7%).
During the study period 49 pathogens were isolated and the most
common one in HAI were Enterobacteriaceae (9, 34%), followed
by Staphylococcus aureus (4, 15%), and Candida (2, 8%). The most
common pathogens in CAI were S. aureus (5, 23%), enterobacteria
(4, 18%), Pseudomonas and Candida 1, 5% each). Five (45%) of all
S. aureus were methicillin-resistant. There were 29 deaths in patients
with infections; most of them in leukemia (26, 89.6%). These
infections were pneumonia (7), bacteremia (5), and clinical sepsis
(5), other infection (12). Seven patientsdied while in palliative care.
About half of the patients were neutropenic (52%) and in induction/
consolidation treatment phase (50%); almost half of all patients that
had pneumonia or were bacteremic had a central venous catheter
placed 7 days before the infection; 30% of all infected patients had
chemotherapy in the previous 7 days. Fifty-four children (10%)
required intensive care, had clinical sepsis (57%), typhlitis (50%), and
bacteremia (33%). Conclusions: The most frequent infectious
event in hospitalized children was phlebitis, a marker of nursing care,
and febrile neutropenia of unknown focus. Neutropenia secondary
to chemotherapy places children at high risk for infections; best
practices during healthcare delivery are imperative to lower infectious
morbi-mortality.
Comparison of LAB ID and Traditional Surveillance
for C difficile, are Proxy Measures Effective
Tools for Identifying Performance Improvement
Opportunities?
Linda R.. Greene, RN, MPS, CIC - Director of Infection
Prevention, Rochester General Hospital
Background/Objectives: The use of proxy measures such
as the c difficile Lab ID event has been used to identify c difficile
incidence and prevalence rates, and has been proposed as an efficient
tool to perform surveillance and to guide infection prevention
efforts. Increased attention on HAIs as a safety and quality issue has
led to public health reporting requirements and a focus on quality
improvement activities. Traditional surveillance to detect C difficle
disease is labor intensive. The use of proxy measures can be useful to
identify issues and provide actionable information. Methods: We
compared 24 months of Healthcare Facility Wide data using both
the Cdifficile surveillance defintion and the Lab ID event module as
per National Healthcare Safety Network (NHSN) criteria. Incidence
rates were calculated and compared based upon the 2 methodologies.
Results: During the 2 year period there were 364,478 patient
days. 352 healthcare facility onset cases were identified (rate 9.6
/10,000 patient days) and 467 combined healthcare facility onset /
community onset, healthcare facility associated cases (rate 12.8 per
10,000 patient days). 379 infections were detected by traditional c
difficile surveillance (rate 10.3 per 10,000 patient days). There was
not a statistically significant difference in incidence rates between
cases identified by traditional means and the health care facility onset
lab ID event . Conclusions: Although the lab ID event has
limitations and underestimates the C difficile healthcare associated
infection rate, our experience suggests that use of the combined
incidence rate compares favorably with traditional surveillance
methodologies and may be a reasonable, less labor intensive
surveillance method. Combining this data with optional fields for
attribution and complications in NHSN provides a reasonable means
of identifying issues and performance improvement opportunities.
163
164
Oral Abstracts: Antimicrobial Resistance
Oral Abstracts
Presentation Number 100
Overuse of Topical Antibiotics among Inmates
Entering Maximum-Security Correctional Facilities
in New York State
Carolyn Herzig, MS - PhD Candidate, Department of Epidemiology,
Columbia University; Oliver Jovanovic, PhD - Instructor,
Department of Microbiology and Immunology; Dhritiman
Mukherjee, PhD - Project Coordinator, Department of Medicine,
Division of Infectious Diseases; Caroline Lee, AB - Senior
Technician, Department of Medicine, Division of Infectious Diseases;
Zoltán Apa, BS - Research Coordinator, Columbia University School
of Nursing; Dana Gage, MD - Clinical Physician II, Bedford Hills
Correctional Facility; Franklin Lowy, MD - Professor of Medicine
and Pathology, Department of Medicine, Division of Infectious
Diseases; Elaine L. Larson, RN, PhD, CIC - Associate Dean for
Research, Columbia University School of Nursing
Background/Objectives: The overuse and inappropriate
use of antimicrobial agents has been shown to promote antimicrobial
resistance. Incarceration is a risk factor for infection with some
antimicrobial pathogens, such as m

APIC 2012 Onsite Program

Transcription

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