Staying informed about important studies appearing in the scientific literature can be overwhelming. To help flag significant studies for our members, APIC’s Communications Committee publishes reviews of select articles appearing in the American Journal of Infection Control (AJIC) and highlights the major points that impact the practice of infection prevention. Reviews are published on an ongoing basis. Check this page frequently for updates.
Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study. Broom J, Broom A, Kirby E, et al., American Journal of Infection Control, August 2017 (Volume 45, Issue 8, Pages 911–916). DOI: http://dx.doi.org/10.1016/j.ajic.2017.03.003
Reviewed by Ida Lyn E. Benemerito, MSN, BSN, RN, CIC, North Chicago, IL
Judicious use of antibiotics remains challenging in the setting of pulmonary infections. Pulmonary infections represent one of the highest proportion of hospital admissions, inpatient days, and contributes to high rates of antibiotic consumption, which makes for an ideal setting to target antimicrobial stewardship and optimize patient outcomes.
Researchers conducted this study to identify social and behavioral factors that influence antibiotic prescribing practices in pulmonary medicine. This initial study, conducted in two teaching hospitals in Australia, is part of a series in a comprehensive research program involving healthcare professionals and subspecialties. Researchers invited twenty-eight physicians and nurses working in pulmonary medicine to participate in the study, which comprised of semi-structured qualitative interviews. The interviews garnered their experiences with antibiotic utilization and perceptions of antimicrobial resistance.
The study identified clinical barriers. Clinical barriers, specifically with the differential diagnoses for pneumonia versus COPD, viral versus bacterial infections, and colonization and infection proved problematic. These clinical barriers influenced the decision to prescribe antibiotics, contributed to overprescribing, and revealed variations in clinical practice among specialty services.
Research also identified social barriers. Results indicated participants perceived the increase of multidrug resistant organisms was not related to or an immediate threat to current practice, attributing resistance to agricultural practices and suboptimal prescribing practices in other countries. The study also revealed the lack of perceived value with implementing a guideline-based care contrary to individualized care. Furthermore, hospital hierarchal structures influenced antibiotic decision-making.
Limitations of this study include the sample size. Researchers contend the need to conduct further research in different cultural and institutional settings. Researchers also suggest garnering perspectives from other specialties managing pulmonary infections, as well as, the pharmacists’ role in antibiotic prescribing practices.
This study highlights the need for multidisciplinary collaboration to address the clinical and social barriers with antimicrobial stewardship in the setting of pulmonary infections to effectively promote the judicious use of antibiotics.
Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Wilson J, Bak A, Loveday H, American Journal of Infection Control, July 2017 (Volume 45, Issue 7, Pages 779–786). DOI: http://dx.doi.org/10.1016/j.ajic.2017.02.019
Reviewed by Peg Pettis, MPA, BSN, CIC, Rochester, NY
Hand hygiene is an important method of decreasing the risk of infection, and infection preventionists are continually reminding healthcare workers to perform hand hygiene. There needs to be increased focus on the use of gloves as recent research find healthcare workers are using nonsterile clinical gloves (NSCG) inappropriately. The researchers of this study feel the impact of the misuse of nonsterile clinical glove use needs to be addressed, and the attitudes and behaviors that influence NSCG use and strategies need to be developed to decrease the inappropriate use of NSCG and improve patient safety.
The researchers observed healthcare worker glove use and found gloves are often applied before any contact with blood or body fluid, such as when handling equipment or bed making. The authors observed that cross-contamination occurred because healthcare workers did not change gloves after or between procedures, such as touching blood or body fluid then touching a patient. Healthcare workers did not perform hand hygiene upon removal of gloves in more than 40 percent of observations.
Interviews of healthcare workers found a variety of reasons for the use of NSCG which fell into two key themes: emotion and socialization. Emotional themes were demonstrated by the healthcare worker feeling the need to protect themselves, examples given by staff were feelings of disgust and uncleanliness and the use of NSCG assisted in depersonalizing care. Socialization themes impacting a healthcare workers decision to wear gloves are influenced by training, peers, and usual ways of working.
Researchers state the use of gloves were impacted by so many variables that simply educating staff or having a policy would not be successful in changing the inappropriate, widespread use of nonsterile clinical gloves.
Merging video coaching and an anthropologic approach to understand health care provider behavior toward hand hygiene protocols. Boudjema S, Tarantini C, Peretti-Watel P, et al., American Journal of Infection Control, May 2017 (Volume 45, Issue 5, Pages 487–491). DOI: http://dx.doi.org/10.1016/j.ajic.2016.12.016
Reviewed by Jessica Silvaggio, MPH, CIC, CSSGB, Los Angeles, CA
Performing appropriate hand hygiene remains an effective and simple way to prevent healthcare-associated infections. Although this practice has been shown to be effective at reducing the risk of transmitting infectious agents in the healthcare setting, data shows that healthcare providers clean their hands, on average, 50 percent of the times they should.
In this study, conducted in a medical ward specializing in tropical and communicable diseases in southeastern France, the authors used an anthropological approach conducting in-depth interviews coupled with video coaching to better understand adherence practices and perceptions of hand hygiene. Forty-three video-recordings were selected for review. Among the videos selected, 15 of 20 healthcare providers participated in in-depth interviews where they watched their respective recorded behaviors and were asked to comment on observance of protocols toward hand hygiene (and wearing gloves) particularly when non-compliance was observed.
Qualitative research findings indicated three thematic pillars:
- Attitudes toward hand disinfection protocols
- Glove (ab)use and hybrid practices
- Risk perception and perceived immunity
A review of the video-recordings showed that healthcare providers frequently were not compliant with hand hygiene protocols and overused gloves. In-depth interviews indicated providers were consciously non-compliant. Although providers displayed knowledge of protocols, they considered the protocols confusing and inadequate. As a result, providers developed hybrid practices to reconcile protocols with constraints in daily practice. Noncompliance with hand hygiene resulted from competing risk and priorities that varied across provider type category (e.g. physician, nurse, therapist, etc.). Researchers found the risk of contamination to be invisible (e.g., not perceptible to the senses) and uncertain (e.g., knowledge about risk is neither complete nor stabilized). Such risk can fuel malleable perceptions and cognitive adaptations including emphasizing one’s personal ability to mitigate or control risk in the healthcare environment. Providers expressed beliefs regarding immunity after prolonged exposure.
Based on the findings in this study, it is essential to consider a hospital as a complex and hierarchized organization with formal and informal rules. Efforts to improve hand hygiene may be more successful if infection control protocols were adapted to existing practices rather than maintaining unachievable expectations.
Isopropyl alcohol is as efficient as chlorhexidine to prevent contamination of blood cultures. Martinez J, Macias JH; Arreguin V, et al., American Journal of Infection Control, April 2017 (Volume 45, Issue 4, Pages 350–353). DOI: http://dx.doi.org/10.1016/j.ajic.2016.11.027
Reviewed by Vicki Allen, MSN, RN, CIC, FAPIC, Gastonia, NC
Prevention of healthcare-associated infections (HAIs) and patient safety is of primary importance for all hospitals. The pressure to reduce and prevent HAIs is a result of increased focus on these events, which includes public reporting and accountability among payers.
The authors of this study present the case that isopropyl alcohol is as efficient as chlorhexidine in preventing contamination of blood cultures. Infection preventionists are all too aware of the ramifications a positive blood culture presents. First and foremost is the direct effect to the patient, which likely will result in an increased length of stay as well as exposure to antibiotic therapy. For the hospital, such events may be subject to penalty and is publicly reported. False positive blood cultures have the same effects including the additional costs to the hospital and event reporting. For patients, false positive blood cultures can result in not only an increased length of stay but also exposure to and potential resistance to unnecessary antibiotics.
Besides comparing the effectiveness of isopropyl alcohol and chlorhexidine for antisepsis, which is impressive, the focus on the strategies to optimize blood culture collection in an effort to prevent contamination should not be ignored. To ensure success during trials and implementation of new products and processes, strategies cited in this study including personnel training and product selection is very important for hospitals to recognize and adhere to. The explicit training and instructions provided to personnel described in this study likely contributed to the low false positive and contaminated specimen results. These are important points to consider when implementing any new product and /or process.
This article provides good rationale for hospitals to consider for product selection as well as the importance of education and training of personnel in efforts to eliminate false-positive blood cultures and the potential to decrease operating cost.
Are hospital floors an underappreciated reservoir for transmission of health care-associated pathogens? Deshpande A, Cadnum J, Fertelli D, et al., American Journal of Infection Control, March 2017 (Volume 45, Issue 3, Pages 336–338). DOI: http://dx.doi.org/10.1016/j.ajic.2016.11.005
Reviewed by Kissa M. Robinson, RN, BSN, MHA, MBA, Capitol Heights, MD
In every issue of the American Journal of Infection Control (AJIC), there is an article that expresses the importance of hand hygiene compliance. Also, there is heavy discussion centered on healthcare-associated organism presence, transmission, and risks. However, there are not many conversations regarding hospital floors and their potential for transferring pathogens to hands. This brief article examines isolation room floor contamination and the possibility for transfer of pathogens from the floor to hands.
In this study, authors conducted a survey to assess patient room floors and high-touch objects on the floor for contamination of pathogens that are potentially spread by hands. Five Cleveland area hospitals were selected and surveyed for patient room floor contamination. Sample cultures were taken from the floor of the hospital rooms and tested for Clostridium difficile (C. diff), MRSA, and VRE. The bare and gloved hands of healthcare workers handling high-touch objects—such as blood pressure cuffs, canes, urinals, and wash basins—from the floor were also cultured.
The sample cultures revealed that C. diff, MRSA, and VRE were found especially in the CDI patient isolation room. While MRSA and VRE were less likely to be found in a non-isolation room. As well, terminal cleaning after patient discharge, the floor remained to be contaminated with C. diff, but not MRSA and VRE. The samples from the hands, bare or gloved, also showed evidence of contamination with at least one of the three pathogens.
This initial study proves to support that patient room floors are contaminated with healthcare-associated pathogens. As hands remain the number one transmitter of pathogens, this study also implies the possible transfer of pathogens from hands, bare or gloved, that pick up patient care items from the floor. Study limitations noted that testing was limited to the selected pathogens, C. diff, MRSA, and VRE; hospital floor cleaning supplies did not contain spore retarding ingredients; cultured rooms were not identified as having a patient with or without C. diff; and culture methods focused on C. diff versus MRSA and VRE.
In conclusion, the authors suggest further research opportunities to explore if hospital floors truly add to the transmission of pathogens. While further research is needed, infection preventionists should begin the conversation with their in-house environmental cleaning team. Appropriate cleaning of hospital patient rooms includes the floor. However, how often it should be cleaned and the products to be used for minimizing pathogens is key.
Hepatitis C virus transmission in a skilled nursing facility, North Dakota, 2013. Calles D, Collier M, Khudyakov Y, et al., American Journal of Infection Control, February 2017 (Volume 45, Issue 2, Pages 126–132). DOI: http://dx.doi.org/10.1016/j.ajic.2016.08.013
Reviewed by Vicki Allen, MSN, RN, CIC, FAPIC, Gastonia, NC
This study highlights the need for strict infection prevention and control practice in healthcare facilities across the continuum of care. The authors describe lapses in infection control resulting in an outbreak of hepatitis C (HCV) in a skilled nursing facility.
There have been numerous documented outbreaks of HCV in a variety of healthcare settings, however this study describes yet another element of transmission: focusing on the importance of infection prevention and control surveillance and the education of personnel to prevent these outbreaks from occurring. The benefit of having a dedicated infection prevention person is presented well in this study.
Previous articles have described the transmission of blood borne pathogens such as hepatitis B (HBV), HCV, and human immunodeficiency virus (HIV) via practices such as unsafe injection practice, drug diversion, and inappropriate or lack of cleaning and disinfection of reusable medical equipment. This study describes the largest HCV infection outbreak reported to the Centers for Disease Control and Prevention (CDC) as of 2015. It also describes that if it weren't for an alert clinician taking the first step to report this outbreak, this event would have continued undetected much longer. Having a dedicated infection preventionist providing education to personnel on all things related to infection prevention such as the epidemiology of important pathogens along with evidence based practice and measures to prevent acquiring and transmitting these pathogens through the appropriate use such things as personal protective equipment, hand washing; cleaning and disinfection of medical equipment and etc. cannot be overstated.
The authors of this study provide evidence that this outbreak likely occurred through lapses in infection control, therefore highlighting the need to continue and further strengthens the necessity of having a presence of infection prevention and control personnel in healthcare facilities across the continuum of care.
Impact of personalized report cards on nurses managing central lines. Morrison T, Raffaele J, Brennaman L, American Journal of Infection Control, January 2017 (Volume 45, Issue 1, Pages 24–28). DOI: http://dx.doi.org/10.1016/j.ajic.2016.09.020
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY
Several factors contribute to the development of a central line-associated bacteremias. The authors note that recommended guidelines for insertion have been well described and their impact on CLABS are fairly well documented.
The impact of guidelines for the maintenance of the central venous lines (CVL) is less well studied and this is the focus of this article. This study examines the impact of direct feedback to nursing units and individual nurses when lapses from established maintenance care are noted.
Using data from prior root cause analyses of the CLABs at their facilities, the authors identified three domains related to care of the central line:
- Dressing related care,
- Tubing related requirement, and
During a 16-week period, a visual observation of the line and a chart audit was conducted on more than 600 CVLs. Nineteen percent of the CVLs failed to meet one or more of the contributing factors.
The authors used this data to create unit-based reports and nurse specific reports. The reports included pertinent educational or policy material. Using this approach, the authors demonstrated a significant decrease in the number of lapses in maintenance technique. They also share nurses’ comments familiar to many of us when asked about lapses in care: “I knew the dressing was wrong, but they didn't change it on the last shift.”
The authors note a decrease in the CLABs rate in the critical care units and a decrease in the absolute number of CLABS from 18 to 10 in the medical surgical units.
Based on these results, the organization added training for new hires on CVL care, a computerized training course and changes in the electronic medical record.
Safety and Utilization of Peripherally Inserted Central Catheters versus Midline Catheters at a Large Academic Medical Center. Xu T, Kingsley L, DiNucci S, et. al. American Journal of Infection Control, December, 2016 (Volume 44, Issue 12, Pages 1458—1461). DOI: http://dx.doi.org/10.1016/j.ajic.2016.09.010
Reviewed by Cynthia Kohan, MS, CIC, FAPIC, Waterbury, CT
This study compares the safety and utilization of the peripherally inserted central catheter (PICC) vs. a midline catheter. In an effort to decrease the rate of central line associated blood stream infection (CLABSI) development, many hospitals are attempting to decrease the use of central access devices. Midline catheters are not centrally placed but can provide safe access to infuse many of the same medications. PICC lines are recommended over midline catheters for the infusion of chemotherapeutic agents and when an infusion is likely to exceed 14 days.
The object of the study was to determine if a midline catheter can be used in place of a PICC to not only reduce an institution’s CLABSI risk, but also provide the same therapeutic value of a PICC without an increase in complications.
A retrospective study was conducted at a single large university medical center. A chart review was conducted on 206 PICC insertions and 200 midline catheters, placed in 367 patients within the time period of January to May, 2015. In addition to demographic data, data on complications related to the catheter was collected. These included:
- Discontinuation related to a non-patent vessel
- Catheter fracture
- Leaking catheter
- Pain or edema at the insertion site
- Discontinuation of the catheter due to infiltration, phlebitis or infection
- Deep vein thrombosis
- Readmission because of an issue related to the PICC or midline
- Positive blood culture
The Charlson Comorbidity Index (CI) and intensive care unit (ICU) location when the catheter was inserted was also determined for each patient.
A total of 17 complications in 12 PICCs and 44 complications in 39 midline catheters were noted. Although the midline was more likely to be associated with any complication, the rates of severe complications were similar between the PICC and midline. Risk stratifying the results utilizing the Charlson Comorbidity Index and whether the catheter was placed while the patient was in an ICU noted that the risk of any complication was more likely in the midline group whether inserted in the ICU or in areas other than the ICU. More complications were also related to midline catheters in both the high and low CI score patient groups. However, the risk of a severe complication was no different in the PICC group vs. the midline group in any care setting or either CI group.
There were five positive blood cultures reported from the PICC group and five from the midline group. Two of the five cultures in the PICC line group met the NHSN CLABSI definition and were reported as such. None of the positive blood cultures in the midline group were thought to be directly related to the midline catheter.
Although the midline catheter was associated with more total complications and readmissions, none contributed to the institution’s CLABSI rate. The authors postulate that since the increase of complications in the midline group were non severe, the midline catheter might be a reasonable substitution as institutions move away from the use of central lines to avoid reporting a CLABSI.
Surveillance of complications was limited to the patients inpatient stay and may have missed occurrences in the outpatient setting. The authors conclude that midline catheters are an acceptable alternative to PICCs despite the increased risk of a non-severe complication, to reduce the occurrence of CLABSI.
The behind-the-scenes activity of parental decision-making discourse regarding childhood vaccination. Gesser-Edelsburg A, Walter N, Shir-Raz Y, et. al. American Journal of Infection Control, November, 2016 (Volume 44, Issue 11). DOI: http://dx.doi.org/10.1016/j.ajic.2016.10.009
Reviewed by Angela Vassallo, MPH, MS, CIC, FAPIC, Los Angeles, CA
Does your facility struggle with healthcare worker vaccination rates? Does the community in which your facility resides struggle with the vaccination rates of its school-aged children? Does your facility treat pediatric patients? Vaccination rates are an important topic for infection preventionists, especially in regards to the role they play in herd immunity. Yet despite what might seem like a simple decision, some parents find the decision to vaccinate their children quite complex. Thus, the researchers in this article took a new approach to understanding parental decision-making by assessing the private discourse between parents at home in regards to vaccinating their children. In particular, the researchers examined whether there were disagreements between parents surrounding childhood vaccination and how these disagreements were resolved.
The study was conducted through an online questionnaire to a diverse group of parents in Israel from December 22, 2015 to April 4, 2016. The target population (N=437) included Jewish and Arab parents (Hebrew and Arabic speaking) of children younger than 14 years of age. The survey was distributed through Google Docs and three different social media outlets (Facebook, general online forums for parents, and Whatsapp).
The target population was divided in to three different parental groups based upon their response to a multiple-choice question about childhood vaccination schedules in Israel:
The survey asked if the parents followed the Israeli childhood immunization schedule. A response of “yes” placed them in the pro-vaccination category, a response of “no” placed them in the anti-vaccination category, and parents who responded with an intermediary response, “for some children and not for others,” “for some vaccines and not for others,” and “I support vaccines but not the schedule,” were grouped as hesitant.
The findings were quite interesting. Hesitant parents were four times more likely to have intrafamily discourse about vaccinations in comparison to the pro-vaccination parents. Hesitant parents were also four times more likely to report intrafamily disagreements than pro-vaccination parents and twice as likely to report disagreements as anti-vaccination parents. Consequently, each group believed that their decision-making process was the social norm. In other words, pro-vaccination parents believed that vaccinating their children was the norm, and so on. The decision-making process and sources used to find information about vaccines was quite different between each of the three groups. Pro-vaccination parents chose doctors and nurses as their most trusted sources for vaccination information. Anti-vaccination parents chose anti-vaccination websites as their most trusted sources for vaccination information. Hesitant parents were the most likely to review scientific literature to get more information about childhood vaccination before making their decisions.
This article illustrates that we must understand private discourse and its role in decision-making in order to improve communication about vaccination. Vaccine risks and outcomes must be communicated to all groups: pro-vaccination, anti-vaccination, and hesitant.
Evaluating the effectiveness of ultraviolet-C lamps for reducing keyboard contamination in the intensive care unit: A longitudinal analysis. Gostine A, Gostine D, Donohue C, et. al. American Journal of Infection Control, October, 2016 (Volume 44, Issue 10, Pages 1089-1094). DOI: http://dx.doi.org/10.1016/j.ajic.2016.06.012
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY
Do your nurses claim their “work stations on wheels” with their names because they know they will keep it cleaner? Do your unit secretaries guard their work areas because they don’t want other staff “contaminating” it after they’ve diligently disinfected the computer and counter top? If you’ve looked at the computer keyboards and mice on any given unit, they can be sorely lacking in cleanliness. We’re often asked: “Who is supposed to clean them?” “What product should I use?” and “How often should I clean it?” This article suggests that ultraviolet (UV) disinfection might help us address these challenges.
The study examines the impact of UV-C disinfection of keyboards and mice in two intensive care units (ICUs), covering 40 workstations. Automated UV lights were installed on keyboards. Once programmed, the system is designed to turn the UV light on and off automatically, completely independent of activation by the ICU staff.
The authors acknowledge that patients’ respiratory or gastrointestinal flora contribute to transmission of infections but stress that the inanimate environment is increasingly recognized as an important vector of cross-contamination. One study cited that nurses’ hands were equally contaminated after touching a patient as they were after touching surfaces in the room. They note studies demonstrating reduction in healthcare-associated infections (HAIs) when UV disinfection is used for terminal cleaning of patient rooms.
The authors set out to achieve two targets:
- Demonstrate that the UV-C disinfection reduced microbial contamination of the keyboards/mice.
- Determine the optimal disinfection cycle and frequency that would not interrupt patient care or exceed safety limits.
The authors collected pre disinfection cultures, adjusted the timing and frequency of the disinfection cycle and collected post disinfection cultures.
Of the more than 200 baseline cultures, 95 percent revealed bacteria growth including Staphylococcus, Pseudomonas, and Klebsiella. After the UV disinfection, 94 percent of the keyboards/mice had no bacterial growth. The colony count on 3 percent of the remaining items was greatly reduced.
The authors felt they met their goal of a 99 percent reduction in growth with all safety measures satisfied. The authors do not report the impact on HAIs on these two units, but perhaps we can expect a future article from these authors on that subject.
Persistent racial and ethnic disparities in flu vaccination coverage: Results from a population-based study. Almario CV, Folasade MP, Maxwell AE, et. al. American Journal of Infection Control, September, 2016 (Volume 44, Issue 9, Pages 1004-1009). DOI: http://dx.doi.org/10.1016/j.ajic.2016.03.064
Reviewed by Kissa Robinson, RN, BSN, MHA, MBA, Washington, DC
Annually, we see campaigns strongly recommending flu vaccination for all. However, there still remain a great number of individuals that decline being vaccinated against the flu. This article examines racial and ethnic disparities with receiving flu vaccination.
The Advisory Committee on Immunization Practices (ACIP) conducted a retrospective cross-sectional study using public data from the 2011-2012 California Health Interview Survey (CHIS), a population-based telephone survey. The survey is conducted every other year by the UCLA Center for Health Policy Research. The ACIP selected the CHIS because it captures health data for all ages. The telephone survey, available in six different languages (English, Spanish, Mandarin, Cantonese, Vietnamese, or Korean), was randomly sent to landline and cell phones. The population-weighted sample of 27,796,484 included all individuals 18 years and older but excluded adults living in group settings.
The main goal of the study was to identify the individuals that received a flu vaccination within a year. Then they looked at the race and ethnicity of those individuals. The study reveals that the highest rates of vaccination were seen in Koreans, Vietnamese, Japanese, and whites, while blacks and Latinos rated the lowest in receiving the flu vaccination. Although impact of race and ethnicity was the focus, the study noted “chronic condition, graduate degree, insurance, usual source of care or recent doctor’s visit” as reasons why people obtained the flu vaccination. The study also showed that blacks were less likely than whites to be vaccinated against the flu, which is an ongoing disparity. Blacks were less likely due to fear about getting the vaccine and its effectiveness. Whereas, in the study Latinos were vaccinated at a similar rate as whites but various barriers (access to insurance and care) prevented vaccination.
The authors identified the following limitations: the sample only included the California population; CHIS data is self-reported and may not be accurate due to “recall bias;” the study did not consider feelings about preventative care or cultural and religious beliefs from the survey; unable to remove those not able to get the flu vaccination; and data from those living in group settings were not included.
In conclusion, the authors found evidence of racial and ethnic disparities in flu vaccination but there was no difference from the national data as it relates to blacks having lower vaccination rates than whites. As we approach the flu season, infection preventionists should begin the conversation on “uptake of flu vaccination.” Individuals need to be educated in flu vaccination with an emphasis on getting the public to understand how the vaccination works.
Enhancement of hand hygiene compliance among health care workers from a hemodialysis unit using video-monitoring feedback. Sánchez-Carrillo LA, Rodríguez-López JM, Galarza-Delgado DA, et. al. American Journal of Infection Control, August, 2016 (Volume 44, Issue 8, Pages 868-872). DOI: http://dx.doi.org/10.1016/j.ajic.2016.01.040
Reviewed by Peg Pettis, RN, MPA, CIC, Rochester, NY
It is refreshing to review facilities efforts to improve on their hand hygiene program using technology. There has been limited research on hand hygiene compliance in hemodialysis units. A review of the literature illustrates how hand hygiene compliance rates vary ranging from a rate of 11.5–57.4 percent employing the usual methods: self-reporting or direct observation.
A hemodialysis unit in Mexico conducted a three-phase longitudinal intervention study looking at hand hygiene compliance over a four month period. In addition to utilizing the direct observation method this study also used video recording to monitor hand hygiene performance. The first phase involved the installation of two video cameras in the 15-bed hemodialysis department, all staff in the hemodialysis unit were aware of the video camera. Following the video installation no hand hygiene monitoring was conducted for two months.
In the next phase hand hygiene compliance was conducted via direct observation and by video camera for four consecutive weeks. The hemodialysis staff assembled and were shown video examples of hand hygiene compliance and non-compliance. In addition, individual reports were given to each staff member, and an over-all report was given to the head of the unit.
The second feedback session was conducted similar to the first but education on the WHO 5 Moments of Hand Hygiene was also included.
The results comparing the two methods of monitoring hand hygiene compliance varied widely: direct observation reported rates of 57 percent, 65 percent, and 73 percent for the preintervention, first, and second interventions respectively. Video surveillance reported rates: 21 percent, 34 percent and 50 percent. The average improvement in hand hygiene compliance was 30.6 percent.
This study had several interesting conclusions: direct observation may not be the best method of monitoring hand hygiene compliance and “video-assisted monitoring offer a more precise method of evaluating hand hygiene compliance.” Most notably the video camera determined the hemodialysis staff consumed between 22–44.3 percent of the work day performing hand hygiene.
Learning from the patient: Human factors engineering in outpatient parenteral antimicrobial therapy. Keller SC, Gurses AP, Arbaje AI, et. al. American Journal of Infection Control, July, 2016 (Volume 44, Issue 7, Pages 758-760). DOI: http://dx.doi.org/10.1016/j.ajic.2016.01.010
Reviewed by Timothy Bowers, MT(ASCP) MS, CIC, FAPIC, Vineland, NJ
As infection prevention goes, seldom does anything happen in a vacuum. There are people, processes, products, procedures, protocols… the list goes on. The belief (and investigations that conclude) incidents occur due to one bad act is increasingly rare, and errors or failure to keep a patient safe is viewed in the context of system in which care is given. Within that context, human factors engineering is an increasingly important part of the infection prevention skillset. “The scientific discipline concerned with interactions among humans and other elements of a system” is a field that in a structured way looks at the potential for harm in that context of care. This commentary from the Armstrong Institute and Johns Hopkins School of Medicine utilizes this skillset outside the walls of the hospital.
The subject of the study, outpatient parenteral antimicrobial therapy, is a great way to prevent patients from unnecessary hospital stays, and as identified has some safety concerns for the patients and/or care givers at home. The level of training for those caring for intravenous access is, typically, not nearly the same. In addition to the level of training, the volume of trained individuals are different. In a hospital or similar setting there are nurses, aides, and doctors all with watchful eyes focused on the care of the patient's central line and IV, whereas at home it is just you and maybe a family member. The setting from an environmental standpoint is not as regulated as the hospital setting as well.
The authors applied human factors engineering to this atypical scenario. It is atypical as this science is usually associated with our CUSP (Comprehensive Unit-based Safety Projects) or Team STEPPS (Strategies and Tools to Enhance Performance and Patient Safety) initiatives for CAUTI, CLABSI, SSI, or other inpatient safety programs. In looking at the system the authors listed five specific ways the system could cause harm. The authors did not list all potential failures but showed the scope of investigation as it relates to evaluating the system of outpatient parenteral antimicrobial therapy. As systems are a living breathing entity an exhaustive list of potential failures is not a static list but must be evaluated and reevaluated over time. The five listed failures though are generalizable and meaningful enough to be considered adequate, in my opinion, to serve as examples for the human factors engineering process.
In addition to listing the system failures, the risk factors which exist in the system that could cause that failure are identified. As we are looking at a system there should be multiple risk factor in this step. The authors correctly identified the major three or four broad categories, and for each category has listed at least one potential intervention.
This study shows us the tools we use for infection prevention in the acute setting to improve standard reporting metrics have the ability to be used in other settings as well. This commentary develops the framework for others to study infection prevention interventions in nontraditional settings or metrics using human factors engineering.
Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong. Cheng VC, Tai JW, Li WS, et. al. American Journal of Infection Control, June, 2016 (Volume 44, Issue 6, Pages 621-624). DOI: http://dx.doi.org/10.1016/j.ajic.2015.11.024
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY
With so much focus on the hand hygiene practices of healthcare workers, it was refreshing to read this article from the authors from Queen Mary Hospital about their efforts to encourage patients to cleanse their hands.
Having previously published results that demonstrated reduced risk of acquiring MDROs through a directly observed hand hygiene program, the authors sought to expand the program. The initial program was an educational program directed to patients. Each patient received a pamphlet, signs were posted at all bedside, and sanitizers were placed in proximity to the patient. Similar to the WHO Five Moments for Hand Hygiene, the authors defined Three Moments when patient should cleanse their hands: 1) before meals and medications, 2) after bedside bedpan or urinal use and 3) after toileting in a bathroom. The infection prevention team conducted observational audits to monitor compliance with patient self initiated hand hygiene. Overall compliance with patient initiated hand hygiene was 37.5 percent. The authors stratified the results by type of activity with 89 percent compliance with hand hygiene after toileting in a bathroom.
An ambassador assisted hand hygiene program was introduced on 44 units that cared for medical, surgical, ob/gyn, and orthopedic patients. Ninety six front line staff—health care assistants—were trained for this role. They received special recognition from hospital leaders as well as a formal certificate. The ambassadors actively delivered sanitizers to conscious patients before medications and meals and observed them performing hand hygiene.
Using this method, the overall compliance increased to 97.3 percent. The data analysis included key factors that might increase the risk of MDROs, including presence of invasive devices and antibiotic use, as well as patient related characteristics such as age and comorbidities. While the authors would like to extend the directly observed hand hygiene to all three moments, manpower resources limit the ambassadors program to before medications and meal times.
The authors acknowledge that the audit process varied between the two phases in an effort to eliminate bias. Although they did not comment on any impact on incidence of MDROs or healthcare-associated infections, this program would likely have a positive impact on patient satisfaction.
Risk of infection following colonization with carbapenem-resistant Enterobacteriaceae: A systematic review. Tischendorf J, de Avila R, Safdar N. American Journal of Infection Control, May, 2016 (Volume 44, Issue 5, Pages 539–543). DOI: http://dx.doi.org/10.1016/j.ajic.2015.12.005
Reviewed by Ida Lyn E. Benemerito, BSN, RN, CIC, North Chicago, IL
The emergence of carbapenem-resistant Enterobacteriaceae (CRE) is a global healthcare challenge that requires targeted strategies to prevent infection of this pathogenic organism. CRE is considered highly resistant and associated with increased morbidity and mortality (up to 50 percent). Tischendorf, de Avila, and Safdar conducted a systematic review of 10 observational studies that comprised of 1,806 adult inpatients colonized with CRE. The study revealed CRE colonization portends the risk for CRE infection. Out of 1,806 CRE colonized adults, 299 developed infections for a cumulative rate of 16.5 percent. Report from quantitative data of 223 colonized patients indicated the following sites of infection:
- Pneumonia, clinical syndrome (50 percent)
- Urinary tract infections (20 percent)
- Primary bloodstream (13 percent)
- Skin and soft tissue, including surgical site infections (7 percent)
Adverse outcomes associated with CRE colonization or infection is an estimated two-fold increased length of stay. Mortality rate of infected and colonized patients was reported at 10 percent. In three studies, mortality rates increased to 30–75 percent with clinical infection. Some of the contributing factors to high mortality rates include increased length of stay, site of infection, and comorbid conditions. Of great significance are the limited available options of antimicrobial treatment due to the emergence of panresistant Enterobacteriaceae, emphasizing the urgency to develop new antibiotics to combat these organisms.
Implications for practice are identification and eradication of colonized patients to prevent and reduce the risk for CRE infection. New studies on decolonization demonstrate modest results warranting further large scale studies in outbreaks and endemic settings. The article recommends conducting prospective research on the utility of routine, wholehouse surveillance for CRE in hospitalized patients. It also recommends determining strategies to eliminate CRE colonization.
The authors addressed the limitations of the study. First, there were inherent limitations from the 10 observational studies included in their systematic review. Second, heterogeneity in their study method and population confounded the study. Third, limited data did not allow for analysis of risk factors for CRE infection and mortality. Fourth, the study is predisposed to concerns of misclassification due to the lack of a standardized method for identification of colonization and infection. Lastly, the authors report susceptibility to publication bias.
Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings: A cross-sectional survey. Thompson D, Bowdey L, Brett M, et. al. American Journal of Infection Control, April, 2016 (Volume 44, Issue 4, Pages 374–380). DOI: http://dx.doi.org/10.1016/j.ajic.2015.11.029
Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX
The University of New Mexico, School of Medicine and the New Mexico Department of Health had second year medical students assess infection prevention policies and practices in outpatient healthcare settings. The study, conducted in summer 2014, evaluated practices in 15 outpatient settings across New Mexico, both rural and urban. The settings were private group, private solo, hospital-affiliated, federal facilities (e.g., Veteran’s Administration or Indian Health Service), state facilities, and one unclassified practice.
The objectives were to have “medical students understand minimum expectations for safe care and infection prevention in the outpatient setting, assess infection prevention policies and practices, and identify infection prevention educational and quality improvement opportunities within a clinical setting.” The students used standardized data collection tools. Their findings were not surprising.
For the infection prevention review, there were 14 topic areas with 92 subelements including facility policies, general infection prevention education and training, occupational health, hand hygiene, surveillance and disease reporting, and point of care testing. Fifty-three percent of the 92 sub elements had 100 percent compliance. Examples of the ones below 100 percent compliance were annual respiratory fit testing (58 percent), TB screening upon hire and annually (64 percent), and system in place to track which instrument was used on a patient for each procedure (50 percent).
Injection safety had 163 observations at 14 sites (one facility was excluded due to lack of sufficient injection practices) and found that 66 percent of the time all the recommended injection safety elements were followed. Missing elements included hand hygiene prior to preparation (missed 29 times), rubber septum not disinfected prior to entering medication vial (missed 33 times), and new needle and/or syringe used (missed 8 times).
Hand hygiene observations had the least surprising results. Observations were of entering and exiting the patient room and preparing medications. Alcohol-based hand rubs were used 34 percent of the time, soap and water 29 percent, and 37 percent of the time there was no hand hygiene done.
My favorite part of the study was the quality improvement recommendations made by the medical students. Examples of key recommendations were adding more alcohol hand rub dispensers in rooms, in the halls, and by medication prep areas; adding signs to the waiting rooms for respiratory hygiene; placing hand hygiene posters in the offices; and conducting formal cleaning demonstrations to ensure proper staff cleaning of the rooms.
I hope this group will follow up with these medical student evaluators as they start their own practice to see if they are using the infection prevention information they learned during this study.
Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates. Hobbs M, Robinson S, Neyens D, et al. American Journal of Infection Control, March, 2016 (Volume 44, Issue 3, Pages 258-62). DOI: http://dx.doi.org/10.1016/j.ajic.2015.10.041
Reviewed by Vicki Gillie Allen, MSN, RN, CIC, Huntersville, NC
This article explores one of the most effective infection control measures to prevent the transmission of pathogens—hand hygiene. It also offers a new twist in that the focus of this paper is on the effort to assess the compliance for hand sanitizing of visitors upon entry into the hospital setting.
Research on hospital visitor hand hygiene is limited, but previous studies indicate observed compliance to this practice being less than one percent. The author also cites studies that suggest that placement and location of hand hygiene dispensers along with visual aids may influence the use for hand hygiene sanitizers. One study cited found that hand hygiene practice was highest at the hospital entrance and yet another found the location of dispensers along with instructions prompting hand hygiene at the hospital entrance was influential in improving visitor hand hygiene.
Location of dispensers and hand hygiene supplies is a long known environmental barrier in hospitals. Poor product placement and access decreases compliance for healthcare workers to appropriately practice good hand hygiene. Continued and on-going assessment for the location of dispensers and availability of supplies should be a priority for infection preventionists during environmental rounding and surveillance. Knowing placement of dispensers and supplies can be a barrier for good and appropriate hand hygiene, it only makes sense that this could also be a factor and should be considered when educational efforts for performing hand hygiene and keeping patients safe is directed to family members and visitors
This paper suggest numerous ideas and opportunities for hospitals to assess the general rate for hand hygiene compliance for visitors entering the hospital and could very well lead to best strategies for partnering with visitors and families in continued efforts to improve the safety for our patients.
Reducing infection transmission in the playroom: Balancing patient safety and family-centered care. Ivany A, LeBlanc C, Grisdale M, et al. American Journal of Infection Control, January 2016 (Volume 44, Issue 1, Pages 61–65). DOI: http://dx.doi.org/10.1016/j.ajic.2015.07.036
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY
This article discusses practices related to sibling visiting in pediatric playrooms. This is a timely article for the cold and flu season. It is also useful that the authors examined a ritual practice— not allowing visitation—while a relatively simple process can increase safety for patients and their families.
Sibling visits is consistent with practicing family centered care. Citations regarding the benefits of family centered care enhancing physical and emotion well-being of children are noted. Both the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) support sibling visits but only with their own sibling, not in a communal setting such as a playroom.
However, there is scant literature on allowing children to visit their siblings in the playroom and the authors recognized that their facility—a tertiary care hospital in Canada—did not have a formal process for it.
Using an S-B-A-R approach, a quality improvement project was developed involving nurses, unit staff, child life specialists and the infection preventionists. Their objective was to create a system that would maximize sibling visitation yet minimize communicable disease transmission.
The project included four key components:
- A literature search on the topic of sibling visitation identified 19 articles although none of them specifically discussed siblings in the playroom.
- They queried the 24 IPs from the Pediatric and Neonatal Interest Group of Infection Prevention and Control Canada. The current policies and practices of five pediatric centers were included. Their practices included three centers that allowed playroom visitation but with varying levels of screening for communicable diseases and two additional centers that allowed visitation with formal screening.
- They developed and implemented a screening tool that was completed by the parents/guardians after receiving education by the nurse or child life specialist.
- They evaluated the results of 42 screening that were collected during a two-year period. The results showed that nearly 10 percent of siblings had potentially communicable illnesses—the majority of which were respiratory in nature.
The authors acknowledge these limitations:
- A small number of screenings.
- No formal evaluation of transmission of illness either before or after the tool was implemented.
The authors expect to expand the use of the process to allow visitation in the playrooms. They also noted a secondary gain that it encouraged more collaboration among the various staff members, particularly in their awareness of infection prevention practices.
The role of message strategy in improving hand hygiene compliance rates. Taylor RE. American Journal of Infection Control, November 2015 (Volume 43, Issue 11, Pages 1166–1170). DOI: http://dx.doi.org/10.1016/j.ajic.2015.06.015
Reviewed by Margaret (Peg) Pettis, MPA, BSN, RN, CIC, Rochester, NY
Hand hygiene has been recognized for many years as one of the easiest and best methods of reducing the spread of infection. Healthcare workers know when to wash their hands and how to clean their hands. Hand sanitizer is provided throughout healthcare facilities, and there have been numerous endeavors to increase hand hygiene compliance rates: songs, videos, posters. However, even with these efforts the hand hygiene rates among health care workers remains low.
The author of this article feels that one explanation for the low hand hygiene compliance rates may be related to message strategy. “Message strategy refers to a guiding approach to a company’s or institution’s promotional communication efforts for its products, its services or itself.” The idea that one message will resonant with everyone is not true. You cannot give the same message to everyone.
There are several models used to in an effort to try and change healthcare workers behavior. Some theories believe that providing information will influence behavior. Other theories propose that behavior is emotion-driven.
Our author reviews a different theory, the theory that there are two persuasive methods of messaging. This messaging theory is described as a circle; the right side of the circle is labeled “transformational” and the left side is labeled “rational.” Transformational communication is directed to the emotional side of people, messages would appeal to one’s beliefs, attitudes, and self-image. Rational communication imparts knowledge and information and would appeal to one’s cognitive or logical side. In addition, behaviors that are less important to the individual are on the bottom of the circle, and items that are more important are on the top.
The author feels “there are at least six paths to persuasion, and there may be different paths for different people under different contexts.” To relate this to hand hygiene: One person may be motivated to wash their hands because they want to protect their family whereas another healthcare worker performs hand hygiene because it is the professional thing to do.
The results of the study substantiates the idea that providing a variety of messaging and rotating the messages throughout the health system may be instrumental in increasing hand hygiene compliance.
Questionable validity of the catheter-associated urinary tract infection metric used for value-based purchasing. Calderon LE, Kavanaugh KT, Rice, MK. American Journal of Infection Control, October 2015 (Volume 43, Issue 10, Pages 1050–1052). DOI: http://dx.doi.org/10.1016/j.ajic.2015.05.024
Reviewed by Cynthia Kohan, MS, CIC, Waterbury, CT
It is estimated that catheter-associated urinary tract infection (CAUTI) is one of the most common hospital acquired conditions projected to occur in U.S. hospital patients annually and is a component of the Hospital Acquired Condition (HAC ) value based purchasing. Beginning October 2014, hospitals are penalized one percent of their Medicare fee schedule if their performance is ranked in the lowest quartile for the prevention of HACs. This study examined two government metrics related to the occurrence of CAUTI, the CDC’s National Healthcare Safety Network (NHSN) and the Agency for Healthcare Research and Quality (AHRQ) and compared the results from each network.
The CDC/NHSN metric is self-reported and converted into a standard infection ratio (SIR) whose denominator is the number of catheter days while the numerator is the number of CAUTI identified. The ratio is then adjusted for the various factors including unit type, unit size, and whether the hospital is considered a major teaching facility. The AHQR metric is derived from the medical record review of 18,000—33,000 randomly selected medical records per year from patients diagnosed with myocardial infarction, heart failure, pneumonia, and major surgical patients. These are abstracted from 800 randomly selected CMS participating hospitals. The denominator is hospital discharges while the numerator is the number of CAUTI identified.
Analyzing the results from the two government systems show discordant results. In the NHSN system, a three percent increase in CAUTI was identified when comparing results from the 2009 baseline SIR to the 2012 data, and a six percent increase when comparing the 2009 SIR with the 2013. THE AHRQ outcome data shows a 28.2 percent decrease in CAUTI between the years 2010 and 2013. One government outcome monitoring system shows the CAUTI infection rate is increasing nationally while the other shows a substantial and significant decrease.
The authors suggest that using the CDC/NSHN system for its value-purchasing initiative should be examined carefully and properly validated. As the two systems give grossly discordant results, they believe that the difference results in the definitions and data collection methods. The CDC/NHSN system does not take into account catheter use, but focuses only on catheter care. Because the AHRQ system uses a denominator of hospital discharges, it measures both catheter use and catheter care. The authors note that a metric that does not account for catheter use may place hospitals that curtail their catheter use at a disadvantage. Hospitals may receive a financial penalty while they decrease catheter use, increase their workload on the nursing staff, and provide better patient care. The authors also question the reliability of self-reported data collected by hospital employees who may have a conflict of interest and are, for the most part, not independently validated. The CDC reports that only 20 of 50 states have validation checks for quality and completeness.
The authors conclude that because the results of the two government sponsored CAUTI data collections differ, the CDC/NHSN method should be scrutinized so that hospitals are not unfairly penalize while they may actually be a well performing hospital. They note that any system with a financial penalty should be independently validated and they suggest that the CDC redefine the metric used for CAUTI by using a denominator that includes a risk-adjusted catheter use ratio.
Retrospective cohort study of inappropriate piperacillin-tazobactam use for lower respiratory tract and skin and soft tissue infections: Opportunities for antimicrobial stewardship. Havey TC, Hull MW, Romney MG, et al. American Journal of Infection Control, September 2015 (Volume 43, Issue 9, Pages 946–950). DOI: http://dx.doi.org/10.1016/j.ajic.2015.05.020
Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX
Antimicrobial stewardship has skyrocketed to the forefront of healthcare interest, including a national action plan set forth by President Obama. Overprescribing, inappropriate prescribing, and inappropriate usage by individuals have led to a serious problem with antibiotic resistance. However, antimicrobials are still needed and used daily in healthcare settings to treat known as well as suspected infections. This is done by using broad-spectrum antibiotics initially and then adjusting when organism is known.
Havey, et al, looked at the empiric use of piperacillin-tazobactam (TZP) in patients admitted with skin and skin structure infections (SSTIs) as well as lower respiratory tract infections (LRTIs) at two Vancouver hospitals within the same healthcare network (including same lab and electronic information system). They also reviewed duration of therapy with TZP from day three of admission. For this study, researchers retrospectively reviewed charts for 60 patients with SSTI and 169 patients with LRTI.
In the review of the SSTI cases, the empiric therapy with TZP was found to be inappropriate for 41.7 percent of the total cases. Of the inappropriate usage, the majority were cellulitis (with 86.7 percent inappropriate), with abscess close behind with 66.7 percent inappropriate use. A total of 138 patient days of inappropriate empirical use were seen with the SSTIs. A review done on day three could have potentially averted 89 days of inappropriate TZP therapy. The organisms seen in cultures on 42 of the patients were MSSA, streptococci, MRSA, and coagulase-negative staphylococci.
The LRTI review was mainly divided in to community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HAP) (patients with recent admission, from nursing home or long-term acute care, receiving hemodialysis, chemotherapy, or wound care) with CAP being the larger group (101 patients vs. 68). It was found that empiric TZP therapy was deemed inappropriate for 61 percent of CAP patients and 4.3 percent of HAP patients. A total of 315 patient days of inappropriate empiric use were seen in the LRTIs. Had a day three review been done, potentially 167 days of inappropriate therapy could have been saved.
The study reviewed records from January 1 through June 30, 2012. At the time, neither facility had an antimicrobial stewardship program. Havey, et al, concluded that a comprehensive and active antimicrobial stewardship program will positively affect prescribing practices. The study was limited by the retrospective design and having to solely rely on extraction from electronic records and perhaps not having all the information about antimicrobial choices at the time.
Identifying the psychological determinants of handwashing: Results from two cross-sectional questionnaire studies in Haiti and Ethiopia. Contzen N, Mosler HJ. American Journal of Infection Control, August 2015 (Volume 43, Issue 8, Pages 826–832). DOI: http://dx.doi.org/10.1016/j.ajic.2015.04.186
Reviewed by Timothy Bowers, MT(ASCP), MS, CIC, Vineland, NJ
The issues behind hand hygiene compliance have been at the forefront of infection prevention since Semelweis wrote the seminal article more than 100 years ago. Typically in healthcare we use education as a tool very often as the sole intervention to achieve a desired change in behavior. This effort goes to great lengths to illustrate the complexities of hygienic behavior. We could use this as a step to better understand our people and why they are exhibiting these behaviors.
The authors identify that many efforts are underway in the developing countries of Haiti and Ethiopia around hand hygiene. These efforts are undertaken by development and relief organizations in the form of awareness and knowledge building. Evidence shows the impact of those interventions is low in areas where the knowledge base is already high. Thus the continued effort around awareness may no longer be as effective. The authors, and the purpose of their article, is to find the next level of interventions after knowledge building.
The authors used the psychological Risk, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) of behavioral change theory in a face-to-face interview with the primary caregiver in each home. The RANAS behavioral change theory compiles many different theories so as to compare the impact of each individual theory on overall hand hygiene compliance. In terms of the study itself the number of households was high (811 in Haiti and 463 in Ethiopia) and skewed toward a major city. There was less than 5 percent refusal rate for each arm of the study. Mostly impoverished women who could not read or write participated in this study.
The study showed varying impact of each factor (ability, norm, attitude, and self-regulation) related to self-reported hand hygiene behavior. Risk factors, meaning awareness and health knowledge, were sometimes unrelated to the intended behavior, yet comprised the majority of the effort to increase hand hygiene in these countries. The conclusion of the author is that if a standard framework for hand washing campaign is developed, it should focus on more than just risk (awareness and knowledge).
The limitations of this study noted by the authors are that technological and contextual factors were not included. Additionally, other limitations included to reduce the length of the survey some factors were only measured a few times, self-reported hand hygiene compliance is unreliable, and that the studies were conducted during emergency recovery time periods.
Variation in Healthcare Worker Removal of Personal Protective Equipment. Zellmer C, Van Hoof S, et. al. American Journal of Infection Control, June 2015 (Volume 43, Issue 7, Pages 750–751). DOI: http://dx.doi.org/10.1016/j.ajic.2015.02.005
Reviewed by Maria Whitaker, MT, CIC, Cortland, NY
Appropriate removal of personal protective equipment (PPE) is crucial to reduce contamination to healthcare workers (HCWs), especially with all the new emerging pathogens. Breaches in use, including improper removal of PPE, may lead to transmission of infections.
The Centers for Disease Control and Prevention (CDC) recommendations for PPE removal were used in the study, which include removal of contaminated gloves followed by gentle removal of the gown from the back of the neck in the patient’s isolation room. This is considered full compliance. “Gentle” removal of PPE is careful, not forceful, movements.
Direct observations were performed by trained, non-infection prevention staff. They were given a checklist to collect the data. Observations were completed and documented on all HCWs entering and exiting patient’s rooms during an 18-day period, covering five different units in the tertiary academic medical center.
Deviations from protocol were common. The majority of staff did not remove their PPE in the correct order, and most of these staff did not properly dispose their contaminated PPE in the patient room. Many HCWs did not tie the backs of the gowns, which lead to the gown falling over the patient. Also, upon removal, the staff touched the contaminated gowns and gloves to their uncontaminated work clothes or with their bare hands. (Exact rates of compliance can be found in the article.)
Limitations in the study include the following: observations were not seen if doors were closed, the study was done at a single site, and contamination of the HCW following removal of PPE was not assessed.
This study indicated that more education and collaboration with hospital and HCW leaders to improve compliance is needed.
Automated tracking and ordering of precautions for MDR organisms. Quan K, Cousins SM, et. al. American Journal of Infection Control, June 2015 (Volume 43, Issue 6, Pages 577–580). DOI: http://dx.doi.org/10.1016/j.ajic.2014.12.019
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY
The June issue of AJIC contains several articles on the use of technology to assist with infection prevention activities. In one of these articles, Quan et. al. discuss their success in developing an automated system to identify patients requiring contact precautions via the electronic health record and having a seamless means to begin contact precautions that is not dependent on the infection preventionist (IP).
Their program was designed to identify patients who had positive cultures for C. difficile, MRSA, VRE, and MDR gram-negative bacteria, including CRE. Both infected and colonized patients were included. The program applied to currently hospitalized patients, as well as the past history of the patient. The time frame for the retrospective review varied by the organism and an algorithm was created to determine how far in the past the system should search. For example, cases of C. difficile were identified if they occurred within the past 60 days, whereas CRE patients were flagged indefinitely.
When a case was noted, the system sent a flag to the EHR that could be seen by the care providers immediately. Additionally, contact precautions were ordered. There was the ability for the practitioner to review and dispute the order if certain clinical symptoms were not present (e.g., a past history of C. diff but no diarrhea at this admission).
They created an organism specific algorithm to decide when contact precautions could be discontinued.
The authors noted the program had the following benefits:
- Allowed real time monitoring of events. They realized the IP might have other priorities that take them away from locating patients needing isolation.
- Isolation was implemented in a more timely fashion thereby reducing the possibility of inadvertent transmission of organisms or contamination of the environment.
- Permitted appropriate discontinuation of precautions when no longer necessary. This may be a cost saver and certainly improves patient satisfaction.
- An unexpected benefit to the EHR flags was the use by the physicians to guide therapy.
Their project marries the goals of the Joint Commission, SHEA, IDSA, and HICPAC that requires health systems to have a means to identify patients with MDROs including upon readmission. Although their efforts likely required a significant commitment from the facility, it saved 850 hours of the IP’s time, which equates to 43 hours per 1000 admissions. This is approximately one half of a work year.
Cleaning and disinfecting environmental surfaces in healthcare: Toward an integrated framework for infection and occupational illness prevention. Quinn MM, Henneberger PK, et al. American Journal of Infection Control, May 2015 (Volume 43, Issue 5, Pages 424-434). DOI: http://dx.doi.org/10.1016/j.ajic.2015.01.029
Reviewed by Vicki Allen, MSN, RN, CIC, Beaufort, SC
The cleaning and disinfection of environmental surfaces within healthcare organizations has become a focus not only for healthcare organizations themselves, but also from the solicited and unsolicited scrutiny of patients, the general public, and the media. Healthcare organizations are viewing the results of this scrutiny in several ways, including patient satisfaction surveys (e.g., Hospitals Consumer Assessment of Healthcare Providers and Systems, LeapFrog Group) such that patient perception of hospital cleanliness can impact overall patient satisfaction. The Centers for Medicare & Medicaid Services (CMS) are imposing penalties for healthcare-associated infections (HAIs) and focusing efforts on HAI prevention. Part of this effort includes the cleaning and disinfection of the environment, as well as instruments and equipment used on patients. Transparency and publishing of hospital data allows the public to shop around and offers the option to pick and choose the best and highest scoring hospitals to entrust for their care.
This study presents the results of the findings from an international cleaning and disinfecting working group of more than 40 members that reviewed current knowledge and policy, gaps in knowledge, and needs for future research and practice. The study presents very helpful information and considerations for the infection preventionist (IP) to help reduce the incidence of infectious disease and colonization in healthcare workers and patients. It offers guidance to the IP for product selection, provides recommendations for hazard communication and training, and presents the provision of safer alternatives to the many users of these products throughout the healthcare environment.
The focus to keep the healthcare environment and equipment clean, safe, and disinfected is a primary infection prevention strategy, proven many times over in the literature. The study notes that this, along with the emphasis to decrease the incidence and risk for HAIs and conditions, can result in exposure to many cleaning and disinfectant products. A thorough investigation of all disinfectants and cleaners used within the organization should review more than just the “kill claim” of the product. The authors note that considerations must be reviewed and acknowledged in an effort to protect the patient and the user from potential acute and chronic health effects, such as respiratory illness that could result from exposure.
The study recommends utilizing a multidisciplinary team—including occupational health—and an integrated approach to selection and use, hazard communication, consideration of safer alternatives, and appropriate education and training, as this is essential in the prevention of occupational illness promotion of patient safety.
Predictors of asymptomatic Clostridium difficile colonization on hospital admission. Kong LY, Dendukuri N, et. al. American Journal of Infection Control, March 2015 (Volume 43, Issue 3, Pages 248–253). DOI: http://dx.doi.org/10.1016/j.ajic.2014.11.024
Reviewed by Cynthia A. Kohan, MS, CIC, Waterbury, CT
In the article, Kong and colleagues attempt to quantify the occurrence of Clostridium difficile (C. diff) colonization in patients admitted to six acute care hospitals in Quebec, Canada. This is an extension of a study conducted in 2006 to determine the host and pathogen risk factors for healthcare-associated C. diff infection (CDI). In this study, an attempt is made to determine host and pathogen characteristics associated with asymptomatic colonization with C. diff at the time of hospital admission.
Stool samples or rectal swabs were analyzed in 5,232 patients from six acute care, university-affiliated hospitals between March 6, 2006 and June 25, 2007. Samples were taken upon admission, once per week and upon onset of diarrhea. A culture for toxigenic C. diff was performed on each sample. Cytotoxin assay and nucleic acid amplification testing was performed on the isolates to identify specific toxins, and pulse-field gel electrophoresis was performed for strain typing.
Demographic data and information on known risk factors were collected on all participating patients. This information included the use of antibiotics, chemotherapy, proton pump inhibitors, H2 blockers, corticosteroids and non-steroidal anti-inflammatory drugs in the eight weeks prior to the hospital admission. Additional factors included whether the patient was being hemodialyzed, receiving home care, or used a nasogastric tube in the eight weeks preceding hospitalization.
Those patients culture positive for C. diff on admission, or within the first 72 hours of their stay, but had no symptoms of diarrheal disease, were considered to be an asymptomatic carrier. Risk factors for this group were compared to those testing negative for C. diff.
Of the 5,232 patients tested, 4.05 percent were determined to be asymptomatic carriers. Multivariate logistic regression analysis showed that hospitalization within the last 12 months, use of corticosteroids, prior CDI, and the presence of antibody against toxin B were associated with colonization on admission. The authors conclude that additional study is needed because it is still unclear if the asymptomatic carrier may be contributing to the transmission of C. diff. History of CDI within the six months prior to admission may signify that the patient remains colonized, and able to shed, for a significant period of time. Tests of cure are not recommended and common practice is to discontinue isolation precautions upon resolution of symptoms. Screening a population of patients with targeted risk factors may prompt early isolation, a decreased amount of environmental contamination and decreased transmission.
Middle East Respiratory Syndrome Coronavirus: Implications for Health Care Facilities. Maltezou HC, Tsiodras S. American Journal of Infection Control, December 2014 (Volume 42, Issue 12, Pages 1261–1265). DOI: http://dx.doi.org/10.1016/j.ajic.2014.06.019
Reviewed by Cynthia A. Kohan, MS, CIC, Waterbury, CT
Middle East Respiratory Syndrome coronavirus (MERS-CoV) was first identified in a 60-year-old patient with fatal pneumonia in September 2012. Later, it was discovered that a cluster of severe respiratory infections that occurred in March 2012 was related to the same virus. In the following two years, 191 laboratory confirmed cases were identified, of which 82 were fatal. In March 2014, an increase in cases was noted with many occurring in healthcare settings. By May 2014, the number of identified cases rose to 536 with 145 fatal cases. The authors of this article reviewed published case descriptions and data about MERS-CoV and presented information on transmission and prevention of this disease with special emphasis on the prevention of healthcare-associated cases.
Molecular analysis of MERS-CoV and similar viruses from camels and bats suggest that these two species are the natural reservoir for the virus. Notably, the virus is stable in camel milk and suggests that zoonotic transmission occurs from the ingestion of the raw milk. The authors suggest that because there is no evidence of a genetic change in the virus to increase its transmissibility, an increase in human to human transmission from March to May 2014 may be due to an increase in primary infections as well as an increase in hospital-acquired cases.
Symptoms noted in infected patients range from none or mild symptoms, to severe pneumonia, acute respiratory distress syndrome, septic shock, and multi-organ failure. Other less severe symptoms include fever and cough, chills, sore throat, myalgias, arthralgia, vomiting, and diarrhea. It is noted that patients with existing co-morbidities will more likely develop severe symptoms.
A two-month long outbreak in Saudi Arabia, in four affiliated healthcare facilities and involving 34 patients including two healthcare workers was described. This is the largest outbreak studied thus far. Spread to healthcare workers is speculated to occur due to inadequate infection control practices with delayed identification of cases. This outbreak also raises the possibility that transmission can occur not only from direct human-to-human contact, but also indirect contact with contaminated environmental surfaces or fomites. It was found that the virus can remain viable for up to 48 hours on surfaces under common hospital environmental conditions. It was also determined through study of this outbreak that the incubation period is approximately 5.2 days.
Although this viral syndrome is primarily affecting the Arabian Peninsula, easy access to travel requires that hospitals throughout the globe be prepared to identify and isolate this virus. As there is no treatment or vaccine against MERS-CoV, prompt isolation is key to prevent additional transmission. In the U.S., the Centers for Disease Control and Prevention recommends that patients with confirmed or suspected MERS-CoV should be placed on contact and airborne precautions. This requires the use of an N95 respirator mask or equivalent, gloves, isolation gown, and eye protection. A negative pressure airborne isolation room is also required.
Much more knowledge and research is needed regarding this viral infection. The authors suggest several areas for additional study. These include a clearer determination of transmission pathways, the role asymptomatic cases play in transmission, as well as the development of a vaccine and specific antiviral agents.
Effect of a Ventilator-Focused Intervention on the Rate of Acinetobacter baumannii Infection among Ventilated Patients. Cohen R, Shimoni Z, Ghara R, et al. American Journal of Infection Control, September 2014 (Volume 42, Issue 9, Pages 996–1001). DOI: http://dx.doi.org/10.1016/j.ajic.2014.06.002
Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX
Since 2010, Laniado Medical Center (LMC) in central Israel had noted an increase in multidrug-resistant Acinetobacter baumannii in its ventilated patients. LMC was seeing prolonged hospitalization and ventilation as well as increased mortality. Investigations of outbreaks seem to indicate that the ventilators themselves were colonized; thus, focusing on this factor could be critical to controlling the outbreaks in patients.
The LMC team reviewed the current guidelines for handling and maintaining respiratory equipment and found them to be lacking in evidence and not addressing key circuit components. In addition to the guideline review, local practices regarding care of ventilator circuits were also reviewed. Because critical areas were not addressed properly, the LMC group implemented a local policy and conducted a study from those interventions. The study was conducted January 1, 2012 through March 31, 2013 with the interventions implemented April 2012 through June 2012.
The new policy included the following: 1.) breathing circuits and external bacterial filters changed every 7-14 days; 2.) stopping use of external filter in inspiratory port; 3.) all internal filters were replaced and subsequently had routine autoclave sterilization done every 4-8 weeks; 4.) daily replacement of heat and moisture exchanger filters; and 5.) keeping metered dose inhalers (MDI) connected to tubing unless no longer needed or soiled. The LMC researchers monitored these interventions for a three month period but maintained the interventions thereafter. After certain exclusions, 321 patients took part in the study and 702 sputum cultures were reviewed. A. baumannii was reduced from 33 percent to 16 percent, which was statistically significant. The time to infection was also longer after intervention (from 21 to 59 days).
A limitation of the study, as pointed out by the LMC researchers, is that more than one intervention was done at the same time. This makes it hard to know which of the five interventions was the key factor in reducing these infections. Another limitation involves the range for the circuit and filter change (7-14 days) and for the sterilization (4-8 weeks), because there is no indication of how the team decided which spectrum of the range to use.
Impact of daily chlorhexidine baths and hand hygiene compliance. Martínez-Reséndez MF, Garza-González E, Mendoza-Olazaran S, et al. American Journal of Infection Control, July 2014 (Vol. 42, No. 7, Pages 698-701). DOI: http://dx.doi.org/10.1016/j.ajic.2014.03.354
Reviewed by Crystal Heishman, BSN, RN, CIC, ONC, Louisville, KY
Previously recognized as nosocomial infections, healthcare-associated infections (HAI) are well-known causes of morbidity and mortality. Citing that 25 percent of HAIs develop in critically ill patients, a team in Nuevo Leon, Mexico took on the challenge of studying the combined effects of chlorhexidine bathing and hand hygiene on infection rates.
The study, performed at a 450-bed tertiary care hospital, took place over an 18-month period. This timeframe was divided into six month study periods: pre-intervention period (PIP), intervention period (IVP), and post-intervention period (PoIP). During the PIP, patients were bathed with soap and water, as per normal routine. During the IVP, patients were bathed daily with 2% impregnated chlorhexidine wipes, hair washed with 0.12% chlorhexidine foaming shampoo, and a hand hygiene maintenance program was initiated. Finally, the PoIP carried on with the hand hygiene program, but bathing was returned to soap and water. Prior to the IVP, staff members were instructed on a uniform method for bathing. Hand hygiene practices were discussed in small group settings with verbal reminders and frequent feedback. Observations were performed by a select group of people during the study.
Notably, infection rates decreased significantly between the PIP phase and the IVP. The global infection rate, initially 64.44 per 1,000 hospital days, dropped to 43.30 during the IVP. These rates rose again during the PoIP phase to 58.45 per 1,000 patient days. Similar results were seen for ventilator-associated pneumonia (VAP) and for catheter-associated urinary tract infections (CAUTI). Although a decrease was seen for central line-associated bloodstream infections (CLABSI), the decrease was not significant.
During the process, it was noted that while Gram-positive bacteria decreased, there was still a persistence of most Gram-negative bacteria. Unexpectedly, a decrease in cases related to Acinetobacter baumannii was discovered, dropping from 21 cases during the PIP to just seven during the IVP. In reviewing infection type, it was revealed that VAP cases relating to A. baumannii and CAUTI related to Candida spp were significantly reduced during the PIP to IVP timeframe.
Hand hygiene compliance during this study increased from 59.48 percent during the PIP to 71.23 percent during the IVP. This rate rose to 74.24 percent during the PoIP. This indicates that awareness was sufficient to significantly raise and maintain compliance. Chlorhexidine bathing was 97 percent compliant as well.
In conclusion, chlorhexidine bathing combined with increased hand hygiene compliance had an overall effect on global infection rates in the intensive care units studied. While Gram-negative bacteria remained persistent, a substantial reduction in A. baumannii and general Gram-positive bacteria did occur. VAP and CAUTI experienced significant reduction; however, the decrease in CLABSI was not found to be significant. Incidence of A. baumannii in VAP and Candida spp in CAUTI experienced a noteworthy reduction as well. Hand hygiene compliance alone did not further decrease infection rates, thus signaling the importance of a combined approach.
Hospital Clostridium difficile outbreak linked to laundry machine malfunction. Sooklal S, Khan A, Kannangara S. American Journal of Infection Control, June 2014 (Vol. 42, Issue 6, Pages 674-675). DOI: http://dx.doi.org/10.1016/j.ajic.2014.02.012
Reviewed by Maria Whitaker CIC, Cortland, NY
Clostridium difficile is a spore-forming anaerobic bacillus that is associated with diarrheal disease. C. difficile bacteria and spores are shed in the feces of some people. The spores of C. difficile can survive on surfaces for prolonged periods of time. These spores contaminate the environment. They are spread via healthcare workers hands and suboptimal environmental cleaning practices.
An academic hospital in Pennsylvania noted a drastic increase in the number of cases of healthcare facility-onset C. difficile between April 2013 and June 2013. A multidisciplinary team was formed to investigate. They looked at hospital admissions, community-onset prevalence, affected hospital floors, staffing, laboratory testing, and room cleaning practices and found that nothing had really changed to alter the surveillance data.
A breakthrough came when the laundry records were examined. Approximately 100 loads of mop heads were washed without bleach. The machine had accidently been switched to microfiber setting where the preload bleach was not added. The poorly cleansed mop pads were then reused, spreading the C. difficile spores.
To fix the problem, the microfiber setting was made obsolete. All mop pads and rags were double washed, and all hospital rooms were thoroughly cleaned. Education was provided, stressing hand hygiene, use of PPE, and appropriate isolation precautions, as well as adherence to cleaning protocols.
During the two months following the intervention, no cases of healthcare facility-onset C. difficile were noted.
This case investigation shows the importance of surveillance and outbreak investigations to reduce the risk for future occurrences.
Surgical wound irrigation: A call for evidence-based standardization of practice. Barnes S, Spencer M, Graham D, et al. American Journal of Infection Control, May 2014 (Vol. 42, Issue 5, Pages 525-529). DOI: http://dx.doi.org/10.1016/j.ajic.2014.01.012
Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY
Although long used in surgery, there is little evidence or recommendations from the American College of Surgeons, the Association of PeriOperative Registered Nurses, or APIC to support wound irrigation. An expert panel consisting of surgeons, IPs, and epidemiologists reviewed current practices and studies related to wound irrigation and identified three variables: delivery method, the volume of solution, and additives to the solution.
The amount of pressure appears to be the significant factor of the delivery mode. Studies indicate high pressure is more effective than low pressure in removing bacteria and foreign material from the wound. The authors note three disadvantages of high pressure: it may lead to tissue damage, it can push bacteria deeper into tissues, and it can increase the risk of body fluid exposure to the team.
Data related to pulsatile delivery of irrigants remains inconclusive, and a JAMA article is cited that describes an outbreak of Acinetobacter baumannii because of its use. The volume of fluid to use also remains unresolved.
The type of solution such as sterile water or saline and additives (antibiotics, antiseptics and surfactants) are discussed.
Data is presented against the use of antibiotic solutions citing cardiac and orthopedic studies that showed no difference in outcomes. Antibiotic solutions may contribute to toxicity and the development of resistance.
Surfactants have demonstrated effectiveness in animal models and cadaveric tissue in reducing bacterial contamination. However, negative effects such as hemolysis and impaired clotting limit their usefulness.
None of the commonly used antiseptics (e.g., povidone-iodine, hydrogen peroxide) have demonstrated efficacy in reducing contamination without toxicity. With one exception (a device containing chlorhexidine and sterile water), none have FDA approval for surgical wound irrigation.
The authors also mention the use of wound irrigation as a means to reduce the airborne contamination of the surgical site.
The authors summarize the following practices about surgical irrigation that are supported by published evidence:
- Elimination of antibiotic solution
- Avoidance of surfactants
- Use of sterile normal saline, sterile water and one specific medical device containing CHG followed by sterile saline
Major biological characteristics of Acinetobacter baumannii isolates from hospital environmental and patients’ respiratory tract sources. Obeidat N, Jawdat F, Al-Bakri A, et al. American Journal of Infection Control, April 2014 (Volume 42, Issue 4, Pages 401–404). DOI: http://dx.doi.org/10.1016/j.ajic.2013.10.010
Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX
Jordan University Hospital (JUH), a 550-bed tertiary care teaching hospital, conducted a prospective study to compare the survival potential, biofilm production, and antimicrobial resistance in Acinetobacter baumannii isolates from both hospital (ICU) environmental cultures and respiratory tract cultures of ICU patients. Previous studies have shown A. baumannii’s ability to survive for prolonged periods of time in unfavorable conditions, hence its rising prominence as an important infectious agent.
The nine month study (May 2009 – February 2010) looked at a total of 149 environmental cultures and 142 respiratory cultures collected in the 3 adult ICUs. Various items in the environment, such as pillows, sinks, floors, bed linens, and patient ventilation masks, were sampled randomly with 74 A. baumannii isolates recovered. The respiratory cultures were gathered using bronchoalveolar lavage, endotracheal aspirate, and sputum and were collected from 93 patients within the first 48 hours after ICU admission. Sixty-four isolates grew A. baumannii.
Other than Colistin and Tigecycline, both the environmental and respiratory cultures showed more than 60% resistance to antimicrobial agents (Amikacin, Aztreonem, Ceftazidime, Ciprofloxacin, Gentamycin, Imipenem, Meropenem, and Zosyn were the other agents). Temperature, pH, and water were studied for effect on A. baumannii growth. Isolates from either source did not grow at 4°C or 48°C but grew well at 37°C, 42°C, 45°C, and laboratory room temperature (18-24°C). Environmental isolates survived for 23 days in distilled, tap, and 0.9% saline water with a pH range of 4.5-8. The respiratory isolates liked a higher pH (5.5-8) and preferred tap and 0.9% saline water.
The last area the study addressed was biofilm production. Both the environmental and respiratory specimens formed biofilm with no significant difference in ability. Well-plates and catheters were used for both sets of isolates. A 60-second application of Sterillium or 0.2% sodium hypochlorite (NaClO) removed 99.99% of the biofilm. In dirty conditions, a 0.3% solution hypochlorite was required to have the same biofilm reduction.
The study concluded that A. baumannii strains isolated from hospital environment and the respiratory tract of hospitalized patients have mostly similar antimicrobial resistance patterns and biological characteristics, which allow them to survive very well in the hospital environment. It is extremely important to employ proper disinfection and sanitation measures in order to control the spread of Acinetobacter baumannii.
Duration of colonization with Methicillin-resistant Staphylococcus aureus (MRSA) in an acute care facility: A study to assess epidemiologic features. Rogers C, Sharma A, Rimland D, et al. American Journal of Infection Control, March 2014 (Volume 42, Issue 3, Pages 249-253). DOI: http://dx.doi.org/10.1016/j.ajic.2013.09.008
Reviewed by APIC’s Communications Committee
Healthcare facilities often presume that patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA) continue to be colonized for an extended period of time. Patients with a history of MRSA infection and/or colonization are typically placed under isolation precautions upon readmission to healthcare facilities despite a lack of evidence for duration of colonization. Due to this lack of knowledge, it is unclear how long these patients pose an infection control risk. Previous studies have not been comparable and produced varying colonization estimates ranging from a median of 5 months to longer than 48 months. Identifying factors associated with prolonged MRSA colonization could help target efficient patient screening techniques.
An MRSA directive, focusing on limiting MRSA transmission within Veterans Affairs (VA) hospitals, was issued in January 2007. A cohort study of patients hospitalized between October 1, 2007 and July 31, 2009 was conducted by the Atlanta VA Medical Center to determine the duration of and risk factors associated with MRSA colonization among discharged patients. Three mutually exclusive comparison cohorts were identified:
- Cohort A – Patients who had both a MRSA infection and nasal colonization at discharge.
- Cohort B – Patients who had a MRSA infection but no nasal colonization at discharge.
- Cohort C – Patients who did not have a MRSA infection but had nasal colonization at discharge.
The study included 231 patients with documented MRSA infection and/or nasal colonization who also provided nasal swabs for culture after discharge. Colonization was documented in 39.9 percent of these patients. The overall, median duration of colonization was 33.3 months (range of 18 to 44 months). Cohort A had a significantly longer duration of colonization compared to the other cohorts. In addition, the total duration of hospital stay from previous admissions was a predictor of persistent MRSA colonization, independent of the number of admissions.
Overall, this study determined MRSA colonization is typical for the first six months post discharge. Patients with MRSA infections and colonization (Cohort A) maintain a longer duration of colonization, suggesting a higher primary inoculum of bacteria may be an important element for persistent colonization. While further research needs to be completed, these findings suggest flagging of patients who have both MRSA infection and colonization may be required for longer time periods.
Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene behavior during routine clinical activities. Pineles LL, Morgan DJ, Limper HM, et al. American Journal of Infection Control, February 2014 (Volume 42, Issue 2, Pages 144-147) DOI: http://dx.doi.org/10.1016/j.ajic.2013.07.014
Reviewed by Carol McLay, DrPH, RN, CIC
Hand hygiene is a critical part of infection prevention and health organizations are continuously struggling to improve health care personnel (HCP) compliance with hand hygiene (HH) activities. The current gold standard for monitoring compliance is direct observation, which is time-consuming and costly.
To improve compliance, a growing number of healthcare facilities are installing automated hand hygiene systems. Automated systems include counting systems, ultrasound, infrared, Wi-Fi, and radiofrequency identification (RFID). However, there is little evidence-based research documenting the reliability of these devices in clinical settings.
The aim of this multicenter study was to assess the accuracy of the RFID badge in detecting HCP activity including room entry, room exit, and HH compliance. The authors compared direct observation with data collected by the RFID system in a simulated validation or idealized setting (Phase 1) and to a real-life clinical setting at two large academic medical centers (Phase 2).
Accuracy for identifying HH events was high in the validation setting (88.5 percent) but was relatively low (52.4 percent) during real-life clinical activities. This difference was statistically significant (P<0.01). Accuracy for detecting HCP movement into and out of patient rooms was also high in the simulated setting but not in the real-life clinical setting (100 percent accuracy on entry and exit vs. 54.3 percent accuracy on entry and 49.5 percent on exit, P<0.01). The authors attribute this result to improper positioning of HCP in front of the sensors, and quick “fly-by” handwashing.
The study is limited by the small study population of 31 HCP providing data in the clinical setting. Furthermore, overall unit level HH compliance was not monitored before and after installing the RFID system. However, this is the first multisite validation of a commercially available RFID HH monitoring system, and the study provides useful information to help infection preventionists understand the limitations of using technology as a monitoring tool.
The authors conclude that more research is necessary to further develop these systems and improve accuracy prior to widespread adoption.
Association between health care workers’ knowledge of influenza vaccine and vaccine uptake. Jaiyeoba O, Villers M, Soper DE, et al. American Journal of Infection Control, January 2014 (Volume 42, Issue 1, Pages 69-70). DOI: http://dx.doi.org/10.1016/j.ajic.2013.06.020
Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX
Influenza vaccination rates among healthcare personnel (HCP) have, historically, been low. Medical University of South Carolina (MUSC) saw its vaccination rates prior to 2010 ranging from 40-60 percent, with vaccination being voluntary. For the 2010-2011 season and beyond, MUSC instituted a new policy requiring all employees who refused influenza vaccine to complete a declination form indicating medical contraindication, religious belief, or personal preference. Those refusing would also have to wear a mask at all times when in patient care areas during the designated flu season.
A cross-sectional survey study was conducted to evaluate HCP knowledge and opinions regarding influenza vaccine. The study included nursing staff, attending and resident physicians, and medical students. Only 21 percent of the surveys were completed. Vaccine knowledge survey results noted a) 88 percent of physicians and 67 percent of nurses agreed it was unlikely for the vaccine to cause severe reactions; b) 69 percent of physicians and 42 percent of nurses agreed vaccine was effective in preventing influenza; and c) 84 percent of physicians and 70 percent of nurses agreed it was unlikely to contract influenza from the vaccine.
In 2009 with the voluntary vaccination program, the facility had 55 percent compliance rate. For the 2010-2011 season, the overall vaccination rate had a significant increase to 95 percent (P <.0001). They concluded that the vaccine uptake was due to the declination form and the requirement to wear a mask during influenza season. The study revealed that staff who had been previously vaccinated were more likely to receive subsequent vaccinations. Reasons for declining vaccine were “personal preference” (43 percent of HCP), “concerned about adverse effects” (18 percent), “influenza-like illness with previous vaccination” (16 percent), and only 4 percent had medical contraindications.
The study results may suggest a shift in culture emphasizing patient safety and prevention of adverse events, especially in physicians as 44 percent of them received the vaccine because of patient care compared to only 23 percent of nurses. More education for HCP is needed about the benefits of vaccination, the transmission of disease, and the HCP role in educating patients as they may get a “mandated” vaccine but not recommend or offer the vaccine. MUSC’s study findings mirror that of other organizations that have concluded that voluntary programs are less effective in part because of HCP misconceptions about the vaccine.
Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. Parry MF, Grant B, Sestovic M. American Journal of Infection Control, December 2013 (Volume 41, Issue 12, Pages 1178-1181). DOI: http://dx.doi.org/10.1016/j.ajic.2013.03.296
Reviewed by Maria Whitaker BS, MT, CIC Cortland, NY
Catheter-associated urinary tract infections (CAUTIs) are the most common hospital acquired infection. They lead to excess costs, increased length of stay, and patient morbidity.
Stamford Hospital, a 300-bed community teaching hospital in Connecticut, achieved a 50 percent hospital-wide reduction in catheter use and a 70 percent reduction in CAUTIs over a 36-month period. The primary component of this initiative was a nurse-directed, catheter removal protocol. On a daily basis, nurses used a pre-approved checklist to determine if the catheter was still needed. If criteria were not met, the physician was notified and the nurse removed the catheter.
The interventional study utilized three other key elements:
- Physician documentation of the criteria for catheter insertion was mapped to the nursing checklist. A physician order for catheter use was linked to the order for “Foley Maintenance Protocol” for nursing which included standard care and the nurse-driven removal protocol.
- A device-specific charting module was added to physician electronic progress notes to remind them that the patient has a catheter and questioned if it was still indicated.
- Bi-weekly unit-specific feedback on catheter use rates and CaUTI rates was presented to key stakeholders.
This study showed that lower catheter use, and reduced CAUTI rates were effectively reduced by the implementation of the nurse-driven removal protocol. Savings from the initial program were estimated at $100,000 and six lives.
Tensions inherent in the evolving role of the infection preventionist. Conway LJ, Raveis VH, Pogorzelska-Maziarz M, et al. American Journal of Infection Control, November 2013 (Volume 41, Issue 11, Pages 959-964). DOI: http://dx.doi.org/10.1016/j.ajic.2013.04.008
Reviewed by Elizabeth Monsees, RN, MSN, MBA, CIC, Kansas City, MO
Infection Prevention and Control is a well-established science with an evolving role for the infection preventionist (IP). Using documentation from the Certification Board in Infection Control (CBIC), Conway, et al., identify that in a period of five years the IP paradigm shifted from primary collectors of data to policy setters and leaders of performance improvement teams. The authors outline that while staffing has increased since 1976, it has not accounted for the exponential growth of responsibilities beyond surveillance, despite that task persisting as the largest segment of IP utilization.
The authors conducted a qualitative study with IPs purposively sampled from 250 nonspeciality acute care hospitals across the United States. The interviews addressed the overall structure, function, roles, staffing composition, regulatory requirements and barriers to infection prevention. Respondents all worked in settings with greater than one IP, average tenure was 8.5 years and experience ranged from 1-26 years, and 52 percent were certified in infection prevention and control. Four themes were reported: “1) expanding responsibilities outstrip resources 2) shifting role boundaries create uncertainty 3) evolving mechanisms of influence involve trade-offs and 4) the stress of constant change is compounded by chronic recurring challenges.”
IPs articulated a responsibility to lead organizational efforts but lacked authority to hold staff accountable. Additionally, dialog with IPs yielded that competing administrative or technology demands limited the amount of time they could interact with staff “that leads to real change.” This perception, as noted by the authors, has questionable association with institutional compliance with recommended infection prevention strategies. One of the central tenets of APIC’s Strategic Plan 2020 which supports implementation science methodologies, is to help inform IPs of leadership or educational approaches with proven effectiveness. An understanding of systems-thinking and implementation research will help the IP influence behaviors and move beyond awareness (education) through application (practice) to the way the individual performs consistently (sustainability).
Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: Epidemiology, molecular analysis and risk factors. Iosifidis E, Evdoridou I, Agakidou E, et al. American Journal of Infection Control. October 2013 (Volume 41, Issue 10, Pages 857-861). DOI: http://dx.doi.org/10.1016/j.ajic.2013.02.005
Reviewed by Irena L. Kenneley, PhD, APRN-BC, CIC, Cleveland, OH
Vancomycin-resistant Enterococcus (VRE) has been associated with outbreaks occurring in Neonatal Intensive Care Units (NICU). As a group, the Enterococci are known to cause serious healthcare-associated infections (HAIs), such as bacteremia, peritonitis, endocarditis, and device-related infections. These infections have occurred not only in adults, but in children and neonates as well. In recent years, there has been a documented increase in VRE infections in children and neonates.
Infections caused by VRE have higher mortality rates, longer lengths of hospital stay, and higher costs than the vancomycin susceptible strains. When an outbreak has occurred and VRE was the causative agent, there usually were high levels of colonization by VRE preceding the outbreak. Therefore it is important to detect VRE colonization so that implementation of infection prevention strategies can be instituted.
This study began after the occurrence of two serious cases of VRE infections (ventriculoperitoneal shunt and a bacteremia both successfully treated with linezolid) in a 44-bed NICU in Greece. Bundled infection control interventions included: 1) active surveillance cultures for VRE; 2) enhanced infection control measures; and 3) audits on antimicrobial use. Infection preventionists worked with NICU nurses and physicians as a team to enhance infection control practices, such as contact precautions for all colonized neonates and standard precautions for non-colonized neonates. Those neonates colonized with VRE were cohorted. Written daily reports on the neonates’ VRE status were distributed to all clinicians. Finally, extensive environmental surface cleaning was maintained throughout the outbreak.
The timeframe for the study was June 2008 to December 2008. The VRE isolates were identified using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study approach was conducted in order to identify predictors for neonates at higher risk.
Results of active surveillance cultures showed that 39.9 percent of neonates in the NICU were colonized with VRE. The institution of an active surveillance program in the NICU was found to be extremely important in preventing the further spread of VRE infection. The case-control study results indicated that there was a significant association between a high prevalence of VRE colonization in the NICU and antimicrobial use actually promoted the acquisition of VRE. The authors described colonization pressure occurs when there is a high prevalence of VRE in the NICU.
Conclusions of the study indicate that in order to stop the spread of VRE in the NICU, enhanced infection control measures and optimizing the use of vancomycin led to a significant reduction of VRE incidence and prevalence in the NICU. The authors state that continuous monitoring of bundled infection control interventions in daily practice and the implementation of an antimicrobial stewardship program are essential for optimal infection prevention of VRE.
Prevalence and factors associated with 2009 to 2011 influenza vaccinations at a university medical center. Crowley KA, Myers R, Magda LA, et al. American Journal of Infection Control. September 2013 (Volume 41, Issue 9, Pages 824-830). DOI: http://dx.doi.org/10.1016/j.ajic.2012.11.020
Reviewed by Vicki Allen, MSN, RN, CIC, Huntsville, NC
Mandatory Influenza vaccination of healthcare personnel has become a requirement of many healthcare organizations nationwide. Hospitals and healthcare systems are making the decision to implement mandatory flu vaccination policies in an effort to protect healthcare personnel, patients, families, and visitors against influenza illness. As the vaccination of healthcare personnel can result in reduction of influenza infection and absenteeism, not to mention patient safety factors, it is not difficult to see why healthcare organizations including ACIP, SHEA, APIC, and IDSA are strongly promoting this effort.
This study was designed to identify factors that influenced influenza vaccination during two flu seasons at a major university medical center. A questionnaire requiring around 10 minutes to complete included questions on demographics, general knowledge, vaccination history and barriers to taking the vaccine. It was distributed to clinical and non-clinical personnel.
Review of the results indicated that vaccination rates were highest for clinical personnel over non-clinical personnel. The point was driven home by highlighting that all personnel are essential including non-clinical and support staff, so it is imperative that the importance of the vaccine is stressed for all personnel working in the organization. The study further identified that non-clinical personnel were more apt to take the flu vaccine if they had received prior training again underscoring the significance of education, training, and promotion of the annual flu vaccine.
As TJC (The Joint Commission) requires accredited organizations to annually evaluate influenza vaccination rates and the reasons given for declining the flu vaccine, this article is able to provide some additional knowledge and helpful discussion regarding effective planning and development of influenza campaigns. This study draws attention to the usefulness of reviewing declination reasons in an effort to create and implement strategies aimed at increasing compliance of healthcare workers taking this vaccine.
Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin. Thompson P, Houston S. American Journal of Infection Control. July 2013 (Volume 41 issue 7 Pages 629-633). DOI: http://dx.doi.org/10.1016/j.ajic.2012.09.003
Reviewed by Carol McLay, RN, MPH, DrPH, CIC, Lexington, KY
Methicillin-resistant Staphylococcus aureus (MRSA) has become the leading causative pathogen for surgical site infections (SSIs) in community hospitals. Infections with MRSA are associated with increased mortality rates, longer lengths of hospital stays and increased hospital expenditures.
Prevention of MRSA colonization and infection has been a major focus of the infection prevention team at in this university-affiliated, private not-for-profit, level 1 trauma center in Florida, with a primary goal of preventing hospital-acquired infections in high-risk patient populations.
This case control study examined MRSA SSI rates before and after implementation of a facility-wide MRSA SSI protocol. All adult patients undergoing cardiac, orthopedic, vascular, or neurosurgical procedures received a prophylactic five-day course of intranasal mupirocin and daily nonrinse two percent chlorhexidine gluconate (CHG) cloth baths beginning one day before surgery and continuing the day of surgery and on postoperative days one to three. Facility-wide education was an important component in the successful implementation of this MRSA prophylaxis regimen. The hospital used standardized pre-signed physician order sets for the implementation of this protocol to ensure compliance. No other interventions were made during this time.
Facility-acquired MRSA SSIs among the non-general surgical population in this facility decreased by 72 percent during the study period, a statistically significant decline. The authors reported 19 fewer MRSA SSIs during the first year, and 26 fewer MRSA SSIs during the second year, representing a total of 1,035 fewer hospital days, prevention of 6 deaths, and cost savings of approximately $2,745,000.
This study adds to a growing research base indicating the importance of effective MRSA prophylaxis among surgical populations.
Oral Abstract: Eliminating Annual Employee TST Testing: One Hospital's Story (Publication 009, Presented by Jennifer Pruden, RN, CIC, Infection Preventionist, Hackettstown Regional Medical Center, at APIC Annual Conference 2013)
Reviewed by Carol McLay, RN, MPH, DrPH, CIC, Lexington, KY
Annual tuberculin skin testing (TST) of all employees in the acute care setting is a labor intensive task that requires many steps; including mailing out reminder memos, administering the TST, initial documentation, re-evaluation, and then final documentation. For staff members who require a second reminder letter, or forget to return for the reading, more time is required.
The infection prevention team at this New Jersey healthcare facility analyzed five years of data and after reviewing the NJ State TB Risk Assessment guidelines and the 2005 CDC Guidelines for Preventing Transmission of M. tuberculosis in Health-care Settings, concluded that they were a low-risk facility for TB. Their hospital had no newly diagnosed TB patients, zero employee exposures, zero employee conversions, and a total of five TB patients for the entire county.
They contacted the NJ State TB Program Director to request a re-evaluation of their need for annual employee TB testing and in April 2012 received the approval to suspend their annual employee screening program. This decision was based on the historically low number of TB cases treated at the hospital, and the low probability of an exposure to undiagnosed TB due to low incidence in the community. Their TB Control Program Plan was modified to include: providing the initial two-step employee Mantoux Tuberculin Skin test for new hires, developing an annual employee TB symptom assessment completed with annual N95 mask fit testing and an expanded contact investigation procedure for any future exposures. The annual TST screening will resume if the criterion for “medium risk” be reached in any subsequent year.
Resources are being stretched to their limits due to growing state and federal mandates and reporting requirements. The author of this abstract concluded that facilities with a low risk for TB may benefit from re-examining tuberculosis data to determine if their annual TB practices can be safely modified.