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Hospital Construction and Infection Control: Does Everyone Measure Up?
E104
Vol. 34 No. 5
Publication Number 12-123
A Pseudo Outbreak of Pantoea dispersa in Total Joint Replacement Procedures DT Barron, BSN, CIC AA Eades, MT, MPH, CIC J Kane, MD Infection Control, Kaiser Sunnyside Medical Center, Clackamas, OR, USA BACKGROUND/OBJECTIVES: Kaiser Sunnyside Medical Center is a 196 bed acute care hospital located in a suburb of Portland, Oregon. Infection Control staff includes two full time practitioners (ICPs). In March of 2005 Infectious Disease notified Infection Control of an unusual bacterium cultured from intra-operative tissue specimens of two patients who underwent total joint procedures in March. The organism, Pantoea dispersa, is a gram negative bacillus usually found in the environment and in agriculture. METHODS: Infection Control reviewed charts of both patients and consulted with both surgeons, microbiology and the Orthopedic Charge Nurse. Both patients had complex cases with surgical site infections, caused by coagulase negative Staphalococcus (CNS), complicating the original joint replacement procedure. The procedures when Pantoea was cultured were the second step in a two step process to treat the infection caused by CNS. The first step was to remove the original joint prosthesis and place antibiotic impregnated spacers. The second step was to remove the spacers and insert a new prosthesis. During this second step tissue was taken for stat gram stain and culture. Gram stains for both patients were negative. Cultures grew Pantoea dispersa. Operating Room visits by Infection Control included extensive interviews with Orthopedic Charge Nurse with detailed explanation of procedure for antibiotic impregnated spacers, the only commonality between the two patients. Investigation did not reveal possible source of organism during procedures when spacers were placed. Investigation of procedures when tissue cultures were taken identified three common staff. The OR environment was evaluated including the HVAC system. Cultures of the environment, staff, prep, and scrub solutions did not yield Pantoea. Infection Control staff observed a similar case that included stat gram stain. Tissue samples were taken and handed to the ICP who transported them to the lab. RESULTS: In the lab both ICPs observed the process for stat gram stain. During this procedure sterile saline is added to the tissue and ground up. It was noted that tape on the rack of test tubes containing sterile saline was dated September 2001. Sterile saline used for stat gram stains was prepared by the Regional Lab. The gram stain was negative and the tissue was sent for culture. Two test tubes of sterile saline were also sent for culture. Cultures from tissue and both test tubes grew Pantoea dispersa. CONCLUSIONS: Pantoea dispersa cultured from the intra-operative tissue of 3 total joint patients was a laboratory contaminant and did not cause infections in the patients. This pseudo-outbreak was caused by contaminated sterilized saline used to process stat gram stains that was close to four years old. Saline sterilized at the regional lab and sent to the KSMC lab is now labeled with outdates and discarded after two weeks.
Patient Safety Publication Number 13-124
Hospital Construction and Infection Control: Does Everyone Measure Up? LE Ruhl, BS, RN1 JL Mayfield, RN, MPH1
June 2006
E105
KF Woeltje, MD, PhD2 1 2
Infection Control, Barnes-Jewish Hospital, St. Louis, MO, USA Division of Infectious Disease, Washington University, St. Louis, MO, USA
BACKGROUND/OBJECTIVES: Healthcare associated infections (HAI) related to construction projects are well documented. In June of 2004, a patient was diagnosed with a HAI aspergillus infection. This patient was housed on a nursing unit adjacent to a renovation project. While aspergillus levels are highest in late summer and early fall, the cause of this patient’s infection could not be definitively determined. Infection Control Policies and Procedures are in place and were followed for this project. A review of current practices and evaluation of compliance with these policies was conducted to ensure that this facility does everything necessary to protect patients from exposure to airborne fungi and molds that may be generated or present during construction activities. METHODS: A Failure Mode Effects Analysis (FMEA) team was formed to evaluate current practice and compliance with policies. The team members represented Infection Control, Environmental Health and Safety, Design and Construction, Facilities Engineering, Nursing and Patient Safety and Quality. Hospital policies and procedures were compared to CDC environmental guidelines and process maps were created to identify the failure modes. The undesirable variations in the process were rated based on severity of risk. The team then identified corrective and preventive actions. Finally, the team took on the task of redesigning the underlying systems or the process itself to eliminate barriers to compliance. The process was revamped and the new processes were tested and evaluated. The new strategies were implemented and the results monitored. RESULTS: The Infection Control Risk Assessment (ICRA) was changed to make it easier to use. The process of contractor evaluation was changed. All departments involved in the construction and renovation process were included in the evaluation. Work permits were designed to ensure that smaller projects were included in the ICRA process. An educational program, including in-house contractors, was started. Since the implementation of the new form, and the educational sessions there has been a 283% increase in ICRA submissions. CONCLUSIONS: A multi-disciplinary team evaluating process and practice is beneficial in determining and eliminating barriers. In order for proper practice to be followed, all involved must be aware of process. The process cannot be too difficult, which creates barriers and sets process up to fail.
Publication Number 13-125
Enhanced Isolation Practices To Improve Patient Safety: Preventing Nosocomial Transmission in a Hospital MA Pass, RN, MS, CIC1 X Song, MD1 K Mackie, RN, MA, CIC1 TM Perl, MD1 1
Hospital Epidemiology and Infection Control, The Johns Hopkins Medical Institutions, Baltimore, MD, USA ISSUE: Healthcare associated infections (HAI) are transmitted by predictable routes. Reservoirs and susceptible hosts contribute significantly. Transmission occurs via the indirect spread of pathogens from these identified reservoirs to susceptible hosts. In 2006, the Joint Commission National Patient Safety Goals propose reducing HAI. PROJECT: Isolation precautions (IP) at the Johns Hopkins Hospital (JHH, 1026 bed capacity) are designed to prevent transmission of microorganisms. In an effort to provide quicker and more efficient use of our infection control resources, we developed a new computer program with TheraDoc that generated a log that provides real-time data on patients with 11 epidemiologically significant microorganisms/drug resistance patterns. These logs were transmitted to the units listing patients that required isolation. Patients having more than one organism requiring isolation were triaged ‘‘hierarchally’’ to facilitate appropriate isolation.
Vol. 34 No. 5
Publication Number 12-123
A Pseudo Outbreak of Pantoea dispersa in Total Joint Replacement Procedures DT Barron, BSN, CIC AA Eades, MT, MPH, CIC J Kane, MD Infection Control, Kaiser Sunnyside Medical Center, Clackamas, OR, USA BACKGROUND/OBJECTIVES: Kaiser Sunnyside Medical Center is a 196 bed acute care hospital located in a suburb of Portland, Oregon. Infection Control staff includes two full time practitioners (ICPs). In March of 2005 Infectious Disease notified Infection Control of an unusual bacterium cultured from intra-operative tissue specimens of two patients who underwent total joint procedures in March. The organism, Pantoea dispersa, is a gram negative bacillus usually found in the environment and in agriculture. METHODS: Infection Control reviewed charts of both patients and consulted with both surgeons, microbiology and the Orthopedic Charge Nurse. Both patients had complex cases with surgical site infections, caused by coagulase negative Staphalococcus (CNS), complicating the original joint replacement procedure. The procedures when Pantoea was cultured were the second step in a two step process to treat the infection caused by CNS. The first step was to remove the original joint prosthesis and place antibiotic impregnated spacers. The second step was to remove the spacers and insert a new prosthesis. During this second step tissue was taken for stat gram stain and culture. Gram stains for both patients were negative. Cultures grew Pantoea dispersa. Operating Room visits by Infection Control included extensive interviews with Orthopedic Charge Nurse with detailed explanation of procedure for antibiotic impregnated spacers, the only commonality between the two patients. Investigation did not reveal possible source of organism during procedures when spacers were placed. Investigation of procedures when tissue cultures were taken identified three common staff. The OR environment was evaluated including the HVAC system. Cultures of the environment, staff, prep, and scrub solutions did not yield Pantoea. Infection Control staff observed a similar case that included stat gram stain. Tissue samples were taken and handed to the ICP who transported them to the lab. RESULTS: In the lab both ICPs observed the process for stat gram stain. During this procedure sterile saline is added to the tissue and ground up. It was noted that tape on the rack of test tubes containing sterile saline was dated September 2001. Sterile saline used for stat gram stains was prepared by the Regional Lab. The gram stain was negative and the tissue was sent for culture. Two test tubes of sterile saline were also sent for culture. Cultures from tissue and both test tubes grew Pantoea dispersa. CONCLUSIONS: Pantoea dispersa cultured from the intra-operative tissue of 3 total joint patients was a laboratory contaminant and did not cause infections in the patients. This pseudo-outbreak was caused by contaminated sterilized saline used to process stat gram stains that was close to four years old. Saline sterilized at the regional lab and sent to the KSMC lab is now labeled with outdates and discarded after two weeks.
Patient Safety Publication Number 13-124
Hospital Construction and Infection Control: Does Everyone Measure Up? LE Ruhl, BS, RN1 JL Mayfield, RN, MPH1
June 2006
E105
KF Woeltje, MD, PhD2 1 2
Infection Control, Barnes-Jewish Hospital, St. Louis, MO, USA Division of Infectious Disease, Washington University, St. Louis, MO, USA
BACKGROUND/OBJECTIVES: Healthcare associated infections (HAI) related to construction projects are well documented. In June of 2004, a patient was diagnosed with a HAI aspergillus infection. This patient was housed on a nursing unit adjacent to a renovation project. While aspergillus levels are highest in late summer and early fall, the cause of this patient’s infection could not be definitively determined. Infection Control Policies and Procedures are in place and were followed for this project. A review of current practices and evaluation of compliance with these policies was conducted to ensure that this facility does everything necessary to protect patients from exposure to airborne fungi and molds that may be generated or present during construction activities. METHODS: A Failure Mode Effects Analysis (FMEA) team was formed to evaluate current practice and compliance with policies. The team members represented Infection Control, Environmental Health and Safety, Design and Construction, Facilities Engineering, Nursing and Patient Safety and Quality. Hospital policies and procedures were compared to CDC environmental guidelines and process maps were created to identify the failure modes. The undesirable variations in the process were rated based on severity of risk. The team then identified corrective and preventive actions. Finally, the team took on the task of redesigning the underlying systems or the process itself to eliminate barriers to compliance. The process was revamped and the new processes were tested and evaluated. The new strategies were implemented and the results monitored. RESULTS: The Infection Control Risk Assessment (ICRA) was changed to make it easier to use. The process of contractor evaluation was changed. All departments involved in the construction and renovation process were included in the evaluation. Work permits were designed to ensure that smaller projects were included in the ICRA process. An educational program, including in-house contractors, was started. Since the implementation of the new form, and the educational sessions there has been a 283% increase in ICRA submissions. CONCLUSIONS: A multi-disciplinary team evaluating process and practice is beneficial in determining and eliminating barriers. In order for proper practice to be followed, all involved must be aware of process. The process cannot be too difficult, which creates barriers and sets process up to fail.
Publication Number 13-125
Enhanced Isolation Practices To Improve Patient Safety: Preventing Nosocomial Transmission in a Hospital MA Pass, RN, MS, CIC1 X Song, MD1 K Mackie, RN, MA, CIC1 TM Perl, MD1 1
Hospital Epidemiology and Infection Control, The Johns Hopkins Medical Institutions, Baltimore, MD, USA ISSUE: Healthcare associated infections (HAI) are transmitted by predictable routes. Reservoirs and susceptible hosts contribute significantly. Transmission occurs via the indirect spread of pathogens from these identified reservoirs to susceptible hosts. In 2006, the Joint Commission National Patient Safety Goals propose reducing HAI. PROJECT: Isolation precautions (IP) at the Johns Hopkins Hospital (JHH, 1026 bed capacity) are designed to prevent transmission of microorganisms. In an effort to provide quicker and more efficient use of our infection control resources, we developed a new computer program with TheraDoc that generated a log that provides real-time data on patients with 11 epidemiologically significant microorganisms/drug resistance patterns. These logs were transmitted to the units listing patients that required isolation. Patients having more than one organism requiring isolation were triaged ‘‘hierarchally’’ to facilitate appropriate isolation.