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A Pilot Study for a Community-Level Infection Control Program
E66
American Journal of Infection Control June 2009
issues include securing sharps and medications, linen storage, and cleanliness. The EOC team sends certificates to units with perfect scores which are framed and proudly displayed. Staff are more aware of the need to use safe sharps products, cover linen, keep sharps containers from overflowing, and flag charts of isolated patients. Lessons Learned: Involving many persons in the EOC survey process increases awareness of what is needed to keep the medical center ‘‘survey ready.’’ As with many external surveys, the internal EOC surveys are no longer announced to insure a state of constant readiness. This continuous attention to detail has increased readiness, patient safety, and quality of care.
Presentation Number: 7-74
Routine Implementation of Water Restriction to Prevent Legionnaires’ Disease Carolyn B. Scott, RN, BSN, CIC, Mary Ellen Rafferty, RN MS CIC, Infection Prevention Specialist; Mary George, PhD, Microbiology Director; Raymond P. Smith, MD, Infectious Disease Physician, Lead, Samuel Stratton VAMC, Albany, NY Issue: In September 2006, a culture confirmed case of LegionnairesÕ disease was linked to the potable water in the ICU at the Samuel Stratton by an epidemiologic and laboratory investigation. A house-wide water restriction caused media attention and became disruptive for the facility. Environmental culturing yielded a percent positivity for Legionella pneumophila facility wide of 62%, and 100% positivity in the ICU. Routine sampling from 9/06 through 11/08 has yielded an average 65% positivity in ICU, and 14% positivity facility-wide excluding the ICU. The ICU has remained a nidus for Legionella colonization of the potable water system, despite attempts at remediation. Project: The facility devised and implemented Water Safety Precautions for patients who meet specific clinical or location criteria to prevent potential exposures to Legionella pneumophila from the facility’s potable water. These precautions are implemented with a . 30% positivity facility wide or localized in a specific unit, and as a precaution during planned or unplanned disruptions to the potable water system. Water Safety Precautions include bottled water for ingestion and shower restrictions. Point of use filters were also installed in the ICU March 2008. Results: Patients in the ICU were on Water Safety Precautions from September 2006 through April 2008, until the point of use filters were installed in the unit. Patients outside of the ICU who met specific clinical criteria were on Water Safety Precautions from September 2006 to April 2007. Water Safety Precautions were also initiated for two construction events as a mitigation strategy since September 2006. Since the inception of the Water Safety Precautions strategy, no patients have acquired LegionnairesÕ disease with an epidemiological link to the ICU, despite average 65% positivity in the unit. The implementation of Water Safety Precautions has become routine, without major disruption in facility operations. Lessons Learned: Environmental control of Legionella sp. in potable water systems are complex. Implementation of bottled water facility-wide can be disruptive and costly for facilities. A routine program for the implementation of water restrictions can decrease the risk of LegionnairesÕ disease without major disruption and fear among patients and staff.
Infection Prevention and Control Programs Presentation Number: 8-75
A Pilot Study for a Community-Level Infection Control Program Shahram Rahimian, MD, PhD, Director of Clinical Research, Ilumina Clinical Associates, Johnstown, PA. Background: Multiple Drug Resistance Organisms (MDRO) in General and Methicillin Resistant Staphylococcus Aureus (MRSA) in particular have long been pathogens in healthcare facilities, but in the past decade, mainly
www.ajicjournal.org Vol. 37 No. 5
E67
MRSA has emerged as a problematic pathogen in the community settings as well. MRSA is endemic and a part of the bacterial flora among a portion of the population in the US but studies show that a single clone with different structure and risk factors of Community Associated MRSA (CA-MRSA) accounts for the majority of infections. This strain is originated in the community and is not related to MRSA strains from healthcare settings. The consistent increase of MDRO infections among non-healthcare settings and the related consequences in the United States prompted us to create an infection control program with focus on MRSA as an indicator to determine the colonization level and related risk in the community settings. Objectives: 1.Standardization of community-based infection control programs 2.Development of guidelines and SOP’s for outbreak investigation and responsiveness 3.Evaluate methodology for surveillance and proper remediation and corrective actions in non-healthcare facilities 4.Provide epidemiological data about MRSA as an indicator for other MDRO’s in the community 5.Minimize amount of work-hours lost due to illness (immeasurable) 6.Minimize insurance costs otherwise are sure to increase if MRSA persists 7.Minimize facility costs due to potential lawsuits (immeasurable). Methods: The main barrier was lack of epidemiologic data to support the methodology in non-healthcare settings and almost all of previous statistics were collected from hospitals and we decided to start with a pilot study in a smaller scale utilizing the following methodology;1. Facilities with high density populations (Military and Educational) were selected 2.A site survey was performed to detect the high risk places for targeted surveillance.3. Classic culture, gram-staining, and antibiogram were performed 4. MRSA positive samples were sub-typed by Pulsed-field gel electrophoresis (PFGE), Multi-locus sequence typing (MLST) & Sanger or Next-generation sequencing 6. Surveys were sent to evaluate the infection rate among staff and their families 5. Data was transferred to the research center on a daily bases 6. Results were evaluated to prepare recommendations for corrective actions 7. Repeated environmental sampling. Results: A total of 7,103 samples were collected from 2 facilities; 19% of them were MRSA positive, 8.03% of them were USA300 and 5.11% were USA400 in initial testing and there was a higher infection rate among families than from general population(p,0.05). The data after second testing showed significant decrease (.40%)in the infection rate just by implementing the main infection control procedures. Conclusion: Personal hygiene and infection control measures found to be effective to reduce the infection rate among non-healthcare settings, although in order to show the cost effectiveness of such an infection control program it should be expanded to a larger scale and by creating a network for all involved centers it can be implemented as an biohazard and respond system to fight against epidemic infections and bioterrorism attacks.
Presentation Number: 8-76
A Successful Campaign to Certify Employees in Hand Hygiene Competency Eileen Taylor, RN, BSN, IPP, Dartmouth Hitchcock Medical Center, Lebanon, NH. Issues: Improving hand hygiene (HH) compliance continues to be a challenge for our infection prevention program and the hospital. As part of a multi-faceted hospital wide campaign to improve HH performance, we developed a HH Training and Competency Certification program for all employees. Our aim is to ensure that all employees have completed education and training in HH and has demonstrated competency in why, when and how to perform hand hygiene. Project: We developed an electronic learning module on HH, with a post-module quiz, successful completion of which is required annually for all employees. The module includes our HH policy, with explanation of the why, when and how of hand hygiene. A video demonstration of proper HH techniques is available on line. After completion of the e-learning module, staff are encouraged to be ‘‘certified’’ in HH competency. The infection preventionists carry out the majority of the certifications. There are a few specific groups that have designated ambassadors, trained by the IPP’s to certify staff in their areas. New employees, including house staff, are certified during orientation. For certification of current staff, the hospital’s Engineering department constructed a working, mobile ‘‘hand hygiene
American Journal of Infection Control June 2009
issues include securing sharps and medications, linen storage, and cleanliness. The EOC team sends certificates to units with perfect scores which are framed and proudly displayed. Staff are more aware of the need to use safe sharps products, cover linen, keep sharps containers from overflowing, and flag charts of isolated patients. Lessons Learned: Involving many persons in the EOC survey process increases awareness of what is needed to keep the medical center ‘‘survey ready.’’ As with many external surveys, the internal EOC surveys are no longer announced to insure a state of constant readiness. This continuous attention to detail has increased readiness, patient safety, and quality of care.
Presentation Number: 7-74
Routine Implementation of Water Restriction to Prevent Legionnaires’ Disease Carolyn B. Scott, RN, BSN, CIC, Mary Ellen Rafferty, RN MS CIC, Infection Prevention Specialist; Mary George, PhD, Microbiology Director; Raymond P. Smith, MD, Infectious Disease Physician, Lead, Samuel Stratton VAMC, Albany, NY Issue: In September 2006, a culture confirmed case of LegionnairesÕ disease was linked to the potable water in the ICU at the Samuel Stratton by an epidemiologic and laboratory investigation. A house-wide water restriction caused media attention and became disruptive for the facility. Environmental culturing yielded a percent positivity for Legionella pneumophila facility wide of 62%, and 100% positivity in the ICU. Routine sampling from 9/06 through 11/08 has yielded an average 65% positivity in ICU, and 14% positivity facility-wide excluding the ICU. The ICU has remained a nidus for Legionella colonization of the potable water system, despite attempts at remediation. Project: The facility devised and implemented Water Safety Precautions for patients who meet specific clinical or location criteria to prevent potential exposures to Legionella pneumophila from the facility’s potable water. These precautions are implemented with a . 30% positivity facility wide or localized in a specific unit, and as a precaution during planned or unplanned disruptions to the potable water system. Water Safety Precautions include bottled water for ingestion and shower restrictions. Point of use filters were also installed in the ICU March 2008. Results: Patients in the ICU were on Water Safety Precautions from September 2006 through April 2008, until the point of use filters were installed in the unit. Patients outside of the ICU who met specific clinical criteria were on Water Safety Precautions from September 2006 to April 2007. Water Safety Precautions were also initiated for two construction events as a mitigation strategy since September 2006. Since the inception of the Water Safety Precautions strategy, no patients have acquired LegionnairesÕ disease with an epidemiological link to the ICU, despite average 65% positivity in the unit. The implementation of Water Safety Precautions has become routine, without major disruption in facility operations. Lessons Learned: Environmental control of Legionella sp. in potable water systems are complex. Implementation of bottled water facility-wide can be disruptive and costly for facilities. A routine program for the implementation of water restrictions can decrease the risk of LegionnairesÕ disease without major disruption and fear among patients and staff.
Infection Prevention and Control Programs Presentation Number: 8-75
A Pilot Study for a Community-Level Infection Control Program Shahram Rahimian, MD, PhD, Director of Clinical Research, Ilumina Clinical Associates, Johnstown, PA. Background: Multiple Drug Resistance Organisms (MDRO) in General and Methicillin Resistant Staphylococcus Aureus (MRSA) in particular have long been pathogens in healthcare facilities, but in the past decade, mainly
www.ajicjournal.org Vol. 37 No. 5
E67
MRSA has emerged as a problematic pathogen in the community settings as well. MRSA is endemic and a part of the bacterial flora among a portion of the population in the US but studies show that a single clone with different structure and risk factors of Community Associated MRSA (CA-MRSA) accounts for the majority of infections. This strain is originated in the community and is not related to MRSA strains from healthcare settings. The consistent increase of MDRO infections among non-healthcare settings and the related consequences in the United States prompted us to create an infection control program with focus on MRSA as an indicator to determine the colonization level and related risk in the community settings. Objectives: 1.Standardization of community-based infection control programs 2.Development of guidelines and SOP’s for outbreak investigation and responsiveness 3.Evaluate methodology for surveillance and proper remediation and corrective actions in non-healthcare facilities 4.Provide epidemiological data about MRSA as an indicator for other MDRO’s in the community 5.Minimize amount of work-hours lost due to illness (immeasurable) 6.Minimize insurance costs otherwise are sure to increase if MRSA persists 7.Minimize facility costs due to potential lawsuits (immeasurable). Methods: The main barrier was lack of epidemiologic data to support the methodology in non-healthcare settings and almost all of previous statistics were collected from hospitals and we decided to start with a pilot study in a smaller scale utilizing the following methodology;1. Facilities with high density populations (Military and Educational) were selected 2.A site survey was performed to detect the high risk places for targeted surveillance.3. Classic culture, gram-staining, and antibiogram were performed 4. MRSA positive samples were sub-typed by Pulsed-field gel electrophoresis (PFGE), Multi-locus sequence typing (MLST) & Sanger or Next-generation sequencing 6. Surveys were sent to evaluate the infection rate among staff and their families 5. Data was transferred to the research center on a daily bases 6. Results were evaluated to prepare recommendations for corrective actions 7. Repeated environmental sampling. Results: A total of 7,103 samples were collected from 2 facilities; 19% of them were MRSA positive, 8.03% of them were USA300 and 5.11% were USA400 in initial testing and there was a higher infection rate among families than from general population(p,0.05). The data after second testing showed significant decrease (.40%)in the infection rate just by implementing the main infection control procedures. Conclusion: Personal hygiene and infection control measures found to be effective to reduce the infection rate among non-healthcare settings, although in order to show the cost effectiveness of such an infection control program it should be expanded to a larger scale and by creating a network for all involved centers it can be implemented as an biohazard and respond system to fight against epidemic infections and bioterrorism attacks.
Presentation Number: 8-76
A Successful Campaign to Certify Employees in Hand Hygiene Competency Eileen Taylor, RN, BSN, IPP, Dartmouth Hitchcock Medical Center, Lebanon, NH. Issues: Improving hand hygiene (HH) compliance continues to be a challenge for our infection prevention program and the hospital. As part of a multi-faceted hospital wide campaign to improve HH performance, we developed a HH Training and Competency Certification program for all employees. Our aim is to ensure that all employees have completed education and training in HH and has demonstrated competency in why, when and how to perform hand hygiene. Project: We developed an electronic learning module on HH, with a post-module quiz, successful completion of which is required annually for all employees. The module includes our HH policy, with explanation of the why, when and how of hand hygiene. A video demonstration of proper HH techniques is available on line. After completion of the e-learning module, staff are encouraged to be ‘‘certified’’ in HH competency. The infection preventionists carry out the majority of the certifications. There are a few specific groups that have designated ambassadors, trained by the IPP’s to certify staff in their areas. New employees, including house staff, are certified during orientation. For certification of current staff, the hospital’s Engineering department constructed a working, mobile ‘‘hand hygiene