- Email: [email protected]
An Audit of Appropriateness of Requests Received for Clinical Microbiology Advice
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Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
interventions (hands on training sessions & house wide demonstrations) were developed to increase awareness and improve suboptimal compliance over the course of the initiative. Χ2 tests were performed to compare quarterly differences in compliance rates over the course of the targeted education intervention period compared to baseline. RESULTS: During baseline 43.6% (n = 78/179) of those observed were 100% compliant with PPE use. Overall compliance slowly increased to 49.3% (n = 71/144) during the first quarter of the intervention period, 57.5% (n = 103/179) in the second and 67.3% (n = 146/217) during the third, with only the latter two quarters statistically different from baseline (P = < 0.0001). CONCLUSIONS: Initial PPE compliance rates were indeed suboptimal. Over the course of the initiative, compliance slowly increased approximately 25%. While this initiative was successful, the results suggests that regular reporting of compliance rates and targeted education alone may not be enough to achieve an optimal compliance. Additional initiatives employing the use of focus groups may be needed to determine barriers to PPE use.
Session EPOP-105 12:30-1:30 p.m. A Systems Approach to Reaching 90% Influenza Vaccination of Healthcare Workers Robin Neale, MS, MT(ASCP)SM, CIC, Director, Infection Prevention, Care New England Health System; Mary Ellen Casey, RN, MSN, MEd, CIC, Manager, Infection Prevention, Women & Infants Hospital; Paula Foster, BSN, RN, Manager, Infection Control, VNA of Care New England; Kathleen OConnell, MSN, RN, CIC, Director, Infection Prevention and Control, Kent Hospital; Kimberly Stamatakos, RN, Manager, Infection Prevention, Butler Hospital BACKGROUND: Influenza vaccination has been recommended for healthcare workers by the Centers for Disease Control since 1984. Despite years of education, contests, and friendly competitions, our hospitals failed to achieve our goal of 90% vaccination. We proposed strengthening policies to improve immunization rates. METHODS: Our healthcare system is comprised of over 10,000 paid and voluntary staff serving four hospitals and a home health service. A significant portion of staff are unionized. Following multiple years of labor-intensive voluntary programs, rates were still as low as 60% within our system. In 2012, the health department proposed amending regulations to require vaccination for healthcare workers, defined as paid or unpaid staff who “may have direct contact with a patient”. Workers who were medically exempt or declined vaccination would be required to wear a mask during periods of widespread influenza. Our system publicly supported those changes, testifying at public hearing. The regulation was successfully amended in 2012. Beyond regulatory requirements, our system policy expanded the definition of “healthcare workers” to include all staff, regardless of patient contact. Upon endorsement from medical staff leadership, we mandated vaccination of over 1000 medical staff, serving to role model the importance of vaccination. We implemented a stringent policy for new staff, all volunteers, and students that required annual vaccination as a condition of employment or assignment. RESULTS: Vaccination rates across our system rose to 93% during the first year of implementation, compared to statewide achievement of only 87%. Our rates improved to 96% by 2016. There was no collective objection to our enhanced policy from our workforce.
CONCLUSIONS: Achieving greater than 90% vaccination of workers is attainable and sustainable through a stepwise approach of education, leadership support, applying immunization policies to all staff, requiring masking for those who refuse vaccine, and mandating vaccination as a condition of assignment for new staff.
Session EPOP-106 12:30-1:30 p.m. A Unique Approach to Reduce Clostridium difficile in an Acute Care Setting Christine Guilmette, RN, Infection Preventionist, Providence Saint Jospeph Medical Center; Dolores Sales, Manager, Environmental Service, Providence Saint Joseph Medical Center; Sarah Gaines-Hill, MSN, Manager, Epidemiology, Providence Saint Joseph; Nicholas Testa BACKGROUND: National Healthcare Safety Network requires hospitals achieve a Standard Infection Ratio (SIR) of 1.0 or below, indicating safe hospital infection prevention practices. In 2015 a significant increase in hospital-onset Clostridium difficile infection (HOCDI) cases resulted in an SIR of 1.932 by year end. Will an interdepartmental collaboration to address system failures reduce HO-CDI? METHODS: The Chief Medical Officer (CMO) championed efforts to address the problem. A review of hospital practices revealed a failure to recognize patients with diarrhea and the potential for CDI. A multidisciplinary team was formed to identify process breakdowns within the system. The CMO and Chief Nursing Officer had oversight of all actions, data, and plans created by the team. An agreement between Epidemiology and Microbiology allowed batching of specimens for a final time out to occur prior to testing. This included chart review and discussion between the primary nurse, Epidemiology, and Microbiology to assess appropriateness of testing with just-in-time education provided during the dialogue. Additionally, Environmental Services initiated daily bleach cleaning of every patient room to address potential spore shedding prior to CDI onset or diagnosis. Dietary services provided hand wipes for patients on all meal trays, emphasizing the importance of patient hand hygiene prior to eating. Engagement of the Emergency Department to test patients with diarrhea for CDI before admission, aided with early identification and appropriate treatment. Finally, the Pharmacy initiated probiotic therapy, regardless of age, for patients prescribed known high risk antibiotics. RESULTS: With the actions identified above Quarter 1-Quarter 3, 2016 resulted in an SIR of 1.115. This change was a statistically significant reduction (two-tailed t test, P = .0043). CONCLUSIONS: Through an inter-departmental team approach, identifying process errors, implementing changes, and rectifying knowledge deficits results in the desired reduction of HO-CDI.
Session EPOP-107 12:30-1:30 p.m. An Audit of Appropriateness of Requests Received for Clinical Microbiology Advice Emilia Mamwa, FRCPath, MBChB, DTMH, Consultant Microbiologist, Southern Health and Social Care Trust BACKGROUND: Requests for clinical microbiology advice are urgent. It is important to have a mechanism that screens urgent from non
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
urgent calls and identify requests that may be dealt with by other team members such as Infection control nurses or laboratory staff. The audit is based on the Royal college of pathologist Key performance indicators on availability of interpretative clinical advice and engagement with multidisciplinary teams. The aim was to determine what percentage of all requests for advice received by the duty clinical microbiologist were inappropriate. METHODS: Prospective audit of all microbiology consultant advice requests received between 13 and 25 October 2016. A template was used to record clinical advice given by telephone both in and out of hours. RESULTS: General advice calls constituted 71% and 34% were inappropriate. Result interpretation were 12% and 74% were inappropriate. Sensitivity requests represented 11% and 47% were inappropriate. Infection control calls were 3% and 20% were inappropriate. Prophylaxis requests were 2% and all were appropriate. There was failure to look up the Hospital Antimicrobial guidance prior to calling the consultants. Junior staff were more likely to make inappropriate general advice requests. Poor indication for antibiotic escalation and lack of using own clinical judgement was identified. Lack of generic result interpretation comment on some results or failure of requestors to read the comments was identified. Calls for further sensitivities could have been directed to the laboratory staff. There was failure by some requestors to decipher which antibiotics to select where more than one isolate was reported from one sample. CONCLUSIONS: There were many inappropriate calls made by Junior staff to consultant Microbiologists. The laboratory policy should include risk stratification for the urgency of response to requests and which members of staff to deal with different levels of requests and for which requestors. Generic comments to accompany most results.
Session EPOP-108 12:30-1:30 p.m. An Urban 40 Bed Level III Neonatal Intensive Care Unit reduced Catheter-Associated Bloodstream Infections by Implementing New Guidelines Roberta Glenn, BS, MT(ASCP), CIC, ICP, Thomas Jefferson University Hospital BACKGROUND: Catheter-associated bloodstream infection (CLABSI) in the neonatal population is a major source of morbidity and mortality. The disruption of skin and mucus membranes by the use of invasive devices contributes to the susceptibility of this population. In our Neonatal Intensive Care Unit (NICU), the CLABSI rate was continually increasing. It became evident that new practice guidelines were necessary to reduce the CLABSI rate in this vulnerable population. METHODS: Initial interventions were instituted in 2010, including central line insertion and maintenance checklists, daily line necessity evaluation, introduction of a closed medication administration system, and reinforcement of hand hygiene. Additionally in the following two years, clean gloves for all medication administration was instituted along with a PICC team and changing all central line tubing every 96 hours using a two person aseptic technique with sterile gloves and masks over a sterile field. Finally in 2014 - 2015, chlorhexidine gluconate (CHG) skin prep and CHG discs were implemented using strictly defined age appropriate protocols for all central line insertions and dressing changes and unused injection ports were covered with disinfecting port protectors.
S55
RESULTS: In 2010 the CLABSI rate was 6.52 (20 infections). In 2012, after the initial interventions were implemented, the rate dropped to 0.42 (1 infection) which is statistically significant by Chi-square analysis (P-value = .0001). The infection rate began to rise in 2013 and 2014 and prompted further initiatives. This resulted in zero CLABSIs for greater than 16 months. CONCLUSIONS: Teamwork and vigilance in following the various practice initiatives has resulted in sustained reduction of CLABSIs in the NICU, contributing significantly to patient safety and good outcomes.
Session EPOP-109 12:30-1:30 p.m. Analysis of a Tuberculosis Post-Exposure Event: An Algorithm and Recommendations for TB Contact Investigations Emily Robbins, MPH, Graduate Student—Graduated Dec 2016, University of Pittsburgh, Graduate School of Public Health; Marian Pokrywka, MS, MT(ASCP), CIC, Infection Preventionist, UPMC Mercy Hospital; Linda Rose Frank, PhD, MSN, ACRN, FAAN, Professor, Public Health, Medicine, and Nursing, University of Pittsburgh Graduate School of Public Health; Mohamed Yassin, MD, PhD, Medical Director, Infection Control—Hospital Epi, UPMC Mercy—University of Pittsburgh BACKGROUND: Immunosuppressed patients, such as those undergoing chemotherapy and radiation, are at greater risk of developing active tuberculosis (TB). Without prompt diagnosis, the risk of nosocomial transmission is increased for patients and staff alike. An oncology patient with active TB was undiagnosed for several weeks at a large, university-associated hospital due to the case’s clinical presentation and complex chest X-rays (CXRs). Other immunosuppressed and immunocompetent patients were exposed to the index case. A contact investigation was completed by the hospital’s infection prevention (IP) department. METHODS: A retrospective analysis of the TB contact investigation was conducted. Patient charts were reviewed to determine the rate of compliance of Tuberculin Skin Test (TST) among notified patients as well as the TST conversion rate. Recommendations for an improved contact investigation protocol were formulated. A contact investigation algorithm for infection preventionists (IPs) was developed for use in future exposure events. RESULTS: One hundred forty-two patients were identified as potential contacts. Oncology patients (67) represented 47% of the exposures. Of the 142 contacts, 120 were successfully notified of the exposure by certified mail. Thirty-two percent of the patient contacts completed the recommended TST. There were no detected conversions following exposure to the index patient. However, unknown latent tuberculosis infection (LTBI) was identified in 3 oncology patients. CONCLUSIONS: Low TST compliance limited identification of all potential conversions but findings were consistent with other published studies. New notification methods should be considered such as phone calls to patients and PCP notifications to improve TST compliance. Three cases of LTBI were identified emphasizing the importance of TB screening in high-risk populations, such as oncology patients. Improved protocols should be written for TB exposure events in hospital settings. A TB Contact Investigation Algorithm was developed as a result of this study as a tool for use by IPs conducting post-exposure investigations.
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
interventions (hands on training sessions & house wide demonstrations) were developed to increase awareness and improve suboptimal compliance over the course of the initiative. Χ2 tests were performed to compare quarterly differences in compliance rates over the course of the targeted education intervention period compared to baseline. RESULTS: During baseline 43.6% (n = 78/179) of those observed were 100% compliant with PPE use. Overall compliance slowly increased to 49.3% (n = 71/144) during the first quarter of the intervention period, 57.5% (n = 103/179) in the second and 67.3% (n = 146/217) during the third, with only the latter two quarters statistically different from baseline (P = < 0.0001). CONCLUSIONS: Initial PPE compliance rates were indeed suboptimal. Over the course of the initiative, compliance slowly increased approximately 25%. While this initiative was successful, the results suggests that regular reporting of compliance rates and targeted education alone may not be enough to achieve an optimal compliance. Additional initiatives employing the use of focus groups may be needed to determine barriers to PPE use.
Session EPOP-105 12:30-1:30 p.m. A Systems Approach to Reaching 90% Influenza Vaccination of Healthcare Workers Robin Neale, MS, MT(ASCP)SM, CIC, Director, Infection Prevention, Care New England Health System; Mary Ellen Casey, RN, MSN, MEd, CIC, Manager, Infection Prevention, Women & Infants Hospital; Paula Foster, BSN, RN, Manager, Infection Control, VNA of Care New England; Kathleen OConnell, MSN, RN, CIC, Director, Infection Prevention and Control, Kent Hospital; Kimberly Stamatakos, RN, Manager, Infection Prevention, Butler Hospital BACKGROUND: Influenza vaccination has been recommended for healthcare workers by the Centers for Disease Control since 1984. Despite years of education, contests, and friendly competitions, our hospitals failed to achieve our goal of 90% vaccination. We proposed strengthening policies to improve immunization rates. METHODS: Our healthcare system is comprised of over 10,000 paid and voluntary staff serving four hospitals and a home health service. A significant portion of staff are unionized. Following multiple years of labor-intensive voluntary programs, rates were still as low as 60% within our system. In 2012, the health department proposed amending regulations to require vaccination for healthcare workers, defined as paid or unpaid staff who “may have direct contact with a patient”. Workers who were medically exempt or declined vaccination would be required to wear a mask during periods of widespread influenza. Our system publicly supported those changes, testifying at public hearing. The regulation was successfully amended in 2012. Beyond regulatory requirements, our system policy expanded the definition of “healthcare workers” to include all staff, regardless of patient contact. Upon endorsement from medical staff leadership, we mandated vaccination of over 1000 medical staff, serving to role model the importance of vaccination. We implemented a stringent policy for new staff, all volunteers, and students that required annual vaccination as a condition of employment or assignment. RESULTS: Vaccination rates across our system rose to 93% during the first year of implementation, compared to statewide achievement of only 87%. Our rates improved to 96% by 2016. There was no collective objection to our enhanced policy from our workforce.
CONCLUSIONS: Achieving greater than 90% vaccination of workers is attainable and sustainable through a stepwise approach of education, leadership support, applying immunization policies to all staff, requiring masking for those who refuse vaccine, and mandating vaccination as a condition of assignment for new staff.
Session EPOP-106 12:30-1:30 p.m. A Unique Approach to Reduce Clostridium difficile in an Acute Care Setting Christine Guilmette, RN, Infection Preventionist, Providence Saint Jospeph Medical Center; Dolores Sales, Manager, Environmental Service, Providence Saint Joseph Medical Center; Sarah Gaines-Hill, MSN, Manager, Epidemiology, Providence Saint Joseph; Nicholas Testa BACKGROUND: National Healthcare Safety Network requires hospitals achieve a Standard Infection Ratio (SIR) of 1.0 or below, indicating safe hospital infection prevention practices. In 2015 a significant increase in hospital-onset Clostridium difficile infection (HOCDI) cases resulted in an SIR of 1.932 by year end. Will an interdepartmental collaboration to address system failures reduce HO-CDI? METHODS: The Chief Medical Officer (CMO) championed efforts to address the problem. A review of hospital practices revealed a failure to recognize patients with diarrhea and the potential for CDI. A multidisciplinary team was formed to identify process breakdowns within the system. The CMO and Chief Nursing Officer had oversight of all actions, data, and plans created by the team. An agreement between Epidemiology and Microbiology allowed batching of specimens for a final time out to occur prior to testing. This included chart review and discussion between the primary nurse, Epidemiology, and Microbiology to assess appropriateness of testing with just-in-time education provided during the dialogue. Additionally, Environmental Services initiated daily bleach cleaning of every patient room to address potential spore shedding prior to CDI onset or diagnosis. Dietary services provided hand wipes for patients on all meal trays, emphasizing the importance of patient hand hygiene prior to eating. Engagement of the Emergency Department to test patients with diarrhea for CDI before admission, aided with early identification and appropriate treatment. Finally, the Pharmacy initiated probiotic therapy, regardless of age, for patients prescribed known high risk antibiotics. RESULTS: With the actions identified above Quarter 1-Quarter 3, 2016 resulted in an SIR of 1.115. This change was a statistically significant reduction (two-tailed t test, P = .0043). CONCLUSIONS: Through an inter-departmental team approach, identifying process errors, implementing changes, and rectifying knowledge deficits results in the desired reduction of HO-CDI.
Session EPOP-107 12:30-1:30 p.m. An Audit of Appropriateness of Requests Received for Clinical Microbiology Advice Emilia Mamwa, FRCPath, MBChB, DTMH, Consultant Microbiologist, Southern Health and Social Care Trust BACKGROUND: Requests for clinical microbiology advice are urgent. It is important to have a mechanism that screens urgent from non
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017
Poster Abstracts / American Journal of Infection Control 45 (2017) S16-S93
urgent calls and identify requests that may be dealt with by other team members such as Infection control nurses or laboratory staff. The audit is based on the Royal college of pathologist Key performance indicators on availability of interpretative clinical advice and engagement with multidisciplinary teams. The aim was to determine what percentage of all requests for advice received by the duty clinical microbiologist were inappropriate. METHODS: Prospective audit of all microbiology consultant advice requests received between 13 and 25 October 2016. A template was used to record clinical advice given by telephone both in and out of hours. RESULTS: General advice calls constituted 71% and 34% were inappropriate. Result interpretation were 12% and 74% were inappropriate. Sensitivity requests represented 11% and 47% were inappropriate. Infection control calls were 3% and 20% were inappropriate. Prophylaxis requests were 2% and all were appropriate. There was failure to look up the Hospital Antimicrobial guidance prior to calling the consultants. Junior staff were more likely to make inappropriate general advice requests. Poor indication for antibiotic escalation and lack of using own clinical judgement was identified. Lack of generic result interpretation comment on some results or failure of requestors to read the comments was identified. Calls for further sensitivities could have been directed to the laboratory staff. There was failure by some requestors to decipher which antibiotics to select where more than one isolate was reported from one sample. CONCLUSIONS: There were many inappropriate calls made by Junior staff to consultant Microbiologists. The laboratory policy should include risk stratification for the urgency of response to requests and which members of staff to deal with different levels of requests and for which requestors. Generic comments to accompany most results.
Session EPOP-108 12:30-1:30 p.m. An Urban 40 Bed Level III Neonatal Intensive Care Unit reduced Catheter-Associated Bloodstream Infections by Implementing New Guidelines Roberta Glenn, BS, MT(ASCP), CIC, ICP, Thomas Jefferson University Hospital BACKGROUND: Catheter-associated bloodstream infection (CLABSI) in the neonatal population is a major source of morbidity and mortality. The disruption of skin and mucus membranes by the use of invasive devices contributes to the susceptibility of this population. In our Neonatal Intensive Care Unit (NICU), the CLABSI rate was continually increasing. It became evident that new practice guidelines were necessary to reduce the CLABSI rate in this vulnerable population. METHODS: Initial interventions were instituted in 2010, including central line insertion and maintenance checklists, daily line necessity evaluation, introduction of a closed medication administration system, and reinforcement of hand hygiene. Additionally in the following two years, clean gloves for all medication administration was instituted along with a PICC team and changing all central line tubing every 96 hours using a two person aseptic technique with sterile gloves and masks over a sterile field. Finally in 2014 - 2015, chlorhexidine gluconate (CHG) skin prep and CHG discs were implemented using strictly defined age appropriate protocols for all central line insertions and dressing changes and unused injection ports were covered with disinfecting port protectors.
S55
RESULTS: In 2010 the CLABSI rate was 6.52 (20 infections). In 2012, after the initial interventions were implemented, the rate dropped to 0.42 (1 infection) which is statistically significant by Chi-square analysis (P-value = .0001). The infection rate began to rise in 2013 and 2014 and prompted further initiatives. This resulted in zero CLABSIs for greater than 16 months. CONCLUSIONS: Teamwork and vigilance in following the various practice initiatives has resulted in sustained reduction of CLABSIs in the NICU, contributing significantly to patient safety and good outcomes.
Session EPOP-109 12:30-1:30 p.m. Analysis of a Tuberculosis Post-Exposure Event: An Algorithm and Recommendations for TB Contact Investigations Emily Robbins, MPH, Graduate Student—Graduated Dec 2016, University of Pittsburgh, Graduate School of Public Health; Marian Pokrywka, MS, MT(ASCP), CIC, Infection Preventionist, UPMC Mercy Hospital; Linda Rose Frank, PhD, MSN, ACRN, FAAN, Professor, Public Health, Medicine, and Nursing, University of Pittsburgh Graduate School of Public Health; Mohamed Yassin, MD, PhD, Medical Director, Infection Control—Hospital Epi, UPMC Mercy—University of Pittsburgh BACKGROUND: Immunosuppressed patients, such as those undergoing chemotherapy and radiation, are at greater risk of developing active tuberculosis (TB). Without prompt diagnosis, the risk of nosocomial transmission is increased for patients and staff alike. An oncology patient with active TB was undiagnosed for several weeks at a large, university-associated hospital due to the case’s clinical presentation and complex chest X-rays (CXRs). Other immunosuppressed and immunocompetent patients were exposed to the index case. A contact investigation was completed by the hospital’s infection prevention (IP) department. METHODS: A retrospective analysis of the TB contact investigation was conducted. Patient charts were reviewed to determine the rate of compliance of Tuberculin Skin Test (TST) among notified patients as well as the TST conversion rate. Recommendations for an improved contact investigation protocol were formulated. A contact investigation algorithm for infection preventionists (IPs) was developed for use in future exposure events. RESULTS: One hundred forty-two patients were identified as potential contacts. Oncology patients (67) represented 47% of the exposures. Of the 142 contacts, 120 were successfully notified of the exposure by certified mail. Thirty-two percent of the patient contacts completed the recommended TST. There were no detected conversions following exposure to the index patient. However, unknown latent tuberculosis infection (LTBI) was identified in 3 oncology patients. CONCLUSIONS: Low TST compliance limited identification of all potential conversions but findings were consistent with other published studies. New notification methods should be considered such as phone calls to patients and PCP notifications to improve TST compliance. Three cases of LTBI were identified emphasizing the importance of TB screening in high-risk populations, such as oncology patients. Improved protocols should be written for TB exposure events in hospital settings. A TB Contact Investigation Algorithm was developed as a result of this study as a tool for use by IPs conducting post-exposure investigations.
APIC 44th Annual Educational Conference & International Meeting | Portland, OR | June 14-16, 2017