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Central venous catheter infection rates among bone marrow transplant recipients
AJIC
Volume 27, Number 2
"HIV Pre- and Post-test Counseling, Risk Assessment, and Prevention Education." A multidisciplinary team, called the "HIV Response Team," was formed to provide counseling, risk assessment, and prevention education to patients and employees and to assure compliance with federal law 100-322 (FL 100-322). The following team recommendations were implemented. A medical record form, a checklist outlining the components of FL 100-322, was designed to standardize the counseling process. Standing orders for HIV testing on admission for certain populations of patients were deleted. Three educational brochures were created for the patient/employee. Brochure No. 1 provides pre-test and HIV/AIDS information. Brochures No. 2 and 3 provide negative and positive test information, respectively. An intensive, hospital-wide educational blitz was conducted in June 1997. A brochure explaining the H I V Response Team's purpose, and a listing of the team members, including their phone and pager numbers, was provided to all services and nursing units. Subsequently, a support group for HIVinfected veterans has been initiated. The following outcomes attest to the Team's impact on the medical center. Six months prior to the Team's creation (July-December 1996), 571 HIV antibody tests were performed. JanuaryJune 1997, 350 tests were performed. July-December 1997, 166 tests were performed, and from January-June 1998, only 151 tests were performed. Since the formation of the HIV Response Team, there has been a 74% reduction in H1V tests performed with an estimated cost savings to the hospital for HIV antibody tests alone of over $5,500. Only 10/1238 (0.8%) of the H1V antibody tests were confirmed as positive by Western Blot. In conclusion, the HIV Response Team counseling process not only complies with FL 100-322 but also meets the patient education standard of the JCAHO.
D E V E L O P M E N T OF A PROGRAM TO I D E N T I F Y COMPLICATIONS AMONG O U T P A T I E N T S WITH PERIPHERALLY I N S E R T E D CENTRAL CATHETERS (PICCs). L. J. Walshe, RN,* S. Abdel Malak, MPH, I. Velazquez, RN, J. Eagan, RN, MPH, CIC, K.A. Sepkowitz, MD. Memorial Sloan-Kettering Cancer Center CDC EpiCenter, New York, NY.
BACKGROUND: The increase towards briefer hospitalizations has lead to more intravenous therapies being delivered in the outpatient setting, often by use of PICCs. More than 250 MSKCC patients receive PICCs annually, yet we knew little of rates or risks for complication. Because patients with PICCs are seldom hospitalized, we needed to develop new methods of infection control surveillance for the outpatient domain. To accomplish this, we needed to learn more about the process of providing PICC insertion and care. METHODS: All personnel responsible for the insertion and care of PICCs at MSKCC, a tertiary care cancer center in NYC, were identified. Providers included nurses from the
Abstracts 2 1 9
W team, physicians from interventional radiology, nurse practitioners certified in PICC insertion, and nurses from various home-care companies. RESULTS: A team consisting of members of all above disciplines was formed, including representatives from the 7 home-care companies that provide >75% of IV home-care for MSKCC patients. Home-care representatives were eager to participate. Some home-care companies previously had developed a surveillance tool for their patients, but did not routinely report the information to the referring hospital. Three elements central to PICC use--insertion, inpatient care, and outpatient care--were identified and a 3-part data collection form was developed with the significant input of all team members. All members approved of the new surveillance tool, and all accepted that a m e m b e r from each group might be responsible for different parts of the form. A one-year prospective observational study has since been initiated for all persons receiving a PICC at MSKCC from November 23, 1998, to November 22, 1999 (estimated n= 250). Specific MSKCC and home-care personnel will record data onto the three standardized data extraction sheets. Variables of interest include patient characteristics, PICC characteristics, and PICC care and follow-up. Multivariate analysis will be performed to determine association of variables with catheter outcomes.
CENTRAL V E N O U S CATHETER INFECTION RATES AMONG B O N E MARROW T R A N S P L A N T RECIPIENTS. M. Rogers, RN,* J. Eagan, RN, MPH, CIC, H. Wallace, RN, M. Cowan, RN, M. Montefusco, RN, A. Shedeck, RN, K. Sepkowitz, MD. Memorial SloanKettering Cancer Center, New York, NY.
BACKGROUND: NNIS tracks BSI rates among select patient groups, including cancer patients. However, considerable risk variation exists among cancer patient groups. We have previously studied central venous catheter (CVC) infection rates in breast cancer, leukemic, and intensive care unit (ICU) patients. Because bone marrow transplant (BMT) patients are "sicker" than most other cancer patients, we prospectively studied CVC infection rates in this population. METHODS: The adult BMT unit of MSKCC, in NYC, is a 30-bed unit with a mixed allogeneic/autologous BMT population. Mean length of stay for allogeneic patients is 29.9 days and 11 for autologous which exceeds MSKCC m e a n of 8.2 days. All CVCs on the unit were evaluated daily by RNs on the unit and infections confirmed by m e m b e r s of infection control (IC) staff. Variables assessed included catheter insertion site, w o u n d dressing, patients i m m u n e status, and white blood cell count. CVC infection was defined per CDC 1996 guidelines. A case was defined as CVC infection developing >48 hours after admission. RESULTS: All patients were followed for one month, comprising 789 catheter days. During this time, 6 CVC infections occurred (rate = 7.6 per 1000 catheter days). 4/6
AJIC April 1999
2 2 0 Abstracts
patients were allogeneic transplants. Onset of infection occurred a m e a n of 27.6 days post admission (range 9-75 days) and a mean of 37 days from date of insertion (range 3-110). 3/6 patients were neutropenic at time of infection. All 6 patients had subclavian catheters. Isolated organisms included coagulase-negative staph (4 pts), diphtheroids (2), VRE (1), Enterococcus faecaIis ( 1 ) , Staphylococcus aureus (1), Pseudomonas aeruginosa (1), and Stenotrophomonas maltophilia (1). These rates compared to breast cancer patients (0%), leukemia patients (10.19%), and those in the ICU (7.8%). CONCLUSIONS: BMT recipients have a significant rate of nosocomial CVC infection, possibly owing to their extended hospital LOS. It is unclear whether this represents ongoing risk or selection of "sicker" patients (those with longer LOS). Future studies among cancer patients are necessary to determine optimal catheter care in this population.
MYCOBACTERIUM TUBERCULOSIS CONTAMINAT I O N O F A B R O N C H O S C O P E . M. Bond, RN, MS, CIC*;
B. Kluver, RN, BSN, CIC, D. Alexander, RT. Kaiser Foundation Hospitals, Northeast Bay Service Area, Walnut Creek/Vallejo, CA. PROBLEM: In February 1998, the infection control department was notified that four patients had positive Acid Fast Bacillus (AFB) smears from bronchoscopy, over a 5-day period. All smears were confirmed as mycobacterium tuberculosis (MTB). The index case was a critically ill patient with confirmed MTB. The subsequent three cases were outpatients with chronic respiratory problems. INTERVENTIONS: The possiblility of c o n t a m i n a t i o n from the index patient was suspected. We eliminated specimen c o n t a m i n a t i o n and focused our investigation on the cleaning and sterilization of bronchoscopes. We identified that one bronchoscope was used for all procedures; the scope was pulled from use and cultured. A multidisciplinary committee was assembled to review the problem. OUTCOME OF INVESTIGATION: The bronchoscope was smear positive for AFB, but culture negative. Several potential problems were identified that could have resulted in contamination of the bronchoscope: I) scope cleaning after bronshoscopy was not instituted in a timely manner, 2) the single-use enzymatic cleaner sponge was being used multiple times, 3) the cleaning technique was not consistent, 4) the paracetic acid sterilyzer was found to have a crack in the pan, and 5) when the scope was sent back to the manufacturer for analysis it was found to have a kink in the chamber. CONCLUSION: We concluded that there was no one problem that caused the scope contamination, but rather a n u m b e r of problems identified. A combination of education, cleaning policy changes, and equipment repair was instituted. Patient outcome: the index case was treated for active MTB, the second case was treated as an exposure, and the final two cases (smear positive, culture negative) were monitored closely.
Surveillance U S E O F E L E C T R O N I C S U R V E I L L A N C E F O R C. DIFFICILE I N F E C T I O N S . K. Agnes, RN, BSN, CIC,* A. Tan,
MD, A. Chacko, RN, MS, M. Roghrnann, MD, MS. VA Maryland Health Care System, Fort Howard Medical Center, Baltimore, MD. BACKGROUND: Surveillance for nosocomial infections with feedback to providers is an effective technique for decreasing nosocomial infections. Surveillance, however, can be extremely labor intensive. We describe an electronic surveillance method for C. difficile infections with an effective intervention. METHODS: Results of C difficile toxin testing on stool cultures from patients within our integrated healthcare system are downloaded monthly into a relational database. First positive tests per patient are plotted over time by unit. RESULTS: Surveillance revealed a high rate of infection (1.04 per 1000 patient days) on a chronic ventilator ward compared to a lower rate of infection (0.08 per 1,000 patient days) on an adjacent rehabilitation unit. Chart review confirmed the test results were C difficile infections associated with new diarrhea. A multidisciplinary performance improvement team was formed which provided education on the diagnosis, treatment and prevention of C difficile infections with feedback of unit-specific rates, automatic isolation of patient with new diarrhea and enhanced environmental cleaning of rooms of patients with diarrhea. Since this intervention, no further cases have been identified on the chronic ventilator unit with 1,500 patient days of follow-up. CONCLUSION: This demonstrates that an automated surveillance method can be used to initiate performance improvement activities. Automated surveillance allows infection control practitioners to spend more of their time on interventions.
EVOLUTIONARY TRENDS IN NOSOCOMIAL INFECT I O N S : A T W E N T Y - Y E A R STUDY. S.L. Green, MD, L.
Saunders, RN,* R. Coste, BSN, V. Harpel:* Sentara Hampton General Hospital, Hampton, VA. A 20-year retrospective study of nosocomial infections was conducted at a 220-bed non-teaching community hospital. During this period from 1977 through 1996, "total house" surveillance was performed by infection control professionals using standard CDC criteria and all worksheets were reviewed by the hospital epidemiologist (S.G.). A total of 4,766 infections were identified among 224,474 admissions during this period. Emerging trends were identiffed in all major categories of nosocomial infections (surgical site infection--SSI, respiratory infection--R/, urinary tract infection--UTI, bloodstream infection--BSI, and other infection--OI), nosocomial pathogens, and antimicrohial resistance. The data was then analyzed in 5-year periods, including hospital overall attack rate (OAR).
Volume 27, Number 2
"HIV Pre- and Post-test Counseling, Risk Assessment, and Prevention Education." A multidisciplinary team, called the "HIV Response Team," was formed to provide counseling, risk assessment, and prevention education to patients and employees and to assure compliance with federal law 100-322 (FL 100-322). The following team recommendations were implemented. A medical record form, a checklist outlining the components of FL 100-322, was designed to standardize the counseling process. Standing orders for HIV testing on admission for certain populations of patients were deleted. Three educational brochures were created for the patient/employee. Brochure No. 1 provides pre-test and HIV/AIDS information. Brochures No. 2 and 3 provide negative and positive test information, respectively. An intensive, hospital-wide educational blitz was conducted in June 1997. A brochure explaining the H I V Response Team's purpose, and a listing of the team members, including their phone and pager numbers, was provided to all services and nursing units. Subsequently, a support group for HIVinfected veterans has been initiated. The following outcomes attest to the Team's impact on the medical center. Six months prior to the Team's creation (July-December 1996), 571 HIV antibody tests were performed. JanuaryJune 1997, 350 tests were performed. July-December 1997, 166 tests were performed, and from January-June 1998, only 151 tests were performed. Since the formation of the HIV Response Team, there has been a 74% reduction in H1V tests performed with an estimated cost savings to the hospital for HIV antibody tests alone of over $5,500. Only 10/1238 (0.8%) of the H1V antibody tests were confirmed as positive by Western Blot. In conclusion, the HIV Response Team counseling process not only complies with FL 100-322 but also meets the patient education standard of the JCAHO.
D E V E L O P M E N T OF A PROGRAM TO I D E N T I F Y COMPLICATIONS AMONG O U T P A T I E N T S WITH PERIPHERALLY I N S E R T E D CENTRAL CATHETERS (PICCs). L. J. Walshe, RN,* S. Abdel Malak, MPH, I. Velazquez, RN, J. Eagan, RN, MPH, CIC, K.A. Sepkowitz, MD. Memorial Sloan-Kettering Cancer Center CDC EpiCenter, New York, NY.
BACKGROUND: The increase towards briefer hospitalizations has lead to more intravenous therapies being delivered in the outpatient setting, often by use of PICCs. More than 250 MSKCC patients receive PICCs annually, yet we knew little of rates or risks for complication. Because patients with PICCs are seldom hospitalized, we needed to develop new methods of infection control surveillance for the outpatient domain. To accomplish this, we needed to learn more about the process of providing PICC insertion and care. METHODS: All personnel responsible for the insertion and care of PICCs at MSKCC, a tertiary care cancer center in NYC, were identified. Providers included nurses from the
Abstracts 2 1 9
W team, physicians from interventional radiology, nurse practitioners certified in PICC insertion, and nurses from various home-care companies. RESULTS: A team consisting of members of all above disciplines was formed, including representatives from the 7 home-care companies that provide >75% of IV home-care for MSKCC patients. Home-care representatives were eager to participate. Some home-care companies previously had developed a surveillance tool for their patients, but did not routinely report the information to the referring hospital. Three elements central to PICC use--insertion, inpatient care, and outpatient care--were identified and a 3-part data collection form was developed with the significant input of all team members. All members approved of the new surveillance tool, and all accepted that a m e m b e r from each group might be responsible for different parts of the form. A one-year prospective observational study has since been initiated for all persons receiving a PICC at MSKCC from November 23, 1998, to November 22, 1999 (estimated n= 250). Specific MSKCC and home-care personnel will record data onto the three standardized data extraction sheets. Variables of interest include patient characteristics, PICC characteristics, and PICC care and follow-up. Multivariate analysis will be performed to determine association of variables with catheter outcomes.
CENTRAL V E N O U S CATHETER INFECTION RATES AMONG B O N E MARROW T R A N S P L A N T RECIPIENTS. M. Rogers, RN,* J. Eagan, RN, MPH, CIC, H. Wallace, RN, M. Cowan, RN, M. Montefusco, RN, A. Shedeck, RN, K. Sepkowitz, MD. Memorial SloanKettering Cancer Center, New York, NY.
BACKGROUND: NNIS tracks BSI rates among select patient groups, including cancer patients. However, considerable risk variation exists among cancer patient groups. We have previously studied central venous catheter (CVC) infection rates in breast cancer, leukemic, and intensive care unit (ICU) patients. Because bone marrow transplant (BMT) patients are "sicker" than most other cancer patients, we prospectively studied CVC infection rates in this population. METHODS: The adult BMT unit of MSKCC, in NYC, is a 30-bed unit with a mixed allogeneic/autologous BMT population. Mean length of stay for allogeneic patients is 29.9 days and 11 for autologous which exceeds MSKCC m e a n of 8.2 days. All CVCs on the unit were evaluated daily by RNs on the unit and infections confirmed by m e m b e r s of infection control (IC) staff. Variables assessed included catheter insertion site, w o u n d dressing, patients i m m u n e status, and white blood cell count. CVC infection was defined per CDC 1996 guidelines. A case was defined as CVC infection developing >48 hours after admission. RESULTS: All patients were followed for one month, comprising 789 catheter days. During this time, 6 CVC infections occurred (rate = 7.6 per 1000 catheter days). 4/6
AJIC April 1999
2 2 0 Abstracts
patients were allogeneic transplants. Onset of infection occurred a m e a n of 27.6 days post admission (range 9-75 days) and a mean of 37 days from date of insertion (range 3-110). 3/6 patients were neutropenic at time of infection. All 6 patients had subclavian catheters. Isolated organisms included coagulase-negative staph (4 pts), diphtheroids (2), VRE (1), Enterococcus faecaIis ( 1 ) , Staphylococcus aureus (1), Pseudomonas aeruginosa (1), and Stenotrophomonas maltophilia (1). These rates compared to breast cancer patients (0%), leukemia patients (10.19%), and those in the ICU (7.8%). CONCLUSIONS: BMT recipients have a significant rate of nosocomial CVC infection, possibly owing to their extended hospital LOS. It is unclear whether this represents ongoing risk or selection of "sicker" patients (those with longer LOS). Future studies among cancer patients are necessary to determine optimal catheter care in this population.
MYCOBACTERIUM TUBERCULOSIS CONTAMINAT I O N O F A B R O N C H O S C O P E . M. Bond, RN, MS, CIC*;
B. Kluver, RN, BSN, CIC, D. Alexander, RT. Kaiser Foundation Hospitals, Northeast Bay Service Area, Walnut Creek/Vallejo, CA. PROBLEM: In February 1998, the infection control department was notified that four patients had positive Acid Fast Bacillus (AFB) smears from bronchoscopy, over a 5-day period. All smears were confirmed as mycobacterium tuberculosis (MTB). The index case was a critically ill patient with confirmed MTB. The subsequent three cases were outpatients with chronic respiratory problems. INTERVENTIONS: The possiblility of c o n t a m i n a t i o n from the index patient was suspected. We eliminated specimen c o n t a m i n a t i o n and focused our investigation on the cleaning and sterilization of bronchoscopes. We identified that one bronchoscope was used for all procedures; the scope was pulled from use and cultured. A multidisciplinary committee was assembled to review the problem. OUTCOME OF INVESTIGATION: The bronchoscope was smear positive for AFB, but culture negative. Several potential problems were identified that could have resulted in contamination of the bronchoscope: I) scope cleaning after bronshoscopy was not instituted in a timely manner, 2) the single-use enzymatic cleaner sponge was being used multiple times, 3) the cleaning technique was not consistent, 4) the paracetic acid sterilyzer was found to have a crack in the pan, and 5) when the scope was sent back to the manufacturer for analysis it was found to have a kink in the chamber. CONCLUSION: We concluded that there was no one problem that caused the scope contamination, but rather a n u m b e r of problems identified. A combination of education, cleaning policy changes, and equipment repair was instituted. Patient outcome: the index case was treated for active MTB, the second case was treated as an exposure, and the final two cases (smear positive, culture negative) were monitored closely.
Surveillance U S E O F E L E C T R O N I C S U R V E I L L A N C E F O R C. DIFFICILE I N F E C T I O N S . K. Agnes, RN, BSN, CIC,* A. Tan,
MD, A. Chacko, RN, MS, M. Roghrnann, MD, MS. VA Maryland Health Care System, Fort Howard Medical Center, Baltimore, MD. BACKGROUND: Surveillance for nosocomial infections with feedback to providers is an effective technique for decreasing nosocomial infections. Surveillance, however, can be extremely labor intensive. We describe an electronic surveillance method for C. difficile infections with an effective intervention. METHODS: Results of C difficile toxin testing on stool cultures from patients within our integrated healthcare system are downloaded monthly into a relational database. First positive tests per patient are plotted over time by unit. RESULTS: Surveillance revealed a high rate of infection (1.04 per 1000 patient days) on a chronic ventilator ward compared to a lower rate of infection (0.08 per 1,000 patient days) on an adjacent rehabilitation unit. Chart review confirmed the test results were C difficile infections associated with new diarrhea. A multidisciplinary performance improvement team was formed which provided education on the diagnosis, treatment and prevention of C difficile infections with feedback of unit-specific rates, automatic isolation of patient with new diarrhea and enhanced environmental cleaning of rooms of patients with diarrhea. Since this intervention, no further cases have been identified on the chronic ventilator unit with 1,500 patient days of follow-up. CONCLUSION: This demonstrates that an automated surveillance method can be used to initiate performance improvement activities. Automated surveillance allows infection control practitioners to spend more of their time on interventions.
EVOLUTIONARY TRENDS IN NOSOCOMIAL INFECT I O N S : A T W E N T Y - Y E A R STUDY. S.L. Green, MD, L.
Saunders, RN,* R. Coste, BSN, V. Harpel:* Sentara Hampton General Hospital, Hampton, VA. A 20-year retrospective study of nosocomial infections was conducted at a 220-bed non-teaching community hospital. During this period from 1977 through 1996, "total house" surveillance was performed by infection control professionals using standard CDC criteria and all worksheets were reviewed by the hospital epidemiologist (S.G.). A total of 4,766 infections were identified among 224,474 admissions during this period. Emerging trends were identiffed in all major categories of nosocomial infections (surgical site infection--SSI, respiratory infection--R/, urinary tract infection--UTI, bloodstream infection--BSI, and other infection--OI), nosocomial pathogens, and antimicrohial resistance. The data was then analyzed in 5-year periods, including hospital overall attack rate (OAR).