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Clostridium difficile Infection Reduction: Environmental Cleaning Is Only Part of the Story
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
significant room for improvement. Although authoritative bodies provide targets and guidance on practice, success requires implementation of programs at the local level. This study provides significant insight into perceived gaps between infection prevention and nursing professionals and raises concern about implementation among professional staff. Understanding the absolute importance and magnitude of these gaps provides targets for high impact interventions within the local HH program.
Presentation Number 9-416 Should Electronic Markers for Catheter-associated Urinary Tract Infections (CAUTI) Be Used for CAUTI Surveillance in Pediatric Hospitals? Judy Tran MPH, MT(ASCP), Infection Prevention Specialist, Children’s Medical Center Dallas; Michelle Macaluso RN, MN, CIC, Infection Prevention Specialist, Children’s Medical Center Dallas; Kim Newman RN, CIC, Director, Infection Prevention and Control, Children’s Medical Center Dallas; Jane Siegel MD, Medical Director, Infection Prevention and Control, Children’s Medical Center Dallas BACKGROUND/OBJECTIVES: Our facility is the only academic freestanding pediatric hospital in North Texas, with 490 licensed beds and more than 360,000 patient visits annually . Reducing healthcare-associated infections (HAIs) begins with establishing baseline rates and identifying units with increased rates. Given limited resources, targeted surveillance on high risk units has been the preferred approach to CAUTI surveillance. However, hospital-wide CAUTI surveillance is ultimately necessary if we are to capture all required HAI data. The objective of this study is to evaluate the effectiveness of electronic infection marker analysis for detecting CAUTIs in a pediatric hospital. METHODS: CAUTIs are defined according to National Healthcare Safety Network (NHSN) criteria, last updated January 2012. All positive urine culture results from all inpatient locations during January to November 2012 were obtained using Cerner’s Statistical Reports function and were reviewed to determine how many met the CAUTI definition using NHSN criteria. Clinical data were obtained from the electronic health record (EHR). These results were compared with those obtained by using a MedMinedÒ scorecard that summarizes urine Nosocomial Infection Markers (NIMs) analysis. RESULTS: NIM analysis yielded 133 results. 34 of the 133 were attributed to ICU locations. Following EHR review, 11 CAUTIs were identified. This results in a sensitivity of 0.733 (specificity unavailable). Cerner reports yielded 307 results. 92 of the 307 were collected from the ICU locations. EHR review yielded 4 additional CAUTIs missed by the NIM analysis. This results in a sensitivity of 1.0 and a specificity of 0.872. Of note were 3 of the 4 missed CAUTIs. Although these 3 urine NIMs did not meet the CAUTI criteria, each NIM did reveal a subsequent positive urine culture that was considered a duplicate by the NIM analysis and not included in the scorecard, which did meet CAUTI criteria.
S119
CONCLUSIONS: We conclude that the electronic marker analysis accurately detects most CAUTIs in pediatric ICUs. However, further studies are required to determine performance for hospital-wide CAUTI surveillance in a pediatric hospital.
Presentation Number 9-417 Clostridium difficile Infection Reduction: Environmental Cleaning Is Only Part of the Story Christina B. Felsen MPH, Senior Health Project Coordinator, University of Rochester Medical Center, Center for Community Health; Gail Quinlan RN, MS, CIC, Infection Preventionist, University of Rochester Medical Center - Center for Community Health; Alexandra Yamshchikov MD, Hospital Epidemiologist, Rochester General Health System; Ghinwa Dumyati MD, Associate Professor of Medicine, University of Rochester Medical Center Center for Community Health; The Rochester Patient Safety Collaborative ISSUE: Clostridium difficile infections (CDI) contribute significantly to the U.S. burden of healthcare-associated infections. Augmenting environmental cleaning by direct observation audits with feedback and quantitative cleanliness measures such as adenosine triphosphate (ATP), as well as enhanced disinfection with bleach and ultraviolet light (UV) may be key CDI prevention components. PROJECT: Four hospitals (size range: 216-739 beds) formed a C. difficile prevention collaborative in June 2011. Intervention implementation occurred during December 2011-March 2012, including environmental cleaning observations using a compliance checklist; environmental services staff education; ATP use; and UV disinfection (UVD) of patient rooms. Thirty-four surfaces and 13 actions in non-Intensive Care Units (ICU) and 33 surfaces and 12 actions in ICUs were observed. Cleaning compliance was calculated by dividing the number of surfaces cleaned/actions performed by the number evaluated. ATP readings (measured in Relative Light Units [RLUs]) were taken on 6 high touch surfaces after cleaning observations. Wilcoxon 2-sample tests were used to compare mean RLUs during-and post-implementation. Healthcare Facility-onset (HO) CDI rates were monitored using the Centers for Disease Control and Prevention’s National Healthcare Safety Network. Rates were monitored for 9 months pre- (March-November 2011) and postimplementation (April-December 2012). RESULTS: Cleaning compliance was 93% (n¼103) and 88% (n¼62) in non-ICUs and ICUs, respectively, during implementation. Postimplementation, compliance increased to 94% in both non-ICUs (n¼416) and ICUs (n¼192). Post-implementation, average ATP readings decreased for five of the measured surfaces. Of these, a significant decrease in RLUs was seen for the call bell (662 vs. 159, p<0.0001), bed control (329 vs. 47, p<0.0001), bed rail (548 vs. 424, p<0.0001), and room light switch (174 vs. 122, p¼0.0084). UVD targeted all rooms in units with increased HO CDI transmission or a high endemic CDI burden. Pre-implementation, the HO CDI rate across hospitals was 10.6 cases per 10,000 patient days.
Method
Hospital- wide (HW) Results
ICU Results (% of HW Results)
Urine Source: Catheter
CAUTIs Identified
ICU-Sensitivity
Cerner NIM
307 133
92 (30%) 34 (26%)
43 16
15 11
1.0 (15/15) 0.733 (11/15)
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
ICU-Specificity 0.872 (526/77+526) N/A
S120
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Post-implementation, this rate was 9.7 cases per 10,000 patient days, an 8.5% reduction. CONCLUSIONS: Our environmental cleaning intervention successfully improved cleaning compliance and cleanliness of high touch surfaces as measured by ATP. However, these improvements did not translate to a substantial reduction in endemic HO CDI rates, potentially due to the short post-implementation period. To achieve a more sustained reduction in endemic HO CDI incidence, expanded interventions including standardized terminal cleaning of all CDI rooms with UVD, antimicrobial stewardship, and enhanced compliance with isolation procedures (hand hygiene, equipment cleaning, and consistent use of personal protective equipment) may be necessary.
Presentation Number 9-418 An Interactive Web-based Hand Hygiene (HH) Observation Tool: An Integral Part of a HH Campaign! Christine Bridge MHMS/MBA, Systems Analyst, UPMC Mercy; Mohamed H. Yassin MD, PhD, Medical Director of Infection Control, UPMC Mercy; Julliet Ferrelli MS, MT(ASCP), CIC, Infection Control Coordinator, UPMC Mercy; Marian Pokrywka MS, CIC, Infection Preventionist, UPMC Mercy ISSUE: Hand hygiene (HH) compliance is essential for infection prevention. All over the country, HH campaigns are launched with variable success. Challenges include 1) providing health care workers (HCW) an effective tool to perform hand hygiene observations; 2) using the data gathered from that tool to generate accurate and meaningful information; 3) keeping the observer anonymous. PROJECT: An internal website was created on the hospital’s Intranet site to provide observers the capability to document on any computer; allowing the observer the freedom to document anywhere while protecting the observers anonymity. The website has password protection and restricted access through the use of an active directory (AD) security group. Only observers and the infection preventionists (IPs) access the website. The web tool was built on active server pages (ASP) technology which sends and obtains data from a structured query language (SQL) Database. ASPs were designed, with a SQL statement, to permit only current month observations. Prior month results cannot be altered. Key features of the website include drop down menus to select various departments, HCW types, and when the observation occurred (before or after contact). A departmental access database was also designed, with an open data base connection (ODBC) to the SQL database, which provides the IPs a menu of options of reports to show how departments and HCWs are performing in real time. RESULTS: Summary charts are posted for all employees to view on the hospital’s Intranet Site. Monthly detailed reports are sent to each department to discuss with staff. Detailed real time information has allowed IPs to work with specific HCWs, departments, and physicians to improve compliance. Within a year, the HH compliance rate has improved to a steady and sustained rate of 83%: the last two audits were 87% compliance. LESSON LEARNED: Web-based data gathering tools are innovative techniques that are helpful to the IPs to gather HH observations on a large scale, maintaining anonymity, and providing critical feed-
back to staff. A website was created that has been proven to be crucial in providing a method for our observers to enter data while staying anonymous. Real time accessible information has been important to improving our HH compliance by providing HCWs and IPs with immediate feedback.
Presentation Number 9-419 Full-time Infection Preventionist Improves Outcomes at Rural Community Hospital Jeff Wood MSN, Infection Preventionist, Coosa Valley Medical Center; Heather Bennett BSN, Director of Case Management, Infection Prevention, and Education, Coosa Valley Medical Center ISSUE: The public is becoming increasingly aware of hospital infection rates. Facilities dedicating resources to a full time infection preventionist can decrease nosocomial infection marker (NIM) rates and decrease hospital acquired infections (HAI). Part-time IP provide the staff and patients with inconsistent resource for infection prevention practices.
PROJECT: Facility leadership decides to make IP a full-time FTE, citing public reporting, increased focus on infection, and increasing NIM rate. The facility invests in APIC membership for the new IP. The IP noticed mismatched specimens labeled as surgical wound instead of stasis or decubitus ulcer, and worked with IT to correctly match specimen source to the correct order in CPSI. A reduction in wound NIMs occurred when staff became educated on source labeling, ordering and collection. Hand hygiene reports of 100% from unit directors were previously submitted. The full-time IP questioned the results and was able to ensure more accurate results are obtained. New monitoring tool added and the staff was educated on 5 moments of hand hygiene from WHO. There is increased staff interest and accountability through the sharing of results on a regular basis, and they respond well to the use of visual aids such as dashboards. When the facility had ½ FTE IP, nursing and observation rounds were not consistent. Consequently, the level of responsibility and follow-up varied. This inconsistency also impacted the device utilization reporting and adherence to isolation policies. With the full time FTE, reporting on device utilization for Foley and CVL usage occurs at both the facility and unit level and is performed consistently. Additionally, the IP sees each patient on
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
significant room for improvement. Although authoritative bodies provide targets and guidance on practice, success requires implementation of programs at the local level. This study provides significant insight into perceived gaps between infection prevention and nursing professionals and raises concern about implementation among professional staff. Understanding the absolute importance and magnitude of these gaps provides targets for high impact interventions within the local HH program.
Presentation Number 9-416 Should Electronic Markers for Catheter-associated Urinary Tract Infections (CAUTI) Be Used for CAUTI Surveillance in Pediatric Hospitals? Judy Tran MPH, MT(ASCP), Infection Prevention Specialist, Children’s Medical Center Dallas; Michelle Macaluso RN, MN, CIC, Infection Prevention Specialist, Children’s Medical Center Dallas; Kim Newman RN, CIC, Director, Infection Prevention and Control, Children’s Medical Center Dallas; Jane Siegel MD, Medical Director, Infection Prevention and Control, Children’s Medical Center Dallas BACKGROUND/OBJECTIVES: Our facility is the only academic freestanding pediatric hospital in North Texas, with 490 licensed beds and more than 360,000 patient visits annually . Reducing healthcare-associated infections (HAIs) begins with establishing baseline rates and identifying units with increased rates. Given limited resources, targeted surveillance on high risk units has been the preferred approach to CAUTI surveillance. However, hospital-wide CAUTI surveillance is ultimately necessary if we are to capture all required HAI data. The objective of this study is to evaluate the effectiveness of electronic infection marker analysis for detecting CAUTIs in a pediatric hospital. METHODS: CAUTIs are defined according to National Healthcare Safety Network (NHSN) criteria, last updated January 2012. All positive urine culture results from all inpatient locations during January to November 2012 were obtained using Cerner’s Statistical Reports function and were reviewed to determine how many met the CAUTI definition using NHSN criteria. Clinical data were obtained from the electronic health record (EHR). These results were compared with those obtained by using a MedMinedÒ scorecard that summarizes urine Nosocomial Infection Markers (NIMs) analysis. RESULTS: NIM analysis yielded 133 results. 34 of the 133 were attributed to ICU locations. Following EHR review, 11 CAUTIs were identified. This results in a sensitivity of 0.733 (specificity unavailable). Cerner reports yielded 307 results. 92 of the 307 were collected from the ICU locations. EHR review yielded 4 additional CAUTIs missed by the NIM analysis. This results in a sensitivity of 1.0 and a specificity of 0.872. Of note were 3 of the 4 missed CAUTIs. Although these 3 urine NIMs did not meet the CAUTI criteria, each NIM did reveal a subsequent positive urine culture that was considered a duplicate by the NIM analysis and not included in the scorecard, which did meet CAUTI criteria.
S119
CONCLUSIONS: We conclude that the electronic marker analysis accurately detects most CAUTIs in pediatric ICUs. However, further studies are required to determine performance for hospital-wide CAUTI surveillance in a pediatric hospital.
Presentation Number 9-417 Clostridium difficile Infection Reduction: Environmental Cleaning Is Only Part of the Story Christina B. Felsen MPH, Senior Health Project Coordinator, University of Rochester Medical Center, Center for Community Health; Gail Quinlan RN, MS, CIC, Infection Preventionist, University of Rochester Medical Center - Center for Community Health; Alexandra Yamshchikov MD, Hospital Epidemiologist, Rochester General Health System; Ghinwa Dumyati MD, Associate Professor of Medicine, University of Rochester Medical Center Center for Community Health; The Rochester Patient Safety Collaborative ISSUE: Clostridium difficile infections (CDI) contribute significantly to the U.S. burden of healthcare-associated infections. Augmenting environmental cleaning by direct observation audits with feedback and quantitative cleanliness measures such as adenosine triphosphate (ATP), as well as enhanced disinfection with bleach and ultraviolet light (UV) may be key CDI prevention components. PROJECT: Four hospitals (size range: 216-739 beds) formed a C. difficile prevention collaborative in June 2011. Intervention implementation occurred during December 2011-March 2012, including environmental cleaning observations using a compliance checklist; environmental services staff education; ATP use; and UV disinfection (UVD) of patient rooms. Thirty-four surfaces and 13 actions in non-Intensive Care Units (ICU) and 33 surfaces and 12 actions in ICUs were observed. Cleaning compliance was calculated by dividing the number of surfaces cleaned/actions performed by the number evaluated. ATP readings (measured in Relative Light Units [RLUs]) were taken on 6 high touch surfaces after cleaning observations. Wilcoxon 2-sample tests were used to compare mean RLUs during-and post-implementation. Healthcare Facility-onset (HO) CDI rates were monitored using the Centers for Disease Control and Prevention’s National Healthcare Safety Network. Rates were monitored for 9 months pre- (March-November 2011) and postimplementation (April-December 2012). RESULTS: Cleaning compliance was 93% (n¼103) and 88% (n¼62) in non-ICUs and ICUs, respectively, during implementation. Postimplementation, compliance increased to 94% in both non-ICUs (n¼416) and ICUs (n¼192). Post-implementation, average ATP readings decreased for five of the measured surfaces. Of these, a significant decrease in RLUs was seen for the call bell (662 vs. 159, p<0.0001), bed control (329 vs. 47, p<0.0001), bed rail (548 vs. 424, p<0.0001), and room light switch (174 vs. 122, p¼0.0084). UVD targeted all rooms in units with increased HO CDI transmission or a high endemic CDI burden. Pre-implementation, the HO CDI rate across hospitals was 10.6 cases per 10,000 patient days.
Method
Hospital- wide (HW) Results
ICU Results (% of HW Results)
Urine Source: Catheter
CAUTIs Identified
ICU-Sensitivity
Cerner NIM
307 133
92 (30%) 34 (26%)
43 16
15 11
1.0 (15/15) 0.733 (11/15)
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
ICU-Specificity 0.872 (526/77+526) N/A
S120
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Post-implementation, this rate was 9.7 cases per 10,000 patient days, an 8.5% reduction. CONCLUSIONS: Our environmental cleaning intervention successfully improved cleaning compliance and cleanliness of high touch surfaces as measured by ATP. However, these improvements did not translate to a substantial reduction in endemic HO CDI rates, potentially due to the short post-implementation period. To achieve a more sustained reduction in endemic HO CDI incidence, expanded interventions including standardized terminal cleaning of all CDI rooms with UVD, antimicrobial stewardship, and enhanced compliance with isolation procedures (hand hygiene, equipment cleaning, and consistent use of personal protective equipment) may be necessary.
Presentation Number 9-418 An Interactive Web-based Hand Hygiene (HH) Observation Tool: An Integral Part of a HH Campaign! Christine Bridge MHMS/MBA, Systems Analyst, UPMC Mercy; Mohamed H. Yassin MD, PhD, Medical Director of Infection Control, UPMC Mercy; Julliet Ferrelli MS, MT(ASCP), CIC, Infection Control Coordinator, UPMC Mercy; Marian Pokrywka MS, CIC, Infection Preventionist, UPMC Mercy ISSUE: Hand hygiene (HH) compliance is essential for infection prevention. All over the country, HH campaigns are launched with variable success. Challenges include 1) providing health care workers (HCW) an effective tool to perform hand hygiene observations; 2) using the data gathered from that tool to generate accurate and meaningful information; 3) keeping the observer anonymous. PROJECT: An internal website was created on the hospital’s Intranet site to provide observers the capability to document on any computer; allowing the observer the freedom to document anywhere while protecting the observers anonymity. The website has password protection and restricted access through the use of an active directory (AD) security group. Only observers and the infection preventionists (IPs) access the website. The web tool was built on active server pages (ASP) technology which sends and obtains data from a structured query language (SQL) Database. ASPs were designed, with a SQL statement, to permit only current month observations. Prior month results cannot be altered. Key features of the website include drop down menus to select various departments, HCW types, and when the observation occurred (before or after contact). A departmental access database was also designed, with an open data base connection (ODBC) to the SQL database, which provides the IPs a menu of options of reports to show how departments and HCWs are performing in real time. RESULTS: Summary charts are posted for all employees to view on the hospital’s Intranet Site. Monthly detailed reports are sent to each department to discuss with staff. Detailed real time information has allowed IPs to work with specific HCWs, departments, and physicians to improve compliance. Within a year, the HH compliance rate has improved to a steady and sustained rate of 83%: the last two audits were 87% compliance. LESSON LEARNED: Web-based data gathering tools are innovative techniques that are helpful to the IPs to gather HH observations on a large scale, maintaining anonymity, and providing critical feed-
back to staff. A website was created that has been proven to be crucial in providing a method for our observers to enter data while staying anonymous. Real time accessible information has been important to improving our HH compliance by providing HCWs and IPs with immediate feedback.
Presentation Number 9-419 Full-time Infection Preventionist Improves Outcomes at Rural Community Hospital Jeff Wood MSN, Infection Preventionist, Coosa Valley Medical Center; Heather Bennett BSN, Director of Case Management, Infection Prevention, and Education, Coosa Valley Medical Center ISSUE: The public is becoming increasingly aware of hospital infection rates. Facilities dedicating resources to a full time infection preventionist can decrease nosocomial infection marker (NIM) rates and decrease hospital acquired infections (HAI). Part-time IP provide the staff and patients with inconsistent resource for infection prevention practices.
PROJECT: Facility leadership decides to make IP a full-time FTE, citing public reporting, increased focus on infection, and increasing NIM rate. The facility invests in APIC membership for the new IP. The IP noticed mismatched specimens labeled as surgical wound instead of stasis or decubitus ulcer, and worked with IT to correctly match specimen source to the correct order in CPSI. A reduction in wound NIMs occurred when staff became educated on source labeling, ordering and collection. Hand hygiene reports of 100% from unit directors were previously submitted. The full-time IP questioned the results and was able to ensure more accurate results are obtained. New monitoring tool added and the staff was educated on 5 moments of hand hygiene from WHO. There is increased staff interest and accountability through the sharing of results on a regular basis, and they respond well to the use of visual aids such as dashboards. When the facility had ½ FTE IP, nursing and observation rounds were not consistent. Consequently, the level of responsibility and follow-up varied. This inconsistency also impacted the device utilization reporting and adherence to isolation policies. With the full time FTE, reporting on device utilization for Foley and CVL usage occurs at both the facility and unit level and is performed consistently. Additionally, the IP sees each patient on
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013