- Email: [email protected]
Lessons Learned from Legionella in the water of an Ambulatory Care Center
S26
Poster Abstracts / American Journal of Infection Control 47 (2019) S15−S50
point toward a surface-component contamination and tissue-air risk connection. This investigation was designed to seek new data regarding any FAW-bacteria correlation in an effort to both better understand possible, associated, FAW-use risks and contribute to infection-control protocols that more effectively assist in mitigating or diminishing consequential Healthcare Associated Infection (HAI) risk. METHODS: A total of 320 surface and air samples were collected and cultured from in and around 35 unique FAW devices actively in-use in operating room (OR) settings at three hospital facilities in an associated acute-care system. Surface samples were taken from multiple FAW device points: the internal hose surface, the proximal hose end and the distal hose end. Each retrieved sample was bagged, plated and incubated under sterile procedures. RESULTS: The results show that 24.4 percent (78 of 320) of all samples collected were at higher than maximum acceptable Colony Forming Unit (CFU) pathogens levels. Forty-two and half, 42.5, percent (136 of 320) of all samples were at higher than minimum acceptable CFU levels; 37.2 percent (119 of 320) were equipment samples; 5.3 percent (17 of 320) were air samples. Study results also identified a correlation of positive airborne samples for instances that had high-pathogen contamination in the warmer-temperature components, resulting in a possible increased patient infection risk and possible attributable SSI as primary concerns. CONCLUSIONS: FAW device-component contamination may be a risk in the OR. Cross-contamination of the environment remains a risk as well. A reduction in surface and airborne CFUs may positively reduce SSI and HAI infection risk.
Presentation Number ECR-65 The Hidden Truth in the Faucets: A QualityImprovement Project and Splash Study of Hospital Sinks Kristen VanderElzen MPH, CIC, Michigan Medicine; Harry Zhen BS; Emily Shuman MD; Amanda Valyko MPH, CIC, FAPIC BACKGROUND: Sinks are potential sources of Healthcare Associated Infections (HAI) and have been linked to outbreaks. However, transmission of microorganisms from sink to patient is not well understood. Sink contents may be splashed onto patient care items, contaminating them during faucet use. A splash study was performed to understand the splash potential of the different faucet and sink designs in a larger academic teaching hospital in the Midwest, and an audit of sink cleanliness was conducted. METHODS: Faucets/sinks in intensive care units (ICU) were assessed. Adenosine triphosphate (ATP) monitoring was used to assess cleanliness of the faucet spout and sink bowl/drain cover. Cultures were performed for some faucets/sinks. A splash study was performed using a commercially available fluorescent indicator. Photos were taken to record notable findings during the audit and the splash study. RESULTS: Twenty faucet/sinks in four ICU's were evaluated, and eight different designs were observed. Faucet spouts were more soiled with organic material than sink bowls/drain covers as indicated by higher ATP readings. Pink slime/biofilm was observed on several faucet spouts and aerators. Visible biofilm was associated with higher ATP readings. Aerators were found on sinks where they had been removed previously. Cultures grew Pseudomonas aeruginosa, mold and other environmental organisms. The splash study showed visible splashing on the operator’s body and over four feet from the sink.
CONCLUSIONS: Some sink designs enable splashing sink contents onto patient care items, healthcare worker hands and into patient care spaces. Faucets were much dirtier than expected and a faucet replacement program, eliminating aerators, is currently being developed.
Presentation Number ECR-66 Infection Prevention and Control's Role in the Design and Construction of a new Ambulatory Care Center. Lessons Learned Richard Vogel MS, CIC, FAPIC, New York Presbyterian BACKGROUND: An urban, teaching medical center started designing a new 740,000 sq. foot ambulatory care center in 2013 with the Center scheduled to open in April 2018. Infection Prevention and Control (IPC) was included in the Planning and Design team, attending numerous meetings over the next 3?years. METHODS: At project design meetings, IPC input was incorporated into all areas of the center including Infusion Services, Intervention Radiology, Endoscopy, Ambulatory Surgery, Central Sterile Processing, and Diagnostic Imaging. Input included, the number of Isolation Rooms, number and location of handwashing stations and hand sanitizers, construction materials and finishes, and work flow. IPC signoff of the final design was required for all areas of the Center. At the start of construction, because dust control measures were not needed, IPC was not included in the construction meetings. RESULTS: Towards the end of construction, IPC joined in multidisciplinary weekly walkthrough of the various areas in the Center. Modifications and changes had been made to the design plans without input from IPC. Some of changes the included: Medication room counter use which encroached on the handwashing sink, locations of hand sanitizers, hot water circulating temperature and the addition of a second visual pressure monitor which in some instances was in conflict with the electronic monitor. To fix some of the changes required modification of the already built space. However, others could not be changed and resulted in a space that, from an Infection Prevention and Control perspective was not optmal. CONCLUSIONS: Had IPC continued to attend project meeting during construction, many of the modifications that were made could have been prevented, or a better solution could have been designed. This experience has taught us that IPC should be part of all construction projects for the entire project.
Presentation Number ECR-67 Lessons Learned from Legionella in the water of an Ambulatory Care Center Kristen VanderElzen MPH, CIC, Michigan Medicine; Kevin Thompson MPH, CIC; Amanda Valyko MPH, CIC, FAPIC; Laraine Washer MD BACKGROUND: Water Management Programs are an important part of preventing Legionella infection in healthcare settings. As part of a proactive risk assessment, Legionella was cultured from the potable water of an ambulatory care center. Investigation and remediation efforts give important lessons for future programs. METHODS: Chlorine levels, temperatures, the plumbing system and Legionella cultures were assessed. Remediation efforts included: super-heating and flushing of the hot water system, replacement of all drinking fountains with models that do not utilize carbon filters,
APIC 46th Annual Educational Conference & International Meeting| Philadelphia, PA | June 12-14 2019
Poster Abstracts / American Journal of Infection Control 47 (2019) S15−S50
and point-of-use filtration installed on showers. Follow-up cultures confirmed remediation efforts. RESULTS: Two potable water samples were cultured and were positive (10 colony-forming units per milliliter [cfu/ml]) for L. pneumophila serogroup 3. Follow-up cultures were performed with a total of 13 out of 50 positive ≥ one cfu/ml. All grew L. pneumophila serogroup 3. Assessment of the building’s hot water system showed it was designed to be set at 140⁰ F, however, it was set to 128⁰ F. Three positive cultures occurred after the initial super-heating (1 sink and 1 shower (hot water) and one drinking fountain (cold water)). After a second super-heating, all culture results were below action levels. CONCLUSIONS: Routine culture for Legionella in the water system of an ambulatory care center gave rise to an extensive investigation. Bottled water was brought in to provide drinking water until remediation was deemed sufficient. We learned that chlorine levels in municipal water may not control Legionella below the OSHA 10?cfu/ ?ml threshold for potable water in a medium-sized building (100,000 square feet), one event of super-heating may not remediate all outlets sufficiently, mechanical design of a water system may not match current state, carbon filters in drinking fountains remove all residual chlorine allowing for contamination and growth, and follow-up plans including thresholds for action should be determined prior to culture.
Presentation Number ECR-68 From Response to Recovery: Infection Prevention’s Role in a Flood Disaster Event Karen Guerin MS, RN, CIC, CPPS, UCHealth Memorial; Christopher Olson BS, M(ASCP)MLT, CIC, UCHealth Memorial, Highlands Ranch Hospital BACKGROUND: Environmental issues are a constant concern in healthcare as facilities and processes can fail when tested during natural and man-made disasters. Water damage can have more of an impact than just the initial cosmetic damage. Soil and silt intrusion from external flooding may bring in harmful bacteria and mold spores. During a recent disastrous flood, water flowed through the basement affecting critical departments including: operating rooms, sterile processing, laboratory, pharmacy, EVS and the kitchen. The Infection Prevention team adapted traditional construction principles to manage and mitigate harm to patients, healthcare workers, and visitors. METHODS: Following the flood, response and recovery efforts must prioritize patient, staff and visitor safety. Incident command gathered experts early and developed prioritized response activities. As consultants in the hospital’s incident command, the Infection Prevention team developed response and containment pathways to ensure hospital safety and tactics to move the process from response to recovery of critical services. Mitigation efforts were based on assessment of the situation and prioritization to restore essential hospital functions. Additionally, prospective patient surveillance was established to monitor for flood related outcomes including fungal and bacterial infections. RESULTS: Innovative restoration of functions and strategic placement of barriers and ante-rooms allowed the facility to remain open and come off of divert status quickly. Due to the severity of the event, services were relocated or modified; food was catered, lab and the gastrointestinal services were moved to pre-op with temporary walls and cooling units. CONCLUSIONS: The evidence supporting the purpose and function of the Infection Preventionist in construction and renovation is available but our practices are not well integrated in emergency or large scale disasters due to a lack of resources and functional, concrete tools. Using priority-driven goals, containment, and strategic remediation
S27
techniques, we were able to restore facility function while protecting patients and healthcare workers.
Healthcare Worker Safety and Occupational Health Presentation Number WSOH-70 Improved Skin Health in a One-Year Prospective Bioengineering Analysis of Healthcare Workers’ Hands in Long Term?Care Amna Handley MSN, FNP-C, APRN, CIC, Georgia-Pacific; Yin Z. Hessefort MS, Georgia-Pacific BACKGROUND: Compromised skin integrity is a known barrier to optimal hand hygiene (HH) practice and a contributing factor to decreased HH events amongst healthcare workers (HCWs). Because traditional sensorial assessments of skin health are subjective, skin evaluation an be difficult. Adding to the complexity, HCWs daily routines such as use of personal hygiene products, impacts in-use studies of skin responses that are typically conduced over short periods of time, days or weeks. Furthermore, while these results may conclude statistically, other variables such as seasonal changes, temperature and humidity variations, episodes of increased HH due to outbreaks during the year (i.e. norovirus), limits accuracy of the skin health evaluation and true skin status of HCWs hands. METHODS: A prospective one-year tracking test protocol was designed to assess skin physiologic properties of thirty-six HCW’s in a?skilled nursing facility every six to eight weeks between February of?2016 to January of 2017 in response to two test products: antimicrobial soap formulated with milder surfactants, conditioners and moisturizers and alcohol sanitizer that contained emollients and moisturizers. Due to work shift, turnover, and medical absenteeism, 12 of the 36 HCW’s participated in every skin bioengineering mea?surement. RESULTS: Results indicated that skin barrier function by transepidermal water loss (TEWL) showed significant improvement compared to baseline and directional improvement for hydration. Data further revealed that seasonal changes reflect on skin hydration changes, warmer weather induced higher skin hydration levels than colder weather. Skin redness showed no sign of change both instrumentally and visually, while skin pH was directionally decreased and aligned with the TEWL trend, demonstrating improvement in skin health. CONCLUSIONS: Soap and sanitizer formulation with moisturizers have accumulative benefits in maintaining skin health and should be considered when choosing products for HCW’s to promote optimal HH practice.
Implementation Science and Research Presentation Number ISR-71 Utilizing a Business Case to Link Reduction in Infections to Reduction in? Costs Pearl E. Lavalette MSN, RN, CIC, St. Joseph’s Health; Debra Steves RN, BSN, St. Joseph’s Health BACKGROUND: A review of literature indicates that expanding chlorhexidine gluconate (CHG) bathing beyond those at high risk to all patients can reduce hospital-acquired infection (HAI) rates. However, infection
APIC 46th Annual Educational Conference & International Meeting| Philadelphia, PA | June 12-14 2019
Poster Abstracts / American Journal of Infection Control 47 (2019) S15−S50
point toward a surface-component contamination and tissue-air risk connection. This investigation was designed to seek new data regarding any FAW-bacteria correlation in an effort to both better understand possible, associated, FAW-use risks and contribute to infection-control protocols that more effectively assist in mitigating or diminishing consequential Healthcare Associated Infection (HAI) risk. METHODS: A total of 320 surface and air samples were collected and cultured from in and around 35 unique FAW devices actively in-use in operating room (OR) settings at three hospital facilities in an associated acute-care system. Surface samples were taken from multiple FAW device points: the internal hose surface, the proximal hose end and the distal hose end. Each retrieved sample was bagged, plated and incubated under sterile procedures. RESULTS: The results show that 24.4 percent (78 of 320) of all samples collected were at higher than maximum acceptable Colony Forming Unit (CFU) pathogens levels. Forty-two and half, 42.5, percent (136 of 320) of all samples were at higher than minimum acceptable CFU levels; 37.2 percent (119 of 320) were equipment samples; 5.3 percent (17 of 320) were air samples. Study results also identified a correlation of positive airborne samples for instances that had high-pathogen contamination in the warmer-temperature components, resulting in a possible increased patient infection risk and possible attributable SSI as primary concerns. CONCLUSIONS: FAW device-component contamination may be a risk in the OR. Cross-contamination of the environment remains a risk as well. A reduction in surface and airborne CFUs may positively reduce SSI and HAI infection risk.
Presentation Number ECR-65 The Hidden Truth in the Faucets: A QualityImprovement Project and Splash Study of Hospital Sinks Kristen VanderElzen MPH, CIC, Michigan Medicine; Harry Zhen BS; Emily Shuman MD; Amanda Valyko MPH, CIC, FAPIC BACKGROUND: Sinks are potential sources of Healthcare Associated Infections (HAI) and have been linked to outbreaks. However, transmission of microorganisms from sink to patient is not well understood. Sink contents may be splashed onto patient care items, contaminating them during faucet use. A splash study was performed to understand the splash potential of the different faucet and sink designs in a larger academic teaching hospital in the Midwest, and an audit of sink cleanliness was conducted. METHODS: Faucets/sinks in intensive care units (ICU) were assessed. Adenosine triphosphate (ATP) monitoring was used to assess cleanliness of the faucet spout and sink bowl/drain cover. Cultures were performed for some faucets/sinks. A splash study was performed using a commercially available fluorescent indicator. Photos were taken to record notable findings during the audit and the splash study. RESULTS: Twenty faucet/sinks in four ICU's were evaluated, and eight different designs were observed. Faucet spouts were more soiled with organic material than sink bowls/drain covers as indicated by higher ATP readings. Pink slime/biofilm was observed on several faucet spouts and aerators. Visible biofilm was associated with higher ATP readings. Aerators were found on sinks where they had been removed previously. Cultures grew Pseudomonas aeruginosa, mold and other environmental organisms. The splash study showed visible splashing on the operator’s body and over four feet from the sink.
CONCLUSIONS: Some sink designs enable splashing sink contents onto patient care items, healthcare worker hands and into patient care spaces. Faucets were much dirtier than expected and a faucet replacement program, eliminating aerators, is currently being developed.
Presentation Number ECR-66 Infection Prevention and Control's Role in the Design and Construction of a new Ambulatory Care Center. Lessons Learned Richard Vogel MS, CIC, FAPIC, New York Presbyterian BACKGROUND: An urban, teaching medical center started designing a new 740,000 sq. foot ambulatory care center in 2013 with the Center scheduled to open in April 2018. Infection Prevention and Control (IPC) was included in the Planning and Design team, attending numerous meetings over the next 3?years. METHODS: At project design meetings, IPC input was incorporated into all areas of the center including Infusion Services, Intervention Radiology, Endoscopy, Ambulatory Surgery, Central Sterile Processing, and Diagnostic Imaging. Input included, the number of Isolation Rooms, number and location of handwashing stations and hand sanitizers, construction materials and finishes, and work flow. IPC signoff of the final design was required for all areas of the Center. At the start of construction, because dust control measures were not needed, IPC was not included in the construction meetings. RESULTS: Towards the end of construction, IPC joined in multidisciplinary weekly walkthrough of the various areas in the Center. Modifications and changes had been made to the design plans without input from IPC. Some of changes the included: Medication room counter use which encroached on the handwashing sink, locations of hand sanitizers, hot water circulating temperature and the addition of a second visual pressure monitor which in some instances was in conflict with the electronic monitor. To fix some of the changes required modification of the already built space. However, others could not be changed and resulted in a space that, from an Infection Prevention and Control perspective was not optmal. CONCLUSIONS: Had IPC continued to attend project meeting during construction, many of the modifications that were made could have been prevented, or a better solution could have been designed. This experience has taught us that IPC should be part of all construction projects for the entire project.
Presentation Number ECR-67 Lessons Learned from Legionella in the water of an Ambulatory Care Center Kristen VanderElzen MPH, CIC, Michigan Medicine; Kevin Thompson MPH, CIC; Amanda Valyko MPH, CIC, FAPIC; Laraine Washer MD BACKGROUND: Water Management Programs are an important part of preventing Legionella infection in healthcare settings. As part of a proactive risk assessment, Legionella was cultured from the potable water of an ambulatory care center. Investigation and remediation efforts give important lessons for future programs. METHODS: Chlorine levels, temperatures, the plumbing system and Legionella cultures were assessed. Remediation efforts included: super-heating and flushing of the hot water system, replacement of all drinking fountains with models that do not utilize carbon filters,
APIC 46th Annual Educational Conference & International Meeting| Philadelphia, PA | June 12-14 2019
Poster Abstracts / American Journal of Infection Control 47 (2019) S15−S50
and point-of-use filtration installed on showers. Follow-up cultures confirmed remediation efforts. RESULTS: Two potable water samples were cultured and were positive (10 colony-forming units per milliliter [cfu/ml]) for L. pneumophila serogroup 3. Follow-up cultures were performed with a total of 13 out of 50 positive ≥ one cfu/ml. All grew L. pneumophila serogroup 3. Assessment of the building’s hot water system showed it was designed to be set at 140⁰ F, however, it was set to 128⁰ F. Three positive cultures occurred after the initial super-heating (1 sink and 1 shower (hot water) and one drinking fountain (cold water)). After a second super-heating, all culture results were below action levels. CONCLUSIONS: Routine culture for Legionella in the water system of an ambulatory care center gave rise to an extensive investigation. Bottled water was brought in to provide drinking water until remediation was deemed sufficient. We learned that chlorine levels in municipal water may not control Legionella below the OSHA 10?cfu/ ?ml threshold for potable water in a medium-sized building (100,000 square feet), one event of super-heating may not remediate all outlets sufficiently, mechanical design of a water system may not match current state, carbon filters in drinking fountains remove all residual chlorine allowing for contamination and growth, and follow-up plans including thresholds for action should be determined prior to culture.
Presentation Number ECR-68 From Response to Recovery: Infection Prevention’s Role in a Flood Disaster Event Karen Guerin MS, RN, CIC, CPPS, UCHealth Memorial; Christopher Olson BS, M(ASCP)MLT, CIC, UCHealth Memorial, Highlands Ranch Hospital BACKGROUND: Environmental issues are a constant concern in healthcare as facilities and processes can fail when tested during natural and man-made disasters. Water damage can have more of an impact than just the initial cosmetic damage. Soil and silt intrusion from external flooding may bring in harmful bacteria and mold spores. During a recent disastrous flood, water flowed through the basement affecting critical departments including: operating rooms, sterile processing, laboratory, pharmacy, EVS and the kitchen. The Infection Prevention team adapted traditional construction principles to manage and mitigate harm to patients, healthcare workers, and visitors. METHODS: Following the flood, response and recovery efforts must prioritize patient, staff and visitor safety. Incident command gathered experts early and developed prioritized response activities. As consultants in the hospital’s incident command, the Infection Prevention team developed response and containment pathways to ensure hospital safety and tactics to move the process from response to recovery of critical services. Mitigation efforts were based on assessment of the situation and prioritization to restore essential hospital functions. Additionally, prospective patient surveillance was established to monitor for flood related outcomes including fungal and bacterial infections. RESULTS: Innovative restoration of functions and strategic placement of barriers and ante-rooms allowed the facility to remain open and come off of divert status quickly. Due to the severity of the event, services were relocated or modified; food was catered, lab and the gastrointestinal services were moved to pre-op with temporary walls and cooling units. CONCLUSIONS: The evidence supporting the purpose and function of the Infection Preventionist in construction and renovation is available but our practices are not well integrated in emergency or large scale disasters due to a lack of resources and functional, concrete tools. Using priority-driven goals, containment, and strategic remediation
S27
techniques, we were able to restore facility function while protecting patients and healthcare workers.
Healthcare Worker Safety and Occupational Health Presentation Number WSOH-70 Improved Skin Health in a One-Year Prospective Bioengineering Analysis of Healthcare Workers’ Hands in Long Term?Care Amna Handley MSN, FNP-C, APRN, CIC, Georgia-Pacific; Yin Z. Hessefort MS, Georgia-Pacific BACKGROUND: Compromised skin integrity is a known barrier to optimal hand hygiene (HH) practice and a contributing factor to decreased HH events amongst healthcare workers (HCWs). Because traditional sensorial assessments of skin health are subjective, skin evaluation an be difficult. Adding to the complexity, HCWs daily routines such as use of personal hygiene products, impacts in-use studies of skin responses that are typically conduced over short periods of time, days or weeks. Furthermore, while these results may conclude statistically, other variables such as seasonal changes, temperature and humidity variations, episodes of increased HH due to outbreaks during the year (i.e. norovirus), limits accuracy of the skin health evaluation and true skin status of HCWs hands. METHODS: A prospective one-year tracking test protocol was designed to assess skin physiologic properties of thirty-six HCW’s in a?skilled nursing facility every six to eight weeks between February of?2016 to January of 2017 in response to two test products: antimicrobial soap formulated with milder surfactants, conditioners and moisturizers and alcohol sanitizer that contained emollients and moisturizers. Due to work shift, turnover, and medical absenteeism, 12 of the 36 HCW’s participated in every skin bioengineering mea?surement. RESULTS: Results indicated that skin barrier function by transepidermal water loss (TEWL) showed significant improvement compared to baseline and directional improvement for hydration. Data further revealed that seasonal changes reflect on skin hydration changes, warmer weather induced higher skin hydration levels than colder weather. Skin redness showed no sign of change both instrumentally and visually, while skin pH was directionally decreased and aligned with the TEWL trend, demonstrating improvement in skin health. CONCLUSIONS: Soap and sanitizer formulation with moisturizers have accumulative benefits in maintaining skin health and should be considered when choosing products for HCW’s to promote optimal HH practice.
Implementation Science and Research Presentation Number ISR-71 Utilizing a Business Case to Link Reduction in Infections to Reduction in? Costs Pearl E. Lavalette MSN, RN, CIC, St. Joseph’s Health; Debra Steves RN, BSN, St. Joseph’s Health BACKGROUND: A review of literature indicates that expanding chlorhexidine gluconate (CHG) bathing beyond those at high risk to all patients can reduce hospital-acquired infection (HAI) rates. However, infection
APIC 46th Annual Educational Conference & International Meeting| Philadelphia, PA | June 12-14 2019