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Policies and Practices for Multi-Drug Resistant Organisms in a National Sample of NHSN Hospitals
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American Journal of Infection Control June 2009
training of nursing quality unit-based representatives and dissemination of a pocket guide to isolation. A lunch and learn program (offering continuing education credits) was provided to nursing through the summer of 2008. In June 2008 two full-time employees were hired to exclusively observe HCW compliance with CP and hand hygiene. Observers collect daily observations on each patient in CP which included hand hygiene before and after patient contact and correct use of gowns and gloves. CP results were reported to leadership. In October 2008 IP began writing an Infection Control note in the EMR outlining the pathogen, culture information, type of isolation required, duration of isolation, IP contact information and other pertinent data. Results: From June 23 to December 12, 2008, a total of 1083 CP observations were collected (50% nurses, 8% physicians, 42% others). Overall compliance with CP increased from an average of 53% in July to an average of 86% in December. Compliance measured after the introduction of the infection control EMR note was statistically different than in the pre-note period (358 compliant / 408 non-compliant vs. 211 compliant / 106 non-compliant p , 0.000001) Nursing compliance increased from an average of 55% to 63% after introduction of the IP EMR note. Physician compliance remained essentially the same (60% - 63%). Lessons Learned: A multi-faceted approach increased compliance with CP at our institution. Integrating the EMR into the IP practice has allowed us to document requirements for isolation and acceptable conditions for discontinuing isolation. IP documentation may have been one reason for the impact on compliance with precautions. Written orders, IP notes and provider education has increased our visibility and integrated our activities as part of the patient care team. Increased IP activity via in-services and unit rounding allows us to reinforce policies and procedures and facilitate dialogue with HCW. Further efforts will include an expansion of educational materials for providers, patients and families accessible by links in the EMR IP note. 1:45 pm – 2:00 pm Publication Number: 241 New Investigator Award Winner Blue Ribbon Award Winner
Policies and Practices for Multi-Drug Resistant Organisms in a National Sample of NHSN Hospitals Monika Pogorzelska, MPH, Project Coordinator; Elaine Larson, RN, PhD, FAAN, CIC, Professor of Pharmaceutical and Therapeutic Research and Associate Dean for Research; Patricia Stone, RN, PhD, FAAN, MPH, Associate Professor of Nursing, Columbia University School of Nursing, New York, NY Background: Identification of infections caused by multi-drug resistant organisms (MDRO) in high risk populations is an important component of some infection prevention and control programs. The objective of this study was to determine the range of MDRO policies and practices employed by infection preventionists in Intensive Care Units (ICUs) across the nation and to investigate whether the presence and/or implementation of these practices varied with certain hospital characteristics. Methods: A web-based survey was sent to 441 eligible hospitals. Respondents were asked to indicate whether an ICU had a policy to routinely screen for any of the following MDRO: Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), multi-drug resistant Gram Negative Rods (GNR), C. difficile and other. They were also asked if the ICU: screened ‘‘all patients upon admission’’ or ‘‘periodically’’, the use of presumptive isolation/contact precautions and cohorting, as well as monitoring these policies and the percent of time correctly implemented. Descriptive statistics and logistic regressions were conducted. Results: 250 hospitals provided data on 415 ICUs (response rate 57%). Study ICUs routinely screened for the following: MRSA (59%), VRE (22%), multi-drug resistant GNR (12%), C. difficile (11%) and other (6.8%). Hospitals in the Northeast were two times more likely to routinely screen for MRSA as compared to hospitals located in the West (p 5 .029). Additionally, routine screening for MRSA was associated with increasing bed size (p 5 0.001). There was a two fold increase in routine MRSA screening in teaching hospitals (p 5 0.004). No significant association was found by type of ICU. Forty percent of the ICUs had a written policy in place regarding screening all patients upon admission; an additional 27% reported a written policy requiring periodic screening. A written policy
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for presumptive isolation/contact precautions pending an MDRO screen existed in 31% of the ICUs and 43% of the ICUs had a written policy to cohort patients colonized with an MDRO in the same room. Conclusions: This study provides a description of current policies and practices dealing with MDROs and shows that these policies and practices varied in this select group of hospitals. Published recommendations on appropriate practices also vary which indicates the need for more research. 2:00 pm – 2:15 pm Publication Number: 242
A Sensitive Screening Marker for the Identification of Multi-Drug Resistant Gram Negative Bacilli: Using Resistance to Imipenem or Cefepime as a Predictor Sarah A. Jadin, MPH, Clinical Consultant; Salah S. Qutaishat, PhD, CIC, FSHEA, Director, Infection Prevention, Premier Inc, Charlotte, NC Background: The incidence of multidrug resistant gram negative bacilli (MDR-GNB) has increased in recent years. Patient to patient transmission in hospitals has likely contributed to this rapid rise and a method to promptly and clearly identify infected or colonized patients is needed. A commonly used definition for a MDR-GNB is resistance to three or more classes of antibiotics. This may be interpreted differently and can be difficult for clinicians to rapidly identify. We conducted a study to determine if resistance to one or two selected drugs could be used as an automated method to indentify multi-drug resistance MDR-GNB. Methods: From July 1 to September 30, 2008, patients with isolates collected from any source yielding Acinetobacter baumanii, Enterobacter aerogenes, Enterobacter cloacae, Escherichia coli, Klebsiella oxytoca, Klebiella. pneumoniae, Proteus mirabilis or Pseudomonas aeurginosa from three US hospitals in various geographic locations were included in this study. Duplicate isolates and isolates with no associated susceptibility data were excluded. MDR was designated if the isolate was resistant to three of the four antibiotic classes. For flurorquinolones, aminoglycosides and carbapenems, an isolate was resistant to the class if it was resistant to any drug in the class. For beta-lactams, resistance to any 3rd generation or higher cephalosporin signified resistance. The test method used to predict MDR-GNB was resistance to either imipenem or cefepime. The sensitivity, specificity and positive and negative predictive values were calculated. Results: Of the isolates included in the study (2,484), 6.2% were determined to be MDR-GNB. Using cefepime or imipenem as a predictor for MDR, the sensitivity, specificity, positive predictive value and negative predictive value was 92%, 95%, 56% and 99% respectively. Conclusions: MDR-GNB are becoming more prevalent in hospitals and transmission among patients is of great concern. This study was undertaken to determine if the test method of resistance to either cefepime or imipenem could be used as a marker for MDR. The results show that this method is highly sensitive and specific. However, due to the low positive predictive value, this method would best be employed as a screening tool to alert clinicians to the possibility of resistance.
2:15 pm – 2:30 pm Publication Number: 243
The Role of Environmental Services in a Collaborative Infection Prevention Model to Reduce Clostridium difficile in the Greater New York Region Barbara A. Smith, RN, BSN, MPA, CIC, Nurse Epidemiologist, St. Luke’s Roosevelt Hospital Center, New York, NY; Audrey B. Adams, RN, BSN, MPH, CIC, Manager, Infection Prevention, Montefiore Medical Center, Bronx, NY; Donna M. Armellino, RN, Director, Epidemiology, North Shore University Hospital, Manhasset, NY; David Calfee, MD, Hospital Epidemiologist, Mount Sinai Medical Center, New York, NY; Hillary Jalon, MS, Project Director, United
American Journal of Infection Control June 2009
training of nursing quality unit-based representatives and dissemination of a pocket guide to isolation. A lunch and learn program (offering continuing education credits) was provided to nursing through the summer of 2008. In June 2008 two full-time employees were hired to exclusively observe HCW compliance with CP and hand hygiene. Observers collect daily observations on each patient in CP which included hand hygiene before and after patient contact and correct use of gowns and gloves. CP results were reported to leadership. In October 2008 IP began writing an Infection Control note in the EMR outlining the pathogen, culture information, type of isolation required, duration of isolation, IP contact information and other pertinent data. Results: From June 23 to December 12, 2008, a total of 1083 CP observations were collected (50% nurses, 8% physicians, 42% others). Overall compliance with CP increased from an average of 53% in July to an average of 86% in December. Compliance measured after the introduction of the infection control EMR note was statistically different than in the pre-note period (358 compliant / 408 non-compliant vs. 211 compliant / 106 non-compliant p , 0.000001) Nursing compliance increased from an average of 55% to 63% after introduction of the IP EMR note. Physician compliance remained essentially the same (60% - 63%). Lessons Learned: A multi-faceted approach increased compliance with CP at our institution. Integrating the EMR into the IP practice has allowed us to document requirements for isolation and acceptable conditions for discontinuing isolation. IP documentation may have been one reason for the impact on compliance with precautions. Written orders, IP notes and provider education has increased our visibility and integrated our activities as part of the patient care team. Increased IP activity via in-services and unit rounding allows us to reinforce policies and procedures and facilitate dialogue with HCW. Further efforts will include an expansion of educational materials for providers, patients and families accessible by links in the EMR IP note. 1:45 pm – 2:00 pm Publication Number: 241 New Investigator Award Winner Blue Ribbon Award Winner
Policies and Practices for Multi-Drug Resistant Organisms in a National Sample of NHSN Hospitals Monika Pogorzelska, MPH, Project Coordinator; Elaine Larson, RN, PhD, FAAN, CIC, Professor of Pharmaceutical and Therapeutic Research and Associate Dean for Research; Patricia Stone, RN, PhD, FAAN, MPH, Associate Professor of Nursing, Columbia University School of Nursing, New York, NY Background: Identification of infections caused by multi-drug resistant organisms (MDRO) in high risk populations is an important component of some infection prevention and control programs. The objective of this study was to determine the range of MDRO policies and practices employed by infection preventionists in Intensive Care Units (ICUs) across the nation and to investigate whether the presence and/or implementation of these practices varied with certain hospital characteristics. Methods: A web-based survey was sent to 441 eligible hospitals. Respondents were asked to indicate whether an ICU had a policy to routinely screen for any of the following MDRO: Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), multi-drug resistant Gram Negative Rods (GNR), C. difficile and other. They were also asked if the ICU: screened ‘‘all patients upon admission’’ or ‘‘periodically’’, the use of presumptive isolation/contact precautions and cohorting, as well as monitoring these policies and the percent of time correctly implemented. Descriptive statistics and logistic regressions were conducted. Results: 250 hospitals provided data on 415 ICUs (response rate 57%). Study ICUs routinely screened for the following: MRSA (59%), VRE (22%), multi-drug resistant GNR (12%), C. difficile (11%) and other (6.8%). Hospitals in the Northeast were two times more likely to routinely screen for MRSA as compared to hospitals located in the West (p 5 .029). Additionally, routine screening for MRSA was associated with increasing bed size (p 5 0.001). There was a two fold increase in routine MRSA screening in teaching hospitals (p 5 0.004). No significant association was found by type of ICU. Forty percent of the ICUs had a written policy in place regarding screening all patients upon admission; an additional 27% reported a written policy requiring periodic screening. A written policy
www.ajicjournal.org Vol. 37 No. 5
E189
for presumptive isolation/contact precautions pending an MDRO screen existed in 31% of the ICUs and 43% of the ICUs had a written policy to cohort patients colonized with an MDRO in the same room. Conclusions: This study provides a description of current policies and practices dealing with MDROs and shows that these policies and practices varied in this select group of hospitals. Published recommendations on appropriate practices also vary which indicates the need for more research. 2:00 pm – 2:15 pm Publication Number: 242
A Sensitive Screening Marker for the Identification of Multi-Drug Resistant Gram Negative Bacilli: Using Resistance to Imipenem or Cefepime as a Predictor Sarah A. Jadin, MPH, Clinical Consultant; Salah S. Qutaishat, PhD, CIC, FSHEA, Director, Infection Prevention, Premier Inc, Charlotte, NC Background: The incidence of multidrug resistant gram negative bacilli (MDR-GNB) has increased in recent years. Patient to patient transmission in hospitals has likely contributed to this rapid rise and a method to promptly and clearly identify infected or colonized patients is needed. A commonly used definition for a MDR-GNB is resistance to three or more classes of antibiotics. This may be interpreted differently and can be difficult for clinicians to rapidly identify. We conducted a study to determine if resistance to one or two selected drugs could be used as an automated method to indentify multi-drug resistance MDR-GNB. Methods: From July 1 to September 30, 2008, patients with isolates collected from any source yielding Acinetobacter baumanii, Enterobacter aerogenes, Enterobacter cloacae, Escherichia coli, Klebsiella oxytoca, Klebiella. pneumoniae, Proteus mirabilis or Pseudomonas aeurginosa from three US hospitals in various geographic locations were included in this study. Duplicate isolates and isolates with no associated susceptibility data were excluded. MDR was designated if the isolate was resistant to three of the four antibiotic classes. For flurorquinolones, aminoglycosides and carbapenems, an isolate was resistant to the class if it was resistant to any drug in the class. For beta-lactams, resistance to any 3rd generation or higher cephalosporin signified resistance. The test method used to predict MDR-GNB was resistance to either imipenem or cefepime. The sensitivity, specificity and positive and negative predictive values were calculated. Results: Of the isolates included in the study (2,484), 6.2% were determined to be MDR-GNB. Using cefepime or imipenem as a predictor for MDR, the sensitivity, specificity, positive predictive value and negative predictive value was 92%, 95%, 56% and 99% respectively. Conclusions: MDR-GNB are becoming more prevalent in hospitals and transmission among patients is of great concern. This study was undertaken to determine if the test method of resistance to either cefepime or imipenem could be used as a marker for MDR. The results show that this method is highly sensitive and specific. However, due to the low positive predictive value, this method would best be employed as a screening tool to alert clinicians to the possibility of resistance.
2:15 pm – 2:30 pm Publication Number: 243
The Role of Environmental Services in a Collaborative Infection Prevention Model to Reduce Clostridium difficile in the Greater New York Region Barbara A. Smith, RN, BSN, MPA, CIC, Nurse Epidemiologist, St. Luke’s Roosevelt Hospital Center, New York, NY; Audrey B. Adams, RN, BSN, MPH, CIC, Manager, Infection Prevention, Montefiore Medical Center, Bronx, NY; Donna M. Armellino, RN, Director, Epidemiology, North Shore University Hospital, Manhasset, NY; David Calfee, MD, Hospital Epidemiologist, Mount Sinai Medical Center, New York, NY; Hillary Jalon, MS, Project Director, United