- Email: [email protected]
Resistant Organisms: An Innovative Approach to Preventing Healthcare Transmission
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
e99
Table 1 Influenza vaccination compliance rates 2011e2012 FLU season CLINICAL SITES OF CARE (associates & employed physicians) % Compliant with Policy 99.5% % Vaccinated 95% % Approved Exemptions 4,2% HIGHLY PHO PHYSICIANS HIGHLY RECOMMENDED % Compliant with Policy *87% *Preliminary rate OVERALL % VACCINATED HIGHLY RECOMMENDED & MANDATORY % Associates Vaccinated 93.7%
the vaccine. Most recently, the Infectious Diseases Society of America (IDSA) has formally asked federal health officials to recommend making influenza vaccination mandatory for healthcare workers (HCWs). For the purpose of this project, HCW's are defined as associates, volunteers, and physicians physically located or working in health care settings with the potential for exposure to infectious materials. While some HCW's provide direct patient care, others have jobs that may put them into close contact with patients or the patient environment. Transmission of influenza to patients by HCW's is well documented. HCW's may acquire influenza both in the health care setting and in the community, and they can easily transmit the virus to patients in their care. Though there is strong evidence to support vaccination of HCW's with influenza vaccine, success remains low nationally. The Centers for Disease Control and Prevention (CDC) estimates that only about 40% of HCW's in the United States are vaccinated against influenza annually. The organization in this abstract has offered free influenza vaccines to all associates, physicians, volunteers, and students as required by The Joint Commission. The associate vaccination rate has remained consistently low over the past several years between 40% to 50%.
% LOA % Terminated (18) Total number of associates OTHER SITES % Vaccinated Total number of associates
MANDATORY 0.44% 0.06% 27,249 HIGHLY RECOMMENDED 81.2% 2,446
Project: A mandatory influenza vaccination program was implemented for a large healthcare system for the 2011-2012 flu season. All associates, including employed physicians, at clinical sites (hospitals, medical groups, clinics) were mandated to receive the vaccination. Non-employed physicians aligned with the Physician Hospital Organization (PHO) received credit the influenza vaccine through the clinical integration model. The influenza vaccine was highly recommended for other non-employed physicians and associates at non-clinical sites. Key elements of the program include: Interdisciplinary partnership Leadership support Communication Exemption Review Oversight Committee Results: The program was very successful Achieved a compliance rate of 99.5% for mandated sites. (See table 1) Five percent of associates (1,510) applied for either a medical exemption or a religious exemption. Of those reviewed by the oversight committee, 183 were denied. (See Graph 1) 18 associates (out of 30,000) were terminated for failure to comply with the mandatory flu vaccine program. Lesson Learned: Implementation of a mandatory influenza vaccination requires the full support and collaboration of a large interdisciplinary team. Identified below are several opportunities identified during the first year and will provide direction as we work to improve the program for next year. 1. Sharing information amongst data bases. 2. Establish definitive criteria for exemptions. 3. Adherence to defined deadlines.
Presentation Number 8-114 Resistant Organisms: An Innovative Approach to Preventing Healthcare Transmission Michelle Mace MSN, RN, CIC, Administrator, Infection Prevention & Environmental Services, Catawba Valley Medical Center; Ms. Alisa Leonard MHA, RN, CIC, Infection Prevention Coordinator, Catawba Valley Medical Center; Danielle Thurman BSN, RN, CPEN, Patient Care Coordinator, Catawba Valley Medical Center Issue: Incidence and prevalence of all multidrug resistant organisms are on the rise. Highly resistant organisms such as Klebsiella pneumoniae Carbapenemase (KPC), Acinetobacter, C difficile, and Extended Spectrum Beta Lactamases (ESBLs) have become a new threat to the hospitalized patient. Infection Prevention (IP) at a community Magnet hospital recognized a potential risk point after identifying a newly admitted KPC positive patient during surveillance in January 2011. Upon investigation, it was determined that the possible incidence of admitting patients with a highly resistant organism and not placing the patient on isolation was a great risk. In 2010 a Multi-Drug Resistant Organism (MDRO) Prevention Team was formed to address patient care issues with Methicillin Resistant Staphylococcus aureus (MRSA) and C difficile. In 2011, the team was asked to also address care issues related to highly resistant organisms. APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
e100
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Presentation Number 8-115 The Dynamics of a Hand Hygiene Program in a Pediatric Oncology Service in El Salvador: Success Factors and Lessons Learned
Project: The MDRO Prevention Team, comprised of interdisciplinary representatives from administration, IP, pharmacy, lab, Environmental Services (EVS), inpatient units, emergency department and operating room, accepted the task of improving identification, surveillance, and care of the patient having a highly resistant organism. To improve identification of C difficile, in 2011 the lab initiated Polymerase Chain Reaction (PCR) testing. In 2010 the MDRO Prevention Team created a “C diff bundle,” including a small cart for soiled linen and Clorox-based disinfectant wipes in each contact enteric isolation room. In addition, EVS began cleaning these rooms with a Clorox-based disinfectant. The team developed a process for identifying isolates that need further KPC testing using a Modified Hodge Test. In 2011 this team developed a new isolation for highly resistant organisms. Patients having a highly resistant organism are placed on “Strict Contact Isolation.” The major difference in Contact and Strict Contact is the cleaning requirements, keeping patients located in one room and using dedicated equipment. Nursing staff clean high touch surfaces once per shift. Upon discharge EVS clean the patient room twice with different EVS staff at different times. Infection prevention educated administration, clinical staff, medical staff and EVS about highly resistant microorganisms and transmission prevention. EVS staff are monitored every week randomly using a black light process to ensure thorough cleaning. Results: The incidence of patients with a MDRO present on admission has steadily increased since 2009. After creating the MDRO committee and implementing transmission risk reduction strategies the health care acquired MRSA and C difficile rates have steadily decreased, with an 86% reduction of MRSA and a 25% reduction of C difficile from 2009 to 2011. Our other health care acquired MDROs have remained stable at a rate of .06 for 2010 and 2011, although the present on admission have increased showing higher prevalence in the community. Lesson Learned: Implementing Evidence Based Practices to prevent MDROs requires an interdisciplinary approach, with stakeholder buy-in. In addition, MDRO transmission prevention requires innovative thinking from front-line staff to initiate and sustain improvement.
Elsie Gerhardt MA, MPH candidate, Administrative Specialist, St. Jude Children's Research Hospital, University of Memphis; Dr. Roberto Vasquez MD, Director Oncology Service, Hospital Nacional de Ninos Benjamin Bloom; Dr. Soad Fuentes MD, Director Centro Medico Ayudame a Vivir - Fundacion Rafael Meza Ayau outpatient clinic, Hopspital Nacional de Ninos Benjamin Bloom; Dr. Gabriela Maron MD, Staff, Hospital Nacional de Ninos Benjamin Bloom; Ms. Dinora Barrera, nurse - Head nurse of the inpatient area of Hospital Nacional de Ninos Benjamin Bloom - El Salvador, Hospital Nacional de Ninos Benjamin Bloom - El Salvador; Dr. Miriam Gonzalez MD, Student, University of Memphis; Mr. Don Guimera BSN, RN, CIC, CCRP, International Epidemiology Coordinator, St. Jude Childrens Research Hospital; Dr. Miriam De Lourdes, Duenas Pediatric Infectious Diseases Department, Infection Control, Pediatric Infectious Diseases e Magister in Infection Control; Dr. Mario Gamero MD, Director Infectious Diseases Hospital Nacional de Ninos Benjamin Bloom, Hospital Nacional de Ninos Benjamin Bloom - San Salvador, El Salvador; Dr. Kyle M. Johnson PhD, CCRP, Clinical Research Associate II, St. Jude Children's Research Hospital; Dr. Miguela Caniza MD, Director of Infectious Diseases-International Outreach Division, St. Jude Children's Research Hospital Issue: Safety and cost containment are key aspects of infection prevention and control (IPC) efforts. Optimum hand hygiene (HH) decreases the rates of healthcare-associated infections, and implementing a HH program is a first step toward safe care. However, sustaining a HH program can be challenging for a public hospital faced with budget constraints and multiple competing needs. Our U.S. hospital (USH) has collaborated with a public hospital in El Salvador to improve pediatric cancer care for 10 years. Here we report the result of a recent evaluation of the HH program and outline success factors for sustainability, as this relates to the dynamics among IPC team members, unit leaders, personnel, educators, a commercial provider, and patients' families. Project: In 2007, our USH collaborated to implement a HH program by providing alcohol gel to the oncology service of a 300-bed pediatric hospital in El Salvador. Oncology services include 26 inpatient beds and an outpatient clinic. While providing gel, we optimized HH education and promotion, and compliance monitoring. Alcohol-gel handrubs were chosen as an effective solution that can be placed by every bed and elsewhere for maximum access and compliance. A local gel manufacturer has provided service since the program's inception, monitors usage, and distributes the product throughout the oncology service. The USH funded the HH program since the beginning, purchasing gel, and supplementing the salary of a local physician who monitors infection rates and HH practices, and periodically reports this information. Additionally, the USH visits and monitors the site once a year. In November 2011, a USH team assessed the HH program and interviewed oncology service personnel regarding satisfaction with the program, gel, supplier service, and the gel monitoring and ordering process. Results: After 4 years, the HH program is still strong. In the inpatient area, one gel dispenser per bed was available in 22 of the 26 beds; and 2 of the 6 sinks had soap and towels. In the outpatient and short-term stay areas, a gel dispenser was available in all but one of the existing 37 beds and recliners; all of the 3 sinks had soap and towels. Nurses and families are involved in monitoring gel
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
e99
Table 1 Influenza vaccination compliance rates 2011e2012 FLU season CLINICAL SITES OF CARE (associates & employed physicians) % Compliant with Policy 99.5% % Vaccinated 95% % Approved Exemptions 4,2% HIGHLY PHO PHYSICIANS HIGHLY RECOMMENDED % Compliant with Policy *87% *Preliminary rate OVERALL % VACCINATED HIGHLY RECOMMENDED & MANDATORY % Associates Vaccinated 93.7%
the vaccine. Most recently, the Infectious Diseases Society of America (IDSA) has formally asked federal health officials to recommend making influenza vaccination mandatory for healthcare workers (HCWs). For the purpose of this project, HCW's are defined as associates, volunteers, and physicians physically located or working in health care settings with the potential for exposure to infectious materials. While some HCW's provide direct patient care, others have jobs that may put them into close contact with patients or the patient environment. Transmission of influenza to patients by HCW's is well documented. HCW's may acquire influenza both in the health care setting and in the community, and they can easily transmit the virus to patients in their care. Though there is strong evidence to support vaccination of HCW's with influenza vaccine, success remains low nationally. The Centers for Disease Control and Prevention (CDC) estimates that only about 40% of HCW's in the United States are vaccinated against influenza annually. The organization in this abstract has offered free influenza vaccines to all associates, physicians, volunteers, and students as required by The Joint Commission. The associate vaccination rate has remained consistently low over the past several years between 40% to 50%.
% LOA % Terminated (18) Total number of associates OTHER SITES % Vaccinated Total number of associates
MANDATORY 0.44% 0.06% 27,249 HIGHLY RECOMMENDED 81.2% 2,446
Project: A mandatory influenza vaccination program was implemented for a large healthcare system for the 2011-2012 flu season. All associates, including employed physicians, at clinical sites (hospitals, medical groups, clinics) were mandated to receive the vaccination. Non-employed physicians aligned with the Physician Hospital Organization (PHO) received credit the influenza vaccine through the clinical integration model. The influenza vaccine was highly recommended for other non-employed physicians and associates at non-clinical sites. Key elements of the program include: Interdisciplinary partnership Leadership support Communication Exemption Review Oversight Committee Results: The program was very successful Achieved a compliance rate of 99.5% for mandated sites. (See table 1) Five percent of associates (1,510) applied for either a medical exemption or a religious exemption. Of those reviewed by the oversight committee, 183 were denied. (See Graph 1) 18 associates (out of 30,000) were terminated for failure to comply with the mandatory flu vaccine program. Lesson Learned: Implementation of a mandatory influenza vaccination requires the full support and collaboration of a large interdisciplinary team. Identified below are several opportunities identified during the first year and will provide direction as we work to improve the program for next year. 1. Sharing information amongst data bases. 2. Establish definitive criteria for exemptions. 3. Adherence to defined deadlines.
Presentation Number 8-114 Resistant Organisms: An Innovative Approach to Preventing Healthcare Transmission Michelle Mace MSN, RN, CIC, Administrator, Infection Prevention & Environmental Services, Catawba Valley Medical Center; Ms. Alisa Leonard MHA, RN, CIC, Infection Prevention Coordinator, Catawba Valley Medical Center; Danielle Thurman BSN, RN, CPEN, Patient Care Coordinator, Catawba Valley Medical Center Issue: Incidence and prevalence of all multidrug resistant organisms are on the rise. Highly resistant organisms such as Klebsiella pneumoniae Carbapenemase (KPC), Acinetobacter, C difficile, and Extended Spectrum Beta Lactamases (ESBLs) have become a new threat to the hospitalized patient. Infection Prevention (IP) at a community Magnet hospital recognized a potential risk point after identifying a newly admitted KPC positive patient during surveillance in January 2011. Upon investigation, it was determined that the possible incidence of admitting patients with a highly resistant organism and not placing the patient on isolation was a great risk. In 2010 a Multi-Drug Resistant Organism (MDRO) Prevention Team was formed to address patient care issues with Methicillin Resistant Staphylococcus aureus (MRSA) and C difficile. In 2011, the team was asked to also address care issues related to highly resistant organisms. APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
e100
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Presentation Number 8-115 The Dynamics of a Hand Hygiene Program in a Pediatric Oncology Service in El Salvador: Success Factors and Lessons Learned
Project: The MDRO Prevention Team, comprised of interdisciplinary representatives from administration, IP, pharmacy, lab, Environmental Services (EVS), inpatient units, emergency department and operating room, accepted the task of improving identification, surveillance, and care of the patient having a highly resistant organism. To improve identification of C difficile, in 2011 the lab initiated Polymerase Chain Reaction (PCR) testing. In 2010 the MDRO Prevention Team created a “C diff bundle,” including a small cart for soiled linen and Clorox-based disinfectant wipes in each contact enteric isolation room. In addition, EVS began cleaning these rooms with a Clorox-based disinfectant. The team developed a process for identifying isolates that need further KPC testing using a Modified Hodge Test. In 2011 this team developed a new isolation for highly resistant organisms. Patients having a highly resistant organism are placed on “Strict Contact Isolation.” The major difference in Contact and Strict Contact is the cleaning requirements, keeping patients located in one room and using dedicated equipment. Nursing staff clean high touch surfaces once per shift. Upon discharge EVS clean the patient room twice with different EVS staff at different times. Infection prevention educated administration, clinical staff, medical staff and EVS about highly resistant microorganisms and transmission prevention. EVS staff are monitored every week randomly using a black light process to ensure thorough cleaning. Results: The incidence of patients with a MDRO present on admission has steadily increased since 2009. After creating the MDRO committee and implementing transmission risk reduction strategies the health care acquired MRSA and C difficile rates have steadily decreased, with an 86% reduction of MRSA and a 25% reduction of C difficile from 2009 to 2011. Our other health care acquired MDROs have remained stable at a rate of .06 for 2010 and 2011, although the present on admission have increased showing higher prevalence in the community. Lesson Learned: Implementing Evidence Based Practices to prevent MDROs requires an interdisciplinary approach, with stakeholder buy-in. In addition, MDRO transmission prevention requires innovative thinking from front-line staff to initiate and sustain improvement.
Elsie Gerhardt MA, MPH candidate, Administrative Specialist, St. Jude Children's Research Hospital, University of Memphis; Dr. Roberto Vasquez MD, Director Oncology Service, Hospital Nacional de Ninos Benjamin Bloom; Dr. Soad Fuentes MD, Director Centro Medico Ayudame a Vivir - Fundacion Rafael Meza Ayau outpatient clinic, Hopspital Nacional de Ninos Benjamin Bloom; Dr. Gabriela Maron MD, Staff, Hospital Nacional de Ninos Benjamin Bloom; Ms. Dinora Barrera, nurse - Head nurse of the inpatient area of Hospital Nacional de Ninos Benjamin Bloom - El Salvador, Hospital Nacional de Ninos Benjamin Bloom - El Salvador; Dr. Miriam Gonzalez MD, Student, University of Memphis; Mr. Don Guimera BSN, RN, CIC, CCRP, International Epidemiology Coordinator, St. Jude Childrens Research Hospital; Dr. Miriam De Lourdes, Duenas Pediatric Infectious Diseases Department, Infection Control, Pediatric Infectious Diseases e Magister in Infection Control; Dr. Mario Gamero MD, Director Infectious Diseases Hospital Nacional de Ninos Benjamin Bloom, Hospital Nacional de Ninos Benjamin Bloom - San Salvador, El Salvador; Dr. Kyle M. Johnson PhD, CCRP, Clinical Research Associate II, St. Jude Children's Research Hospital; Dr. Miguela Caniza MD, Director of Infectious Diseases-International Outreach Division, St. Jude Children's Research Hospital Issue: Safety and cost containment are key aspects of infection prevention and control (IPC) efforts. Optimum hand hygiene (HH) decreases the rates of healthcare-associated infections, and implementing a HH program is a first step toward safe care. However, sustaining a HH program can be challenging for a public hospital faced with budget constraints and multiple competing needs. Our U.S. hospital (USH) has collaborated with a public hospital in El Salvador to improve pediatric cancer care for 10 years. Here we report the result of a recent evaluation of the HH program and outline success factors for sustainability, as this relates to the dynamics among IPC team members, unit leaders, personnel, educators, a commercial provider, and patients' families. Project: In 2007, our USH collaborated to implement a HH program by providing alcohol gel to the oncology service of a 300-bed pediatric hospital in El Salvador. Oncology services include 26 inpatient beds and an outpatient clinic. While providing gel, we optimized HH education and promotion, and compliance monitoring. Alcohol-gel handrubs were chosen as an effective solution that can be placed by every bed and elsewhere for maximum access and compliance. A local gel manufacturer has provided service since the program's inception, monitors usage, and distributes the product throughout the oncology service. The USH funded the HH program since the beginning, purchasing gel, and supplementing the salary of a local physician who monitors infection rates and HH practices, and periodically reports this information. Additionally, the USH visits and monitors the site once a year. In November 2011, a USH team assessed the HH program and interviewed oncology service personnel regarding satisfaction with the program, gel, supplier service, and the gel monitoring and ordering process. Results: After 4 years, the HH program is still strong. In the inpatient area, one gel dispenser per bed was available in 22 of the 26 beds; and 2 of the 6 sinks had soap and towels. In the outpatient and short-term stay areas, a gel dispenser was available in all but one of the existing 37 beds and recliners; all of the 3 sinks had soap and towels. Nurses and families are involved in monitoring gel
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012