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Risk Factors for Pediatric Mediastinitis after Cardiac Surgery: Investigation of a Case Cluster
E84
Vol. 32 No. 3
whether sufficient personnel and space was available to clean toys after each use. Once it was determined they meet the algorithm criteria for hand-held toys, the policy lists age-appropriate, safe toys the area may choose to use. Child Life experts created and attached an on-line catalog for convenient ordering of approved, easy-to-clean toys. A table listing acceptable cleaning products (including ordering information, shelf life, and mixing information) was supplied. Cleaning/disinfecting and use of toys in isolation room instructions were updated. The policy revisions were approved. Changes were communicated to supervisors and staff through newsletters and environment of care tours. RESULTS: Outpatient allied health staff welcomed the policy. Staff appreciated access to the toy catalog and cleaning product ordering information in one on-line document. The pediatric area was able to use the policy as a supporting factor to obtain approval for remodeling their lobby. Parents were encouraged to bring a child’s favorite toy with them. A number of areas completely eliminated toys. There were no parental complaints about reduced toy availability in lobby areas and exam rooms. LESSONS LEARNED: Buy-in from all stakeholders prior to policy implementation improves compliance. Giving areas a tool to determine their toy needs decreases the number of hand-held toys that are in use. This decreases clutter and staff cleaning time without decreasing patient satisfaction. Standardized, easy-to-clean toys increased staff compliance with the cleaning requirements. The cleaning instructions were applicable to occupational therapy equipment and other items in addition to toys.
Risk Factors for Pediatric Mediastinitis after Cardiac Surgery: Investigation of a Case Cluster E Teszner* S Tabbutt S Shah T Zaoutis K St. John L Bell T Spray S Coffin The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
BACKGROUND: Mediastinitis is a rare but serious complication of cardiothoracic surgery. Active surveillance of children undergoing cardiac surgery with median sternotomy revealed a cluster of five cases of deep sternal wound infection or mediastinitis (DSW-M) within a 2-month period. OBJECTIVES: To identify risk factors for DSW-M in children undergoing median sternotomy. METHODS: Cases of DSW-M were identified by active surveillance of all cardiac surgical patients at the Children’s Hospital of Philadelphia. Four control patients were randomly selected from all patients undergoing median sternotomy who survived for [30 days after surgery. Controls for each case were matched by month of surgery and age group. Data was collected from review of microbiology laboratory reports and medical records. RESULTS: Bacterial cultures revealed three infections due to Staphylococcus aureus, and one due to vancomycinresistant Enterococcus. The fifth patient’s infection was polymicrobial; cultures from this patient grew Serratia marcescens and Pseudomonas aeruginosa. DSW-M was more common in children with complex cardiac physiology. Children with two ventricles with a normal aortic arch at the time of surgical procedure had a lower risk of developing DSW-M (p¼0.02). Factors associated with an increased risk of deep wound infection included prolonged bypass time (p¼0.004), need for re-operation within 48 hours (p¼0.04), and inappropriate timing of peri-operative antibiotic prophylaxis
May 2004
E85
(p¼0.05). Factors not associated with DSW-M included presence of intracardiac pacemaker wires, right atrial catheters, or the use of prosthetic material. In addition, DSW-M was not associated with a specific surgeon, anesthetist, perfusionist, or nurse. CONCLUSION: DSW-M occurs more commonly following surgical intervention for severe congenital heart anomalies. Most identified risk factors for DSW-M were not modifiable. However, improved timing of perioperative antibiotic prophylaxis might reduce the incidence of DSW-M in these susceptible patients.
Comparison of Prevalence Calculations Using Infection Control Surveillance Methods and Cystic Fibrosis Foundation Patient Registry Guidelines S Coffin* S Rettig L Bell T Scanlin K St. John The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
BACKGROUND: In May 2003, the consensus document was published entitled, Infection Control Recommendations for Patients with Cystic Fibrosis (CF): Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission. The recommendations are based on the basic principle that CF pathogens are transmitted by the droplet and contact routes. The CF Foundation Patient Registry (CFFPR) compiles and publishes the age-specific prevalence of respiratory pathogens in CF patients each year. Our CF Center participates in this registry and uses the data to compare our pathogen-specific prevalence with national data. Discrepancies were found when comparing our data with those from the CFFPR due to difference in the methods of calculating prevalence. OBJECTIVE: To understand how different methods of analysis might influence the interpretation of center-specific, as compared to national registry, infection control data. METHODS: The Department of Infection Prevention and Control at Children’s Hospital of Philadelphia (CHOP), in collaboration with the CHOP Cystic Fibrosis Center, conducts active surveillance of cystic fibrosis patients for Burkholderia cepacia (BC) and methicillin-resistant Staphylococcus aureus (MRSA). Traditionally, prevalence data at our institution were reported based on the number of patients ever colonized with BC or MRSA (termed IPC prevalence). Upon review of CFFPR reporting guidelines, we calculated the period prevalence of colonization based on isolation of BC or MRSA within the past calendar year (termed CFFPR prevalence) and stratified our data by age group. RESULTS: Comparison of IPC and CFFPR prevalence revealed discrepant results. For active patients in the CHOP CF Center, IPC prevalence of MRSA was 10.0%. However, the prevalence of MRSA as determined by CFFPR reporting guidelines was markedly lower; CFFR prevalence was 5.5%. In contrast, IPC prevalence of BC was 7.4%, while CFFPR prevalence was 6.7%. Consistent with national data, we observed higher prevalence of these two critical pathogens was observed in the 11–17 and 18–24 age groups compared to younger age groups. CONCLUSIONS: Caution is needed when comparing data from national registries with data collected by infection control departments within individual centers. Differences in collecting and reporting data to the CF Foundation from traditional infection control surveillance methods must be fully appreciated by those using these data for benchmarking purposes.
Vol. 32 No. 3
whether sufficient personnel and space was available to clean toys after each use. Once it was determined they meet the algorithm criteria for hand-held toys, the policy lists age-appropriate, safe toys the area may choose to use. Child Life experts created and attached an on-line catalog for convenient ordering of approved, easy-to-clean toys. A table listing acceptable cleaning products (including ordering information, shelf life, and mixing information) was supplied. Cleaning/disinfecting and use of toys in isolation room instructions were updated. The policy revisions were approved. Changes were communicated to supervisors and staff through newsletters and environment of care tours. RESULTS: Outpatient allied health staff welcomed the policy. Staff appreciated access to the toy catalog and cleaning product ordering information in one on-line document. The pediatric area was able to use the policy as a supporting factor to obtain approval for remodeling their lobby. Parents were encouraged to bring a child’s favorite toy with them. A number of areas completely eliminated toys. There were no parental complaints about reduced toy availability in lobby areas and exam rooms. LESSONS LEARNED: Buy-in from all stakeholders prior to policy implementation improves compliance. Giving areas a tool to determine their toy needs decreases the number of hand-held toys that are in use. This decreases clutter and staff cleaning time without decreasing patient satisfaction. Standardized, easy-to-clean toys increased staff compliance with the cleaning requirements. The cleaning instructions were applicable to occupational therapy equipment and other items in addition to toys.
Risk Factors for Pediatric Mediastinitis after Cardiac Surgery: Investigation of a Case Cluster E Teszner* S Tabbutt S Shah T Zaoutis K St. John L Bell T Spray S Coffin The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
BACKGROUND: Mediastinitis is a rare but serious complication of cardiothoracic surgery. Active surveillance of children undergoing cardiac surgery with median sternotomy revealed a cluster of five cases of deep sternal wound infection or mediastinitis (DSW-M) within a 2-month period. OBJECTIVES: To identify risk factors for DSW-M in children undergoing median sternotomy. METHODS: Cases of DSW-M were identified by active surveillance of all cardiac surgical patients at the Children’s Hospital of Philadelphia. Four control patients were randomly selected from all patients undergoing median sternotomy who survived for [30 days after surgery. Controls for each case were matched by month of surgery and age group. Data was collected from review of microbiology laboratory reports and medical records. RESULTS: Bacterial cultures revealed three infections due to Staphylococcus aureus, and one due to vancomycinresistant Enterococcus. The fifth patient’s infection was polymicrobial; cultures from this patient grew Serratia marcescens and Pseudomonas aeruginosa. DSW-M was more common in children with complex cardiac physiology. Children with two ventricles with a normal aortic arch at the time of surgical procedure had a lower risk of developing DSW-M (p¼0.02). Factors associated with an increased risk of deep wound infection included prolonged bypass time (p¼0.004), need for re-operation within 48 hours (p¼0.04), and inappropriate timing of peri-operative antibiotic prophylaxis
May 2004
E85
(p¼0.05). Factors not associated with DSW-M included presence of intracardiac pacemaker wires, right atrial catheters, or the use of prosthetic material. In addition, DSW-M was not associated with a specific surgeon, anesthetist, perfusionist, or nurse. CONCLUSION: DSW-M occurs more commonly following surgical intervention for severe congenital heart anomalies. Most identified risk factors for DSW-M were not modifiable. However, improved timing of perioperative antibiotic prophylaxis might reduce the incidence of DSW-M in these susceptible patients.
Comparison of Prevalence Calculations Using Infection Control Surveillance Methods and Cystic Fibrosis Foundation Patient Registry Guidelines S Coffin* S Rettig L Bell T Scanlin K St. John The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
BACKGROUND: In May 2003, the consensus document was published entitled, Infection Control Recommendations for Patients with Cystic Fibrosis (CF): Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission. The recommendations are based on the basic principle that CF pathogens are transmitted by the droplet and contact routes. The CF Foundation Patient Registry (CFFPR) compiles and publishes the age-specific prevalence of respiratory pathogens in CF patients each year. Our CF Center participates in this registry and uses the data to compare our pathogen-specific prevalence with national data. Discrepancies were found when comparing our data with those from the CFFPR due to difference in the methods of calculating prevalence. OBJECTIVE: To understand how different methods of analysis might influence the interpretation of center-specific, as compared to national registry, infection control data. METHODS: The Department of Infection Prevention and Control at Children’s Hospital of Philadelphia (CHOP), in collaboration with the CHOP Cystic Fibrosis Center, conducts active surveillance of cystic fibrosis patients for Burkholderia cepacia (BC) and methicillin-resistant Staphylococcus aureus (MRSA). Traditionally, prevalence data at our institution were reported based on the number of patients ever colonized with BC or MRSA (termed IPC prevalence). Upon review of CFFPR reporting guidelines, we calculated the period prevalence of colonization based on isolation of BC or MRSA within the past calendar year (termed CFFPR prevalence) and stratified our data by age group. RESULTS: Comparison of IPC and CFFPR prevalence revealed discrepant results. For active patients in the CHOP CF Center, IPC prevalence of MRSA was 10.0%. However, the prevalence of MRSA as determined by CFFPR reporting guidelines was markedly lower; CFFR prevalence was 5.5%. In contrast, IPC prevalence of BC was 7.4%, while CFFPR prevalence was 6.7%. Consistent with national data, we observed higher prevalence of these two critical pathogens was observed in the 11–17 and 18–24 age groups compared to younger age groups. CONCLUSIONS: Caution is needed when comparing data from national registries with data collected by infection control departments within individual centers. Differences in collecting and reporting data to the CF Foundation from traditional infection control surveillance methods must be fully appreciated by those using these data for benchmarking purposes.