The Impact of Antibiotic Stewardship Program Resources on Infection Prevention Programs.

Doernberg and colleagues describe the role and resourcing of the infectious disease (ID) physician for an effective hospital-based antibiotic stewardship program (ASP). There are similar resource requirements for the ID physician leader in an effective infection prevention (IP) program. This ID physician partnership is supported by professional organizations and predates the imperative of ID physician leadership in ASP. There are regulatory requirements for established IP programs, but they do not specify leadership structure to the same degree as ASP regulations. The Centers for Medicare and Medicaid and The Joint Commission have specified the inclusion of an ID-trained physician leader in ASP, and this has led to the development of curriculum to train more ASP physicians. More robust advocacy may ensure a similar regulatory mandate supporting the participation of ID-trained physicians in IP programs. This may encourage the development of a curriculum to meet the workforce.

The Impact of Supplemental Intraoperative Air Decontamination on the Outcome of Total Joint Arthroplasty: A Pilot Analysis.

BACKGROUND: During the early era of arthroplasty, the concept of ultraclean operating room (OR) was introduced based on the principle that the number of airborne particles in the OR directly influences incidence of device-related infections. The hypothesis of this pilot study was that use of an innovative UV-C air decontamination technology would lead to a reduction in the incidence of periprosthetic joint infection (PJI) following total joint arthroplasty. METHODS: A retrospective, observational, surveillance study was conducted with a consecutive series of patients who underwent total joint arthroplasty (n = 496) between January 2016 and August 2017. All perioperative and postoperative care protocols were identical for both groups, only study variable was that in 231 arthroplasty patients (OR B), an innovative supplemental UV-C air decontamination technology was used, whereas in the remaining 265 patients, arthroplasty was performed with standard turbulent HVAC (OR A). RESULTS: There was no significant difference between patient groups regarding age, body mass index, diabetes diagnosis, smoking status, length of surgery, or revision status. The rate of PJI was documented to be 1.9% in the turbulent air group, and no infections were documented in the cohorts operated under UV-C air decontamination, which was statistically significant (P < .044). CONCLUSION: While PJI is multifactorial in nature, the present retrospective pilot study suggests that use of an intraoperative supplemental air decontamination significantly reduced the overall risk of PJI. The findings of this study are encouraging and should be examined in a larger-scale, prospective, multicenter study.

Economic and quality of care evaluation of dialysis service models in remote Australia: protocol for a mixed methods study.

BACKGROUND: Australia's Northern Territory (NT) has the country's highest incidence and prevalence of kidney disease. Indigenous people from remote areas suffer the heaviest disease burden. Concerns regarding cost and sustainability limit the provision of dialysis treatments in remote areas and most Indigenous people requiring dialysis relocate to urban areas. However, this dislocation of people from their family, community and support networks may prove more costly when the broader health, societal and economic consequences for the individual, family and whole of government are considered. METHODS: The Dialysis Models of Care Study is a large cross organisation mixed methods study. It includes a retrospective (2000-2014) longitudinal data linkage study of two NT cohorts: Renal Cohort 1- comprising approximately 2000 adults who received dialysis and Renal Cohort 2- comprising approximately 400 children of those adults. Linkage of administrative data sets from the Australian and New Zealand Dialysis and Transplant Registry, NT Departments of Health, Housing and Education by a specialist third party (SA/NT Datalink) will enable extraction of activity, financial and outcome data. Interviews with patients, clinicians and service providers, using a snowball technique, will canvass relevant issues and assist in determining the full costs and impacts of the five most used dialysis Models of Care. DISCUSSION: The study uses a mixed methods approach to investigate the quantitative and qualitative dimensions of the full costs and outcomes associated with the choice of particular dialysis models of care for any given patient. The study includes a large data linkage component that for the first time links health, housing and education data to fully analyse and evaluate the impact on patients, their families and the broader community, resulting from the relocation of people for treatment. The study will generate a large amount of activity, financial and qualitative data that will investigate health costs less directly related to dialysis treatment, costs to government such as housing and/or education and the health, social and economic outcomes experienced by patients. This approach fills an evidence gap critical to health service planners.

Commissioning Clinical Spaces During a Pandemic: Merging Methodologies of Human Factors and Simulation.

OBJECTIVES: The objective of this case study is to demonstrate the value of applying tabletop and simulation techniques to highlight high-risk, high-impact outcomes and organizational recommendations in the commissioning of a new clinical spaces. PURPOSE/AIM: Generalizability of lessons learned from this case study aim to support other health organizations in commissioning of clinical spaces during communicable disease outbreaks. BACKGROUND: COVID-19 challenged our healthcare system, requiring teams to prepare in a short span of time. Bridging expertise of human factor and simulation teams provided a novel, interdisciplinary, and timely approach to evaluate and commission spaces. METHODS: Human factors and simulation teams were enlisted to conduct an evaluation of a new space prior to readiness for delivery of safe patient care. An adapted tabletop evaluation and subsequent systems integration simulation was conducted. The goal of the tabletop exercise was to identify and define processes and risks to tested in the physical space using simulation. RESULTS: Applying both human factors science and systems simulation proactively identified the highest risk, highest impact outcomes, validated existing processes and allowed for refining of potential solutions and recommendations of the new space. A strong working relationship between teams fostered an opportunity to share information, debrief, evaluate, and adapt methods while applying timely changes based on emergent findings. CONCLUSIONS: These combined methodologies are important tools that can be learned and applied to healthcare commissioning of new clinical spaces in the identification of high-risk, high-impact outcomes affecting staff and organizational preparedness and safety.

Recommendations for change in infection prevention programs and practice.

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

Correction to: COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

[This corrects the article DOI: 10.1186/s41077-020-00138-w.].

Goals, Recommendations, and the How-To Strategies for Developing and Facilitating Patient Safety and System Integration Simulations.

PURPOSE: The aim of this article is to outline overall goals, recommendations, and provide practical How-To strategies for developing and facilitating patient safety and system integration (PSSI) simulations for healthcare team members and organizations. BACKGROUND: Simulation is increasingly being used as a quality improvement tool to better understand the tasks, environments, and processes that support the delivery of healthcare services. These PSSI simulations paired with system-focused debriefing can occur prior to implementing a new process or workflow to proactively identify system issues. They occur as part of a continuous cycle of quality improvement and have unique considerations for planning, implementation, and delivery of healthcare. METHOD: The Delphi technique was used to develop the recommendations and How-To strategies to guide those interested in conducting a PSSI simulations. The Delphi technique is a structured communication technique and systematic process of gathering information from a group of identified experts through a series of questionnaires to gain consensus regarding judgments on complex processes, where precise information is not available in the literature. The Delphi technique permitted an iterative and multistaged approach to transform expert opinions into group consensus. RESULTS: The goals, recommendations, and How-To strategies include a focus on project management, stakeholder engagement, sponsorship, scenario design, prebriefing and debriefing, and evaluation metrics. The intent is to proactively identify system issues and disseminate actionable findings. CONCLUSIONS: This article highlights salient features to consider when using simulation as a strategy and tool for patient safety and quality improvement.

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

Healthcare resources have been strained to previously unforeseeable limits as a result of the COVID-19 pandemic of 2020. This has prompted the emergence of critical just-in-time COVID-19 education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. Simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. The individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. Establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. Our provincial simulation program in the province of Alberta, Canada (population = 4.37 million; geographic area = 661,848 km2), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over 400 acute care simulations across our province in both urban and rural Emergency Departments, Intensive Care Units, Operating Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic Imaging and In-patient Units over a 5-week period to an estimated 30,000 learners of real frontline team members. Unfortunately, the speed at which the COVID-19 pandemic has emerged in Canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of COVID-19 patients. Our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. The goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of COVID-19 simulation data across the largest health authority in Canada.

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

Development and reconstruction of new healthcare facilities and spaces has the potential for latent safety threats to emerge, specifically unintentional harm that could affect actual patients once the facility opens, such as missing equipment, inefficient setup, or insufficient space for procedures. Process-orientated simulation and testing is a novel innovation in healthcare. The aim of process-orientated simulations and debriefing is to examine the process of care, rather than the outcome of care. These simulations, which take place in actual patient care settings and environments prior to occupancy, are an emerging strategy that can be used to test new environments and new healthcare facilities to ensure that the spaces created match the needs of the staff and administration, while proactively identifying latent safety threats prior to delivering patient care. In turn, these simulations can be also be used as part of the new site orientation and training plan. The aim of this paper is to examine a case study describing the use of the novel innovation of process-orientated simulations to test the opening of a new 300-bed healthcare facility.

The emerging role of the corporate or system-level infection prevention director for integrated delivery networks.

BACKGROUND: One position in integrated delivery networks (IDNs) that provides centralized oversight to optimize patient safety is the corporate-level infection prevention (IP) director. After noting variability in their roles, responsibilities, and IP programs, a national network of IDN IP directors planned a member survey to better understand common and variable elements. Nine network members volunteered to design a survey to describe the current role, responsibilities, and resourcing of all members of the corporate IP director group. METHODS: A 17-question survey was designed using the Survey Monkey multiple-choice format with a comment option. The questions were reviewed by the entire network to ensure content validity. The survey was delivered to all 72 network members by e-mail, and a 44% response rate was achieved. RESULTS: Survey responses revealed variation and commonalities relative to role structure, responsibilities, resourcing, and level of physician support for corporate IP directors. In addition, advantages of the position were described. CONCLUSIONS: The results of the survey will serve as a foundation on which to build, supporting standardization and reliable design for the role, responsibilities, and resourcing of corporate IP directors, with the ultimate goal of improving patient safety.

Revisiting Perioperative Hair Removal Practices.

The standard of practice for perioperative hair removal is largely based on research that is outdated and underpowered. Although there is evidence to support the practice of clipping instead of shaving, current recommendations are to remove hair only when absolutely necessary. Human hair is bacteria-laden and challenging to disinfect, and clipping can be a safe method of hair removal that does not damage the skin. This article considers the removal of hair at the incision site with clippers, either before the patient enters the OR or in a manner that completely contains clipped hair, for every procedure, not just when absolutely necessary. There have been only two studies to date comparing clipping with no hair removal; more research is needed on this subject.

OR Air Quality: Is It Time to Consider Adjunctive Air Cleaning Technology?: 1.3 www.aornjournal.org/content/cme.

Patients undergoing surgery may be at risk for infection from airborne particles such as dust, skin scales, respiratory aerosols, and hair fibers emanating from multiple sources in the OR, including personnel, heater-cooler devices, and surgical smoke. This risk is increased in surgical patients undergoing procedures involving implanted devices. Surgical personnel also are at risk from exposure to surgical smoke, which can contain viable viral particles including human papillomavirus infection. Air quality in the OR is improved by engineering controls (eg, maintaining positive pressure). During the past decade, innovations in the field of adjunctive technology designed to improve OR air quality include using ultraviolet disinfection and mobile ultraviolet disinfection plus high-efficiency particulate air filtration. Some of these technologies additionally provide continuous monitoring of circulating air particle counts. Additional research regarding the benefits of adjunctive air-cleaning technology in the OR is warranted.

A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events.

The scientific literature indicates that blood culture contamination often leads to inappropriate antimicrobial treatment, adverse patient occurrences, and potential reporting of false-positive central line-associated bloodstream infections. The findings of a national infection prevention survey of blood culture practices and related interventions in hospitals support the need for infection preventionists to expand their participation in the review of topics related to the ordering and collection of blood for culture.

Environment of care: Is it time to reassess microbial contamination of the operating room air as a risk factor for surgical site infection in total joint arthroplasty?

In the modern operating room (OR), traditional surgical mask, frequent air exchanges, and architectural barriers are viewed as effective in reducing airborne microbial populations. Intraoperative sampling of airborne particulates is rarely performed in the OR because of technical difficulties associated with sampling methodologies and a common belief that airborne contamination is infrequently associated with surgical site infections (SSIs). Recent studies suggest that viable airborne particulates are readily disseminated throughout the OR, placing patients at risk for postoperative SSI. In 2017, virtually all surgical disciplines are engaged in the implantation of selective biomedical devices, and these implants have been documented to be at high risk for intraoperative contamination. Approximately 1.2 million arthroplasties are performed annually in the United States, and that number is expected to increase to 3.8 million by the year 2030. The incidence of periprosthetic joint infection is perceived to be low (<2.5%); however, the personal and fiscal morbidity is significant. Although the pharmaceutic and computer industries enforce stringent air quality standards on their manufacturing processes, there is currently no U.S. standard for acceptable air quality within the OR environment. This review documents the contribution of air contamination to the etiology of periprosthetic joint infection, and evidence for selective innovative strategies to reduce the risk of intraoperative microbial aerosols.

An enhanced benchmark for prosthetic joint replacement infection rates.

BACKGROUND: The National Nosocomial Infection Surveillance System (NNIS) has historically provided the infection control community with the most accurate benchmark for healthcare-associated infections. However, NNIS does not require postdischarge surveillance. For medical centers where comprehensive postdischarge surveillance is possible, the efficiency of surgical site infection (SSI) detection is enhanced and rates may be higher than those provided by NNIS. METHODS: From 1999 to 2004, a large integrated healthcare system (IHCS) used a standard surveillance methodology inclusive of the postdischarge period. This article compares IHCS and NNIS SSI data. RESULTS: IHCS infection rates, stratified and weighted average (hip, 1.7; knee, 2.1) for the study period are higher than the corresponding NNIS rates (hip, 1.4; knee, 1.2) (hip, P = .006; knee, P = .012) when infections detected by the IHCS during the postdischarge period are included. CONCLUSIONS: The data from the study period show that when comprehensive postdischarge surveillance is used by the IHCS, SSI rates are higher than those reflected in the NNIS database.

APIC position paper: Safe injection, infusion, and medication vial practices in health care.

The transmission of bloodborne viruses and other microbial pathogens to patients during routine health care procedures continues to occur because of the use of improper injection, infusion, medication vial, and point-of-care testing practices by health care personnel. These unsafe practices occur in various clinical settings and result in unacceptable and devastating events for patients. This document updates the Association for Professionals in Infection Control and Epidemiology 2010 position paper on safe injection, infusion, and medication vial practices in health care.

Infection prevention: the surgical care continuum.

Lack of careful attention to the increasing complexity of surgical procedures, instrument cleaning and processing, and the transition of surgical and other invasive procedures from the OR to areas outside the traditional hospital OR can contribute to surgical site infection (SSI) risk. Regardless of the location of an intervention, when basic infection prevention measures are applied reliably, even low infection rates can be reduced. To address infection prevention challenges, infection preventionists (IPs) must be well informed regarding infection risk and prevention during surgical and other invasive procedures and the effect a facility type may have on patients' infection risk. The IP must have a solid understanding of surgical asepsis, instrument disinfection, and sterilization to educate and support clinical teams in identifying opportunities for improvement relative to infection prevention.

A primer on on-demand polymerase chain reaction technology.

Efforts to reduce health care-associated infections (HAIs) have grown in both scale and sophistication over the past few decades; however, the increasing threat of antimicrobial resistance and the impact of new legislation regarding HAIs on health care economics make the fight against them all the more urgent. On-demand polymerase chain reaction (PCR) technology has proven to be a highly effective weapon in this fight, offering the ability to accurately and efficiently identify disease-causing pathogens such that targeted and directed therapy can be initiated at the point of care. As a result, on-demand PCR technology has far-reaching influences on HAI rates, health care outcomes, hospital length of stay, isolation days, patient satisfaction, antibiotic stewardship, and health care economics. The basics of on-demand PCR technology and its potential to impact health care have not been widely incorporated into health care education and enrichment programs for many of those involved in infection control and prevention, however. This article serves as a primer on on-demand PCR technology and its ramifications.

Allomaternal interactions in the Bolivian squirrel monkey (Saimiri boliviensis boliviensis).

Allomaternal behavior is defined as maternal-like interactions between an infant and some animal other than its natural mother. The occurrence of allomothering can have a profound influence on the life of the infant and on the animal with which the infant interacts. Allomaternal interactions were studied during the first 6 months of life in 50 Bolivian squirrel monkeys in two different social settings. Allomaternal interactions began during the first week of life. Sampling indicated that the infants spent 30% of their time on allomothers during the first 6 months of life. Dorsal clinging on allomothers occurred most frequently when the infants were younger and more dependent, and declined with the infant's growing independence. In addition, squirrel monkey infants nursed on allomothers, though the rates were lower than nursing on their dam. Four- to six-year-old young adult females accounted for most of the allomaternal interactions (53%), while adult females 7 to 9 years old provided 21% of the allomaternal interactions. A similar age-related pattern was found for allomaternal nursing; however, reproductive status had a profound influence. Those females with a reproductive failure for the year provided 86% of the allomaternal nursing bouts. Allomaternal interactions were not based solely on kinship relationships. Future studies need to be directed toward establishing the proximal causes of allomaternal behavior in the squirrel monkey. © 1994 Wiley-Liss, Inc.