Contact precautions as a barrier to hand hygiene: The Plan-Do-Study-Act (PDSA) framework to improve compliance with gloved hand hygiene.

In an identified quality improvement effort, nurses were observed regarding their workflow while in contact precaution rooms. Multiple opportunities for hand hygiene were missed while nurses were in gloves, predominantly while moving between "dirty" and "clean" tasks. An education initiative afterward did not show improvement in hand hygiene rates.

Candida auris in the burn unit: a prolonged biphasic outbreak.

Candida auris is an emerging pathogen responsible for healthcare-associated infections and outbreaks. This organism has a high tolerance to both high temperatures and high salinity. We describe our experience with a C. auris outbreak in an 8-bed inpatient burn unit at an academic medical center.

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Purpose of Review: Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive. Recent Findings: There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic. Summary: More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

Staphylococcal decolonization to prevent surgical site infection: Is there a role in colorectal surgery?

Objective: We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs). Design: Retrospective observational study. Setting: Tertiary-care, academic medical center. Patients: Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded. Methods: Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service. Results: In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04). Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

Changes in nursing team composition and risk of device-associated infection in intensive care units.

The relationship between nursing staffing levels and healthcare-associated infections (HAIs) has been explored previously with conflicting results. This study uses daily shift records from 2 intensive care units (ICUs) to evaluate whether nuanced changes in nursing team composition impacts subsequent risk for device associated HAIs. Staffing deficiencies may be associated with periods of risk prior to central line-associated bloodstream infection in the ICU.

The impact of coronavirus disease 2019 (COVID-19) on provider use of electronic hand hygiene monitoring technology.

The use of an electronic hand hygiene monitoring system (EHHMS) decreased due to the coronavirus disease 2019 (COVID-19) pandemic. We analyzed dispenser use, hand hygiene (HH) badge use, and HH compliance to determine the effect of COVID-19 on EHHMS use and HH compliance. HH product shortages and other pandemic-induced challenges influenced EHHMS use.

Management of the COVID-19-Infected Psychiatric Inpatients: Unique Infection Prevention Considerations and Evolving Strategies.

REASON FOR REVIEW: The COVID-19 pandemic has affected the way healthcare services are provided and created challenges to the delivery of behavioral health in the inpatient setting. Here, we present our front-line experience of infection prevention for the psychiatric patient in the COVID era. RECENT FINDINGS: There are unique challenges surrounding COVID-19 precautions within inpatient psychiatric settings. The challenges presented to psychiatric care by COVID-19 begin in the emergency department and follow the patient through the continuum of care once admitted to the facility. Unit infrastructure, patient population, treatment modalities, staffing considerations, and discharge planning are distinct instances where COVID-19 protocols that are well-suited for other hospital settings necessitate revision for psychiatric settings. SUMMARY: The purpose of this communication is to add to the current body of shared experience of infection prevention for the psychiatric patient in the COVID-19 era.

Nurse survey, knowledge gaps and the creation of an environmental hygiene protocol for patient transport and removing linen from patient rooms.

General guidance for personal protective equipment (PPE) is provided by the Occupational Safety and Health Administration and the United States Centers for Disease Control and Prevention. Previous research of PPE demonstrates the ability of gloves to harbor infectious pathogens. We surveyed health care workers to investigate current PPE practices during linen removal from patient rooms and during patient transport. The results suggest a possible risk for cross-contamination of the environment from overuse of gloves.

Effect of ultraviolet-C light disinfection at terminal patient discharge on hospital-acquired infections in bone marrow transplant and oncology units.

We employed an interrupted time series analysis to assess the impact of ultraviolet-C light disinfection at terminal discharge in an oncology unit and a bone marrow transplant unit on the incidence of hospital-acquired infections. The deployment of ultraviolet-C light disinfection was associated with a significant decrease in the rate of Clostridioides difficile infections and a significant decrease in the rate of central line-associated blood stream infections in the bone marrow transplant unit.

Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013-2018.

OBJECTIVE: To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. DESIGN: Interrupted time series. SETTING: The study was conducted in an 865-bed academic medical center. METHODS: Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) "contact plus" isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). RESULTS: Environmental cleaning interventions and enhanced "contact plus" isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). CONCLUSION: Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

The learning hospital: From theory to practice in a hospital infection prevention program.

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Clostridioides difficile nurse driven protocol: A cautionary tale.

In a 12-month study, a nurse driven protocol was implemented at a tertiary academic medical center. The purpose of the nurse driven protocol was to identify community-onset Clostridioides difficile infections, expeditiously isolate patients with presumed C difficile diarrheal illness, and prevent transmission while simultaneously decreasing the incidence of hospital-onset C difficile. The overall adherence to fidelity of the protocol was poor and failed to have a significant impact on infection rates.

Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

PURPOSE OF REVIEW: To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes. RECENT FINDINGS: HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.

Knowledge, attitudes, and practices of bedside nursing staff regarding antibiotic stewardship: A cross-sectional study.

BACKGROUND: Nursing engagement in antibiotic stewardship programs (ASPs) remains suboptimal. The purpose of this study was to determine the knowledge, attitudes, and practices of nursing staff members regarding ASPs and identify barriers to their participation in such programs. METHODS: This cross-sectional study was conducted at Virginia Commonwealth University Health System, an 860-bed tertiary care academic center located in Richmond, Virginia, where a well-resourced ASP has been in place for 2 decades. A survey consisting of 12 questions was administered to nursing staff via REDCap (Research Electronic Data Capture) in February 2018. RESULTS: A total of 159 survey responses were included in the study. The results demonstrated gaps in knowledge regarding antibiotic stewardship (AS) and highlighted the importance of improving communication between nurses and ASPs. Overall, 102 (64.15%) of the study participants indicated familiarity with AS. Time constraints and concerns over physician pushback were identified as major barriers to participation. CONCLUSIONS: Many nurses were unaware of our center's ASP. Nurses identified activities falling within their daily workflow as potential areas for contribution to ASPs. Key barriers to participation were also identified. These data will inform efforts to engage nursing in AS activities at our medical center.

Chlorhexidine gluconate bathing: Patient perceptions, practices, and barriers at a tertiary care center.

Many studies indicate that daily chlorhexidine gluconate (CHG) bathing reduces the risk of hospital-acquired infections. In this study, we found that patient perceptions can be a barrier to bathing practice, and many independent-care patients do not use CHG bathing products correctly. Furthermore, electronic medical record documentation may be a reliable tool to assess CHG bathing compliance.

Disinfection of noncritical equipment on units with high hospital-onset Clostridium difficile infections.

We assessed barriers and knowledge of disinfection of noncritical items (NCIs) between intensive care unit (ICU) and non-ICU staff members. General understanding of cleaning NCIs was low across all staff. Non-ICU staff had a better understanding of who is responsible for disinfecting and where to access information on storing cleaned NCIs. Opportunities exist for heightened disinfection of NCIs through improved point-of-care instructional information, improved cleaning supply access, and increased instrument storage space.

You get back what you give: Decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis.

BACKGROUND: Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs. METHODS: Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates. RESULTS: At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost. CONCLUSIONS: As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

Test stewardship, frequency and fidelity: Impact on reported hospital-onset Clostridioides difficile.

We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.

Infection prevention and enhanced recovery after surgery: A partnership for implementation of an evidence-based bundle to reduce colorectal surgical site infections.

To reduce surgical site infections (SSIs) in colorectal surgeries we introduced a bundle of care elements in partnership with the Enhanced Recovery after Surgery (ERAS) multidisciplinary team. We measured the incidence of National Healthcare Safety Network-defined SSIs, along with adherence to bundle care elements. Despite opportunities for improvement in adherence to some key components, implementation of the ERAS protocol may have facilitated a reduction in the rate of colorectal SSIs at our institution.

Universal staphylococcal decolonization for elective surgeries: The patient perspective.

BACKGROUND: Staphylococcal decolonization decreases the risk of Staphylococcus aureus surgical site infection. This study evaluates patient perceptions and barriers to a universal Staphylococcal decolonization (USD) protocol. METHODS: In October 2013, a protocol for the decolonization of Staphylococcal aureus in elective orthopedic, neurosurgical, and cardiac surgeries was implemented in an effort to further decrease post-operative infections rates. We surveyed patients undergoing these procedures between November 2014 and April 2015 using an anonymous, voluntary, Likert-scale survey; survey questions targeted compliance with the protocol as well as barriers to protocol completion. RESULTS: A sample of 546 patients (n=1289, 42%) undergoing elective neurosurgical and orthopedic surgeries completed surveys. Respondents had 85% compliance with USD. Insufficient time prior to the procedure to complete the protocol was the largest barrier to USD completion. CONCLUSIONS: This study provides evidence that USD is acceptable to patients, and that the biggest barriers are logistical.