Reducing Clostridioides difficile Infections in a Medical Intensive Care Unit: A Multimodal Quality Improvement Initiative.

BACKGROUND: Clostridioides difficile (C. diff) infection causes significant morbidity for hospitalized patients. A large medical intensive care unit had an increase in C. diff infection rates. OBJECTIVES: The aim of this project was to reduce the C. diff polymerase chain reaction (PCR) test positivity rate and the rate of C. diff PCR tests ordered. Rates were compared between preintervention (July 2017 to December 2019) and postintervention (January 2021 to December 2022) timeframes. METHODS: Unit leadership led a robust quality improvement project, including use of quality improvement tools such as A3, Gemba walks, and plan-do-study-act cycles. Interventions were tailored to the barriers identified, including standardization of in-room supply carts; use of single-packaged oral care kits; new enteric precautions signage; education to staff, providers, and visitors; scripting for patients and visitors; and use of a C. diff testing algorithm. Statistical process control charts were used to assess for improvements. RESULTS: The average rate of C. diff PCR test positivity decreased from 34.9 PCR positive tests per 10 000 patient days to 12.3 in the postintervention period, a 66% reduction. The average rate of PCR tests ordered was 28 per 1000 patient days in the preintervention period; this decreased 44% to 15.7 in the postintervention period. DISCUSSION: We found clinically significant improvements in the rate of C. diff infection and PCR tests ordered as a result of implementing tailored interventions in a large medical intensive care unit. Other units should consider using robust quality improvement methods and tools to conduct similar initiatives to reduce patient harm and improve care and outcomes.

Identification of carbapenem-resistant organism (CRO) contamination of in-room sinks in intensive care units in a new hospital bed tower.

BACKGROUND: The origins and timing of inpatient room sink contamination with carbapenem-resistant organisms (CROs) are poorly understood. METHODS: We performed a prospective observational study to describe the timing, rate, and frequency of CRO contamination of in-room handwashing sinks in 2 intensive care units (ICU) in a newly constructed hospital bed tower. Study units, A and B, were opened to patient care in succession. The patients in unit A were moved to a new unit in the same bed tower, unit B. Each unit was similarly designed with 26 rooms and in-room sinks. Microbiological samples were taken every 4 weeks from 3 locations from each study sink: the top of the bowl, the drain cover, and the p-trap. The primary outcome was sink conversion events (SCEs), defined as CRO contamination of a sink in which CRO had not previously been detected. RESULTS: Sink samples were obtained 22 times from September 2020 to June 2022, giving 1,638 total environmental cultures. In total, 2,814 patients were admitted to study units while sink sampling occurred. We observed 35 SCEs (73%) overall; 9 sinks (41%) in unit A became contaminated with CRO by month 10, and all 26 sinks became contaminated in unit B by month 7. Overall, 299 CRO isolates were recovered; the most common species were Enterobacter cloacae and Pseudomonas aeruginosa. CONCLUSION: CRO contamination of sinks in 2 newly constructed ICUs was rapid and cumulative. Our findings support in-room sinks as reservoirs of CRO and emphasize the need for prevention strategies to mitigate contamination of hands and surfaces from CRO-colonized sinks.

A cluster of three extrapulmonary Mycobacterium abscessus infections linked to well-maintained water-based heater-cooler devices.

BACKGROUND: Various water-based heater-cooler devices (HCDs) have been implicated in nontuberculous mycobacteria outbreaks. Ongoing rigorous surveillance for healthcare-associated M. abscessus (HA-Mab) put in place following a prior institutional outbreak of M. abscessus alerted investigators to a cluster of 3 extrapulmonary M. abscessus infections among patients who had undergone cardiothoracic surgery. METHODS: Investigators convened a multidisciplinary team and launched a comprehensive investigation to identify potential sources of M. abscessus in the healthcare setting. Adherence to tap water avoidance protocols during patient care and HCD cleaning, disinfection, and maintenance practices were reviewed. Relevant environmental samples were obtained. Patient and environmental M. abscessus isolates were compared using multilocus-sequence typing and pulsed-field gel electrophoresis. Smoke testing was performed to evaluate the potential for aerosol generation and dispersion during HCD use. The entire HCD fleet was replaced to mitigate continued transmission. RESULTS: Clinical presentations of case patients and epidemiologic data supported intraoperative acquisition. M. abscessus was isolated from HCDs used on patients and molecular comparison with patient isolates demonstrated clonality. Smoke testing simulated aerosolization of M. abscessus from HCDs during device operation. Because the HCD fleet was replaced, no additional extrapulmonary HA-Mab infections due to the unique clone identified in this cluster have been detected. CONCLUSIONS: Despite adhering to HCD cleaning and disinfection strategies beyond manufacturer instructions for use, HCDs became colonized with and ultimately transmitted M. abscessus to 3 patients. Design modifications to better contain aerosols or filter exhaust during device operation are needed to prevent NTM transmission events from water-based HCDs.

Disinfection efficacy of Oxivir TB wipe residue on severe acute respiratory coronavirus virus 2 (SARS-CoV-2).

We assessed Oxivir Tb wipe disinfectant residue in a controlled laboratory setting to evaluate low environmental contamination of SARS-CoV-2. Frequency of viral RNA detection was not statistically different between intervention and control arms on day 3 (P=0.14). Environmental contamination viability is low; residual disinfectant did not significantly contribute to low contamination.

Using the COM-B model to identify barriers to and facilitators of evidence-based nurse urine-culture practices.

Our surveys of nurses modeled after the Capability, Opportunity, and Motivation Model of Behavior (COM-B model) revealed that opportunity and motivation factors heavily influence urine-culture practices (behavior), in addition to knowledge (capability). Understanding these barriers is a critical step towards implementing targeted interventions to improving urine-culture practices.

Disparities in central line-associated bloodstream infection and catheter-associated urinary tract infection rates: An exploratory analysis.

This retrospective review of 4-year surveillance data revealed a higher central line-associated bloodstream infection (CLABSI) rate in non-Hispanic Black patients and higher catheter-associated urinary tract infection (CAUTI) rates in Asian and non-Hispanic Black patients compared with White patients despite similar catheter utilization between the groups.

Using clinical decision support to improve urine testing and antibiotic utilization.

OBJECTIVE: Urine cultures collected from catheterized patients have a high likelihood of false-positive results due to colonization. We examined the impact of a clinical decision support (CDS) tool that includes catheter information on test utilization and patient-level outcomes. METHODS: This before-and-after intervention study was conducted at 3 hospitals in North Carolina. In March 2021, a CDS tool was incorporated into urine-culture order entry in the electronic health record, providing education about indications for culture and suggesting catheter removal or exchange prior to specimen collection for catheters present >7 days. We used an interrupted time-series analysis with Poisson regression to evaluate the impact of CDS implementation on utilization of urinalyses and urine cultures, antibiotic use, and other outcomes during the pre- and postintervention periods. RESULTS: The CDS tool was prompted in 38,361 instances of urine cultures ordered in all patients, including 2,133 catheterized patients during the postintervention study period. There was significant decrease in urine culture orders (1.4% decrease per month; P < .001) and antibiotic use for UTI indications (2.3% decrease per month; P = .006), but there was no significant decline in CAUTI rates in the postintervention period. Clinicians opted for urinary catheter removal in 183 (8.5%) instances. Evaluation of the safety reporting system revealed no apparent increase in safety events related to catheter removal or reinsertion. CONCLUSION: CDS tools can aid in optimizing urine culture collection practices and can serve as a reminder for removal or exchange of long-term indwelling urinary catheters at the time of urine-culture collection.

Impact of alcohol-based hand-rub disinfection on bacterial bioburden on stethoscopes in a real-world clinical setting.

In this randomized study, use of alcohol-based hand-rub disinfection significantly reduced bacterial bioburden of stethoscopes in routine clinical use. Prior cleaning of stethoscopes on the study day did not affect baseline contamination rates, which suggests that the efficacy of alcohol disinfection is short-lived and may need to be repeated between patients.

The impact of a comprehensive coronavirus disease 2019 (COVID-19) infection prevention bundle on non-COVID-19 hospital-acquired respiratory viral infection (HA-RVI) rates.

After implementing a coronavirus disease 2019 (COVID-19) infection prevention bundle, the incidence rate ratio (IRR) of non-severe acute respiratory coronavirus virus 2 (non-SARS-CoV-2) hospital-acquired respiratory viral infection (HA-RVI) was significantly lower than the IRR from the pre-COVID-19 period (IRR, 0.322; 95% CI, 0.266-0.393; P < .01). However, HA-RVIs incidence rates mirrored community RVI trends, suggesting that hospital interventions alone did not significantly affect HA-RVI incidence.

Enhancement of infection prevention case review process to optimize learning from defects.

Hospitals continue to struggle with preventable healthcare-associated infections. Whereas the focus is generally on proactive prevention processes, performing retrospective case reviews of infections can identify opportunities for quality improvement and maximize learning from defects. This brief article provides practical information for structuring the case review process using readily available health system platforms. Using a structured approach for case reviews can help identify trends and opportunities for improvement.

Severe acute respiratory syndrome coronavirus 2 environmental contamination in hospital rooms is uncommon using viral culture techniques.

We assessed environmental contamination of inpatient rooms housing coronavirus disease 2019 (COVID-19) patients in a dedicated COVID-19 unit. Contamination with severe acute respiratory syndrome coronavirus 2 was found on 5.5% (19/347) of surfaces via reverse transcriptase polymerase chain reaction and 0.3% (1/347) of surfaces via cell culture. Environmental contamination is uncommon in hospitals rooms; RNA presence is not a specific indicator of infectious virus.

Burden of healthcare-associated infections among hospitalized children within community hospitals participating in an infection control network.

We describe the frequency of pediatric healthcare-associated infections (HAIs) identified through prospective surveillance in community hospitals participating in an infection control network. Over a 6-year period, 84 HAIs were identified. Of these 51 (61%) were pediatric central-line-associated bloodstream infections, and they often occurred in children <1 year of age.

Sustained reduction in catheter-associated urinary tract infections using multi-faceted strategies led by champions: A quality improvement initiative.

We reviewed the sustainability of a multifaceted intervention on catheter-associated urinary tract infection (CAUTI) in 3 intensive care units. During the 4-year postintervention period, we observed reductions in urine culture rates (from 80.9 to 47.5 per 1,000 patient days; P < .01), catheter utilization (from 0.68 to 0.58; P < .01), and CAUTI incidence rates (from 1.7 to 0.8 per 1,000 patient days; P = .16).

Challenges in hospital-acquired coronavirus disease 2019 (COVID-19) surveillance and attribution of infection source.

We performed surveillance for hospital-acquired COVID-19 (HA-COVID-19) and compared time-based, electronic definitions to real-time adjudication of the most likely source of acquisition. Without real-time adjudication, nearly 50% of HA-COVID-19 cases identified using electronic definitions were misclassified. Both electronic and traditional contact tracing methods likely underestimated the incidence of HA-COVID-19.

Comparison of metrics used to track central-line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) across a regional network.

The paradoxical relationship between standardized infection ratio and standardized utilization ratio for catheter-associated urinary tract infections (CAUTIs) in contrast to central-line-associated bloodstream infections (CLABSIs), in addition to CAUTI definition challenges, incentivizes hospitals to focus their prevention efforts on urine culture stewardship rather than catheter avoidance and care.

In pursuit of the holy grail: Improving C. difficile testing appropriateness with iterative electronic health record clinical decision support and targeted test restriction.

OBJECTIVE: To determine the impact of electronic health record (EHR)-based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI). DESIGN: Quasi-experimental study in 3 hospitals. SETTING: 957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals. INTERVENTIONS: Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis. RESULTS: C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75-0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85-0.98) and level (IRR 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50-0.92) relative to the baseline period. CONCLUSIONS: Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.

Multi-faceted strategies improve collection compliance and sample acceptance rate for carbapenem-resistant Enterobacteriaceae (CRE) active surveillance testing.

BACKGROUND: Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center. METHODS: Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated. RESULTS: Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%. DISCUSSION: Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.

A Multifaceted Surgical Site Infection Prevention Bundle for Cesarean Delivery.

OBJECTIVE: Surgical site infections (SSI, including wound infections, endometritis, pelvic abscess, and sepsis) may complicate cesarean section (C/S). We report outcomes before and after the introduction of an SSI prevention bundle that did not include antibiotics beyond routine prophylaxis (cefazolin, or gentamicin/clindamycin for penicillin-allergic patients). STUDY DESIGN: The prevention bundle was introduced following an increase in C/S-associated SSI, which itself was associated with an institutional switch in preoperative scrub from povidone-iodine to chlorhexidine gluconate (CHG)/isopropanol. Components of the bundle included: (1) full-body preoperative wash with 4% CHG cloths; (2) retraining on surgeon hand scrub; (3) retraining for surgical prep; and (4) patient education regarding wound care. Patients delivered by C/S at ≥24 weeks of gestation were segregated into four epochs over 7 years: (1) baseline (18 months when povidone-iodine was used); (2) CHG scrub (18 months after skin prep was switched to CHG); (3) bundle implementation (24 months); and (4) maintenance (24 months following implementation). RESULTS: A total of 3,637 patients were included (n = 667, 796, 1098, and 1076, respectively, in epochs 1-4). A rise in SSI occurred with the institutional switch from povidone-iodine to CHG (i.e., from baseline to the CHG scrub epoch, 8.4-13.3%, p < 0.01). Following the intervention (maintenance epoch), this rate decreased to below baseline values (to 4.5%, p < 0.01), attributable to a decline in wound infection (rates in the above three epochs 6.9, 12.9, and 3.5%, respectively, p < 0.01), with no change in endometritis. In multivariable analysis, only epoch and body mass index (BMI) were independently associated with SSI. The improvement associated with the prevention bundle held for stratified analysis of specific risk factors such as chorioamnionitis, prior C/S, obesity, labor induction, and diabetes. CONCLUSION: Implementation of a prevention bundle was associated with a reduction in post-C/S SSI. This improvement was achieved without the use of antibiotics beyond standard preoperative dosing.