Implementing strategies to prevent infections in acute-care settings.

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update.

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

High-level disinfection, sterilization, and hand hygiene: What do accreditation surveyors want to see?

Health care organizations accredited by the Joint Commission should follow a standardized approach to the development of infection prevention and control-related processes, policies, and protocols. This approach should start with applicable regulatory requirements and may incorporate evidence-based guidelines and consensus documents chosen by the Health care organizations. Surveyors follow this approach when assessing compliance.

Referrals of Infection Control Breaches to Public Health Authorities: Ambulatory Care Settings Experience, 2017.

BACKGROUND: Beginning in October 2016, the Centers for Medicare & Medicaid Services (CMS) issued expanded guidance requiring accrediting organizations and state survey agencies to report serious infection control breaches to relevant state health departments. This project sought to characterize and summarize The Joint Commission's early experiences and findings in applying this guidance to facilities accredited under the ambulatory and office-based surgery programs in 2017. METHODS: Surveyor notes were retrospectively reviewed to identify individual breaches, and then the Centers for Disease Control and Prevention's Infection Prevention Checklist for Outpatient Settings was used to categorize and code documented breaches. RESULTS: Of 845 ambulatory organizations, 39 (4.6%) had breaches observed during the survey process and reported to health departments. Within these organizations, surveyors documented 356 breaches, representing 52 different breach codes. Common breach domains were sterilization of reusable devices, device reprocessing observation, device reprocessing, disinfection of reusable devices, and infection control program and infrastructure. Eight of the 39 facilities (20.5%) were cited for not performing the minimum level of reprocessing based on the items' intended use, reusing single-use devices, and/or not using aseptic technique to prepare injections. CONCLUSION: The CMS infection control breach reporting requirement has helped highlight some of the challenges faced by ambulatory facilities in providing a safe care environment for their patients. This analysis identified numerous opportunities for improved staff training and competencies as well as leadership oversight and investment in necessary resources. More systematic assessments of infection control practices, extending to both accredited and nonaccredited ambulatory facilities, are needed to inform oversight and prevention efforts.

Bacterial colonization and succession in a newly opened hospital.

The microorganisms that inhabit hospitals may influence patient recovery and outcome, although the complexity and diversity of these bacterial communities can confound our ability to focus on potential pathogens in isolation. To develop a community-level understanding of how microorganisms colonize and move through the hospital environment, we characterized the bacterial dynamics among hospital surfaces, patients, and staff over the course of 1 year as a new hospital became operational. The bacteria in patient rooms, particularly on bedrails, consistently resembled the skin microbiota of the patient occupying the room. Bacterial communities on patients and room surfaces became increasingly similar over the course of a patient's stay. Temporal correlations in community structure demonstrated that patients initially acquired room-associated taxa that predated their stay but that their own microbial signatures began to influence the room community structure over time. The α- and ß-diversity of patient skin samples were only weakly or nonsignificantly associated with clinical factors such as chemotherapy, antibiotic usage, and surgical recovery, and no factor except for ambulatory status affected microbial similarity between the microbiotas of a patient and their room. Metagenomic analyses revealed that genes conferring antimicrobial resistance were consistently more abundant on room surfaces than on the skin of the patients inhabiting those rooms. In addition, persistent unique genotypes of Staphylococcus and Propionibacterium were identified. Dynamic Bayesian network analysis suggested that hospital staff were more likely to be a source of bacteria on the skin of patients than the reverse but that there were no universal patterns of transmission across patient rooms.

Assessment of an Aggregate-Level Hand Hygiene Monitoring Technology for Measuring Hand Hygiene Performance Among Healthcare Personnel.

BACKGROUND Despite significant advances in technological methods for hand hygiene surveillance, a lack of evidence prohibits comparison of systems to one another or against the current gold standard of direct observation. OBJECTIVE To validate a hand hygiene monitoring technology (HHMT) designed to capture hand hygiene behaviors aggregated at the hospital-unit level (GOJO Industries, Akron, OH). METHODS Our team followed a rigorous validation approach to assess the sensitivity and positive predictive value (PPV) of an HHMT. A planned path was first used to measure the accuracy of the system when purposefully activated by investigators. Next, behavioral validation was used to quantify accuracy of the system in capturing real-world behaviors. RESULTS During the planned path phase, investigators performed 4,872 unique events across 3 distinct hospital buildings varying in size and age since construction. Overall sensitivity across the medical center was 88.7% with a PPV of 99.2%. During the behavioral validation phase, trained direct observers recorded 5,539 unique events across 3 distinct hospital buildings. Overall sensitivity across the medical center was 92.7% and PPV was 84.4%. CONCLUSION Objective measures of sensitivity and PPV indicate the promise of the benefit of this and other HHMTs to capture basic behaviors associated with hand hygiene. Infect Control Hosp Epidemiol 2017;38:348-352.

Influenza among afebrile and vaccinated healthcare workers.

BACKGROUND: To prevent transmission of influenza from healthcare workers (HCWs) to patients, many hospitals exclude febrile HCWs from working, but allow afebrile HCWs with respiratory symptoms to have contact with patients. During the 2013-2014 influenza season at our hospital, an influenza-positive HCW with respiratory symptoms but no fever was linked to a case of possible healthcare-associated influenza in a patient. Therefore, we implemented a temporary policy of mandatory influenza testing for HCWs with respiratory symptoms. METHODS: From 3 January through 28 February 2014, we tested HCWs with respiratory symptoms for influenza and other respiratory pathogens by polymerase chain reaction of flocked nasopharyngeal swabs. HCWs also reported symptoms and influenza vaccination status, and underwent temperature measurement. We calculated the proportion of influenza-positive HCWs with fever and prior influenza vaccination. RESULTS: Of 449 HCWs, 243 (54%) had a positive test for any respiratory pathogen; 34 (7.6%) HCWs tested positive for influenza. An additional 7 HCWs were diagnosed with influenza by outside physicians. Twenty-one (51.2%) employees with influenza had fever. Among influenza-infected HCWs, 20 had previously received influenza vaccination, 18 had declined the vaccine, and 3 had unknown vaccination status. There was no significant difference in febrile disease among influenza-infected employees who had received the influenza vaccine and those who had not received the vaccine (45% vs 61%; P = .32). CONCLUSIONS: Nearly half of HCWs with influenza were afebrile prior to their diagnosis. HCWs with respiratory symptoms but no fever may pose a risk of influenza transmission to patients and coworkers.

Staphylococcus aureus bacteremia at 5 US academic medical centers, 2008-2011: significant geographic variation in community-onset infections.

BACKGROUND: The incidence of community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) bacteremia rose from the late 1990s through the 2000s. However, hospital-onset (HO) MRSA rates have recently declined in the United States and Europe. METHODS: Data were abstracted from infection prevention databases between 1 January 2008 and 31 December 2011 at 5 US academic medical centers to determine the number of single-patient blood cultures positive for MRSA and methicillin-susceptible S. aureus (MSSA) per calendar year, stratified into CO and HO infections. RESULTS: Across the 5 centers, 4171 episodes of bacteremia were identified. Center A (Los Angeles, California) experienced a significant decline in CO-MRSA bacteremia rates (from a peak in 2009 of 0.42 to 0.18 per 1000 patient-days in 2011 [P = .005]), whereas CO-MSSA rates remained stable. Centers B (San Francisco, California), D (Chicago, Illinois), and E (Raleigh-Durham, North Carolina) experienced a stable incidence of CO-MRSA and CO-MSSA bacteremia. In contrast, at center C (New York, New York), the incidence of CO-MRSA increased >3-fold (from 0.11 to 0.34 cases per 1000 patient-days [P < .001]). At most of the sites, HO-MRSA decreased and HO-MSSA rates were stable. USA300 accounted for 52% (104/202) of genotyped MRSA isolates overall, but this varied by center, ranging from 35% to 80%. CONCLUSIONS: CO-MRSA rates and the contribution of USA300 MRSA varied dramatically across diverse geographical areas in the United States. Enhanced infection control efforts are unlikely to account for such variation in CO infection rates. Bioecological and clinical explanations for geographical differences in CO-MRSA bacteremia rates merit further study.

The Hospital Microbiome Project: Meeting Report for the 1st Hospital Microbiome Project Workshop on sampling design and building science measurements, Chicago, USA, June 7th-8th 2012.

This report details the outcome of the 1st Hospital Microbiome Project workshop held on June 7th-8th, 2012 at the University of Chicago, USA. The workshop was arranged to determine the most appropriate sampling strategy and approach to building science measurement to characterize the development of a microbial community within a new hospital pavilion being built at the University of Chicago Medical Center. The workshop made several recommendations and led to the development of a full proposal to the Alfred P. Sloan Foundation as well as to the creation of the Hospital Microbiome Consortium.

Identification, management, and clinical characteristics of hospitalized patients with influenza-like illness during the 2009 H1N1 influenza pandemic, Cook County, Illinois.

OBJECTIVE: To describe the identification, management, and clinical characteristics of hospitalized patients with influenza-like illness (ILI) during the peak period of activity of the 2009 pandemic strain of influenza A virus subtype H1N1 (2009 H1N1). DESIGN: Retrospective review of electronic medical records. PATIENTS AND SETTING: Hospitalized patients who presented to the emergency department during the period October 18 through November 14, 2009, at 4 hospitals in Cook County, Illinois, with the capacity to perform real-time reverse-transcriptase polymerase chain reaction testing for influenza. METHODS: Vital signs and notes recorded within 1 calendar day after emergency department arrival were reviewed for signs and symptoms consistent with ILI. Cases of ILI were classified as recognized by healthcare providers if an influenza test was performed or if influenza was mentioned as a possible diagnosis in the physician notes. Logistic regression was used to determine the patient attributes and symptoms that were associated with ILI recognition and with influenza infection. RESULTS: We identified 460 ILI case patients, of whom 412 (90%) had ILI recognized by healthcare providers, 389 (85%) were placed under airborne or droplet isolation precautions, and 243 (53%) were treated with antiviral medication. Of 401 ILI case patients tested for influenza, 91 (23%) had a positive result. Fourteen (3%) ILI case patients and none of the case patients who tested positive for influenza had sore throat in the absence of cough. CONCLUSIONS: Healthcare providers identified a high proportion of hospitalized ILI case patients. Further improvements in disease detection can be made through the use of advanced electronic health records and efficient diagnostic tests. Future studies should evaluate the inclusion of sore throat in the ILI case definition.

Clostridium difficile outbreak strain BI is highly endemic in Chicago area hospitals.

OBJECTIVE: Describe the clinical and molecular epidemiology of incident Clostridium difficile infection (CDI) cases in Chicago area acute healthcare facilities (HCFs). DESIGN AND SETTING: Laboratory, clinical, and epidemiologic information was collected for patients with incident CDI who were admitted to acute HCFs in February 2009. Stool cultures and restriction endonuclease analysis typing of the recovered C. difficile isolates was performed. PATIENTS: Two hundred sixty-three patients from 25 acute HCFs. RESULTS: Acute HCF rates ranged from 2 to 7 patients with CDI per 10,000 patient-days. The crude mortality rate was 8%, with 20 deaths occurring in patients with CDI. Forty-two (16%) patients had complications from CDI, including 4 patients who required partial, subtotal, or total colectomy, 3 of whom died. C. difficile was isolated and typed from 129 of 178 available stool specimens. The BI strain was identified in 79 (61%) isolates. Of patients discharged to long-term care who had their isolate typed, 36 (67%) had BI-associated CDI. CONCLUSIONS: Severe disease was common and crude mortality was substantial among patients with CDI in Chicago area acute HCFs in February 2009. The outbreak-associated BI strain was the predominant endemic strain identified, accounting for nearly two-thirds of cases. Focal HCF outbreaks were not reported, despite the presence of the BI strain. Transfer of patients between acute and long-term HCFs may have contributed to the high incidence of BI cases in this investigation.

Consensus conference on prevention of central line-associated bloodstream infections: 2009.

Health care-acquired infections are a significant cause of morbidity and mortality in all patient care settings. In 2009, a consensus conference was held to evaluate practices and recommendations for the prevention and control of one specific type of health care-acquired infections, those associated with central catheter use. The conference had 2 purposes--to provide a tool for quality changes within health care institutions regarding central catheter infections and to empower those who are responsible for implementing policies needed to reduce the risk of these infections. The findings of the expert panel assembled for the conference are presented in this article.

Back to basics: Four years of sustained improvement in implementation of contact precautions at a university hospital.

BACKGROUND: The use of contact precautions is an essential component of an effective multidrug-resistant organism (MDRO) control plan. Despite reliance on a passive automated reminder system to alert clinicians of the need for contact precautions, poor adherence was recognized at the study medical center. DEVELOPING THE INTERVENTION: A performance improvement project incorporating brief weekly surveillance rounds on each inpatient unit was developed to maximize compliance with implementation of contact precautions and to evaluate risk factors for failure to institute precautions. In the weekly rounds, infection preventionists determined the point prevalence of the appropriate implementation of contact precautions for MDRO (that is, whether or not patients with electronic flags had been appropriately placed on contact precautions). This project was evaluated during a 22-week rollout period followed by a four-year follow-up period. The experience and data derived from the rollout period were intended to shape the long-term plan to sustain high levels of compliance with contact-precaution initiation. RESULTS: During the first week of surveillance, only 70% of eligible patients were isolated, but by week 16 90% were isolated appropriately. Because surveillance rounding was successful in improving institution of contact precautions during the rollout period, this practice was continued. During the following four years (follow-up period), > or = 90% success at implementing isolation precautions was demonstrated during 74% of the weeks. CONCLUSIONS: This experience with surveillance demonstrated an effective, practical, and sustainable method of improving implementation of contact precautions for patients with MDRO.

Correlation between respiratory colonization with gram-negative bacteria and development of gram-negative bacterial infection after cardiac surgery.

This pilot, observational study involving 286 patients who underwent cardiac surgery found that patients who had endotracheal colonization with gram-negative bacteria at 1 week after surgery were more likely to develop subsequent infection compared to those without colonization (8 of 23 vs. 4 of 40; relative risk 2.3 [95% confidence interval, 1.3-4.1; P value <.05]).

Severe eczema vaccinatum in a household contact of a smallpox vaccinee.

BACKGROUND: We report the first confirmed case of eczema vaccinatum in the United States related to smallpox vaccination since routine vaccination was discontinued in 1972. A 28-month-old child with refractory atopic dermatitis developed eczema vaccinatum after exposure to his father, a member of the US military who had recently received smallpox vaccine. The father had a history of inactive eczema but reportedly reacted normally to the vaccine. The child's mother also developed contact vaccinia infection. METHODS: Treatment of the child included vaccinia immune globulin administered intravenously, used for the first time in a pediatric patient; cidofovir, never previously used for human vaccinia infection; and ST-246, an investigational agent being studied for the treatment of orthopoxvirus infection. Serological response to vaccinia virus and viral DNA levels, correlated with clinical events, were utilized to monitor the course of disease and to guide therapy. Burn patient-type management was required, including skin grafts. RESULTS: The child was discharged from the hospital after 48 days and has recovered with no apparent systemic sequelae or significant scarring. CONCLUSION: This case illustrates the need for careful screening prior to administration of smallpox vaccine and awareness by clinicians of the ongoing vaccination program and the potential risk for severe adverse events related to vaccinia virus.

Predictive factors for the development of central line-associated bloodstream infection due to gram-negative bacteria in intensive care unit patients after surgery.

OBJECTIVES: To examine the relative proportions of central line-associated bloodstream infection (BSI) due to gram-negative bacteria and due to gram-positive bacteria among patients who had undergone surgery and patients who had not. The study also evaluated clinical predictive factors and unadjusted outcomes associated with central line-associated BSI caused by gram-negative bacteria in the postoperative period. DESIGN: Observational, case-control study based on a retrospective review of medical records. SETTING: University of Chicago Medical Center, a 500-bed tertiary care center located on Chicago's south side. PATIENTS: Adult intensive care unit (ICU) patients who developed central line-associated BSI. RESULTS: There were a total of 142 adult patients who met the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System definition for central line-associated BSI. Of those, 66 patients (46.5%) had infections due to gram-positive bacteria, 49 patients (34.5%) had infections due to gram-negative bacteria, 23 patients (16.2%) had infections due to yeast, and 4 patients (2.8%) had mixed infections. Patients who underwent surgery were more likely to develop central line-associated BSI due to gram-negative bacteria within 28 days of the surgery, compared with patients who had not had surgery recently (57.6% vs 27.3%; P= .002). On multivariable logistic regression analysis, diabetes mellitus (adjusted odds ratio [OR], 4.6 [95% CI, 1.2-18.1]; P= .03) and the presence of hypotension at the time of the first blood culture positive for a pathogen (adjusted OR, 9.8 [95% CI, 2.5-39.1]; P= .001) were found to be independently predictive of central line-associated BSI caused by gram-negative bacteria. Unadjusted outcomes were not different in the group with BSI due to gram-negative pathogens, compared to the group with BSI due to gram-positive pathogens. CONCLUSIONS: Clinicians caring for critically ill patients after surgery should be especially concerned about the possibility of central line-associated BSI caused by gram-negative pathogens. The presence of diabetes and hypotension appear to be significant associated factors.

Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement.

OBJECTIVE: In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation. DESIGN: Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices. SETTING: Level III NICUs at Chicago-area hospitals. PARTICIPANTS: Neonates and healthcare workers associated with the level III NICUs. METHODS: From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS. RESULTS: Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs. CONCLUSION: The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.