Environmental Contamination of Contact Precaution and Non-Contact Precaution Patient Rooms in Six Acute Care Facilities.

BACKGROUND: Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes. METHODS: Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden. RESULTS: Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms. CONCLUSIONS: CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.

Effectiveness of a multisite personal protective equipment (PPE)-free zone intervention in acute care.

OBJECTIVE: Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions. DESIGN: Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls. SETTING: All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases. INTERVENTION: A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE. RESULTS: We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently. CONCLUSIONS: HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.

Multi-state study of Enterobacteriaceae harboring extended-spectrum beta-lactamase and carbapenemase genes in U.S. drinking water.

Community-associated acquisition of extended-spectrum beta-lactamase- (ESBL) and carbapenemase-producing Enterobacteriaceae has significantly increased in recent years, necessitating greater inquiry into potential exposure routes, including food and water sources. In high-income countries, drinking water is often neglected as a possible source of community exposure to antibiotic-resistant organisms. We screened coliform-positive tap water samples (n = 483) from public and private water systems in six states of the United States for blaCTX-M, blaSHV, blaTEM, blaKPC, blaNDM, and blaOXA-48-type genes by multiplex PCR. Positive samples were subcultured to isolate organisms harboring ESBL or carbapenemase genes. Thirty-one samples (6.4%) were positive for blaCTX-M, ESBL-type blaSHV or blaTEM, or blaOXA-48-type carbapenemase genes, including at least one positive sample from each state. ESBL and blaOXA-48-type Enterobacteriaceae isolates included E. coli, Kluyvera, Providencia, Klebsiella, and Citrobacter species. The blaOXA-48-type genes were also found in non-fermenting Gram-negative species, including Shewanella, Pseudomonas and Acinetobacter. Multiple isolates were phenotypically non-susceptible to third-generation cephalosporin or carbapenem antibiotics. These findings suggest that tap water in high income countries could serve as an important source of community exposure to ESBL and carbapenemase genes, and that these genes may be disseminated by non-Enterobacteriaceae that are not detected as part of standard microbiological water quality testing.

Translation of Contextual Control Model to chronic disease management: A paradigm to guide design of cognitive support systems.

BACKGROUND: Electronic health records (EHRs) continue to be criticized for providing poor cognitive support. Defining cognitive support has lacked theoretical foundation. We developed a measurement model of cognitive support based on the Contextual Control Model (COCOM), which describes control characteristics of an "orderly" joint system and proposes 4 levels of control: scrambled, opportunistic, tactical, and strategic. METHODS: 35 clinicians (5 centers) were interviewed pre and post outpatient clinical visits and audiotaped during the visit. Behaviors pertaining to hypertension management were systematically mapped to the COCOM control characteristics of: (1) time horizon, (2) uncertainty assessment, (3) consideration of multiple goals, (4) causal model described, and (5) explicitness of plan. Each encounter was classified for overall mode of control. Visits with deviation versus no deviation from hypertension goals were compared. RESULTS: Reviewer agreement was high. Control characteristics differed significantly between deviation groups (Wilcox rank sum p<.01). K-means cluster analysis of control characteristics, stratified by deviation were distinct, with higher goal deviations associated with more control characteristics. CONCLUSION: The COCOM control characteristics appear to be areas of potential yield for improved user-experience design.

The orderly and effective visit: impact of the electronic health record on modes of cognitive control.

The clinical Joint Cognitive System (JCS) includes the clinicians, electronic health record (EHR), and other infrastructure that maintain control in the system in the service of accomplishing clinical goals. The purpose of this study is to examine the relationship between levels of control using the COCOM model (scrambled, opportunistic, tactical, and strategic) and patterns of EHR use. Forty-five primary care visits were observed and audio-recorded. Each was coded for COCOM levels of control (IRR = 90%). Screen changes were recorded and time stamped (as either searching or entering). Levels of control were significantly related to preparation intensity (F (2,23) = 6.62; p=0.01), the number of screen changes involved in both searching (F (2,30) = 6.54; p=0.004), and entering information (F (2,22) = 9.26; p=0.001). Combined with the qualitative data, this pattern of EHR usage indicates that the system as designed may not provide effective cognitive support.

Bacteriological water quality along the Tijuana-Ensenada, Baja California, México shoreline.

This survey was part of a Binational Program (Mexico-United States) in microbiological water quality, with a goal to assess the shoreline bacteriological water quality from Tijuana to Ensenada, Mexico. Samples were collected at 29 sites (19 beaches and 10 outfalls), from the United States border to Punta Banda, Baja California, during summer (1998) and winter (1999). Total coliforms, fecal coliforms and enterococci were used as bacterial indicators. Standard methods were used for total and fecal coliforms, while the Enterolert quick method (IDEXX) was used for the enterococci. Compared with outfalls, the beaches exceeded water quality standards by a small percent, 25.3% in summer and 17% in winter. For outfalls, the percentage of shoreline that exceeded bacterial indicator thresholds had a minor value in summer (32.7%) than in winter (50%). Sites near wastewater discharges had the lowest quality and did not meet the microbiological water quality criteria for recreational use.

Comparison of beach bacterial water quality indicator measurement methods.

Three methods (membrane filtration, multiple tube fermentation, and chromogenic substrate technology kits manufactured by IDEXX Laboratories, Inc.) are routinely used to measure indicator bacteria for beach water quality. To assess comparability of these methods, quantify within-laboratory variability for each method, and place that variability into context of variability among laboratories using the same method, 22 southern California laboratories participated in a series of intercalibration exercises. Each laboratory processed three to five replicates from thirteen samples, with total coliforms, fecal coliforms or enterococci measured depending on the sample. Results were generally comparable among methods, though membrane filtration appeared to underestimate the other two methods for fecal coliforms, possibly due to clumping. Variability was greatest for the multiple tube fermentation method. For all three methods, within laboratory variability was greater than among laboratories variability.

Storm effects on regional beach water quality along the southern California shoreline.

Two regional studies conducted during dry weather demonstrated that the Southern California Bight (SCB) shoreline has good water quality, except near areas that drain land-based runoff. Here, we repeat those regional studies 36 h after a rainstorm to assess the influence of runoff under high flow conditions. Two hundred and fifty-four shoreline sites between Santa Barbara, California and Ensenada, Mexico were sampled using a stratified-random sampling design with four strata: sandy beaches, rocky shoreline, shoreline adjacent to urban runoff outlets that flow intermittently, and shoreline adjacent to outlets that flow year-round. Each site was sampled for total coliforms, fecal coliforms (or E. coli), and enterococci. Sixty percent of the shoreline failed water quality standards after the storm compared to only 6% during dry weather. Failure of water quality standards increased to more than 90% for shoreline areas adjacent to urban runoff outlets. During dry weather, most water quality failures occurred for only one of the three bacterial indicators and concentrations were barely above State of California standards; following the storm, most failures were for multiple indicators and exceeded State of California standards by a large margin. The condition of the shoreline in Mexico and the United States was similar following rainfall, which was not the case during dry weather.

Assessment of efficient sampling designs for urban stormwater monitoring.

Monitoring programs for urban runoff have not been assessed for effectiveness or efficiency in estimating mass emissions. In order to determine appropriate designs for stormwater, total suspended solids (TSS) and flow information from the Santa Ana River was collected nearly every 15 min for every storm of the 1998 water year. All samples were used to calculate the "true load" and then three within-storm sampling designs (flow-interval, time-interval, and simple random) and five among-storm sampling designs (stratified by size, stratified by season, simple random, simple random of medium and large storms, and the first m storms of the season) were simulated. Using these designs, we evaluated three estimators for storm mass emissions (mean, volume-weighted, and ratio) and three estimators for annual mass emissions (median, ratio, and regular). Designs and estimators were evaluated with respect to accuracy and precision. The optimal strategy was used to determine the appropriate number of storms to sample annually based upon confidence interval width for estimates of annual mass emissions and concentration. The amount of detectable trend in mass emissions and concentration was determined for sample sizes 3 and 7. Single storms were most efficiently characterized (small bias and standard error) by taking 12 samples following a flow-interval schedule and using a volume-weighted estimator of mass emissions. The ratio estimator, when coupled with the simple random sample of medium and large storms within a season, most accurately estimated concentration and mass emissions; and had low bias over all of the designs. Sampling seven storms is the most efficient method for attaining small confidence interval width for annual concentration. Sampling three storms per year allows a 20% trend to be detected in mass emissions or concentration over five years. These results are decreased by 10% by sampling seven storms per year.