Assessment of Endoscope Reprocessing Using Peer-to-Peer Assessment Through a Clinical Community.

BACKGROUND: Cleaning, disinfection, and sterilization (CDS) of medical devices are intended to help prevent health care-associated infections (HAIs), a significant cause of mortality and morbidity. In February 2013 the Johns Hopkins Health System (JHHS; Baltimore) formed a clinical community of experts and stakeholders--physicians, nurses, administrators, infection control practitioners, risk managers, and regulatory staff--to assess CDS practices across facilities. METHODS: A survey administered to leadership indicated endoscopy areas of risk. An endoscopy tracer tool with eight major performance areas was then created from best practices identified in the literature, regulatory requirements, and national guidelines for endoscope reprocessing. Peer-to-peer (P2P) assessments using the tracer tool were performed at five Johns Hopkins Medicine gastrointestinal endoscopy sites (three hospital-based; two freestanding ambulatory surgery centers) selected on the basis of their large procedural volumes and their operational ability to participate in further areas of the project. RESULTS: The P2P assessments revealed that 20 (42%) of the 48 possible criteria had a noted deficiency at one or more sites. Three of the eight major performance areas on the tracer tool had no deficiencies identified at any of the five sites. Deficiencies were mostly minor process improvements, and only one critical process required immediate alteration of practice. Because the assessments were nonpunitive, horizontal communication enabled feedback on process improvements, alternate methods to achieve outcomes, and solutions to common issues. CONCLUSIONS: A nonpunitive and collaborative peer methodology was successful in capturing and sharing best practices in endoscopy areas. Successful replication in other clinical areas can be an effective way to assess CDS processes and facilitate dialogue for improvements.

Hand hygiene in emergency medical services.

BACKGROUND: Hospital-acquired infections (HAIs) affect millions of patients annually (World Health Organization. Guidelines on Hand Hygiene in Healthcare. Geneva: WHO Press; 2009). Hand hygiene compliance of clinical staff has been identified by numerous studies as a major contributing factor to HAIs around the world. Infection control and hand hygiene in the prehospital environment can also contribute to patient harm and spread of infections. Emergency medical services (EMS) practitioners are not monitored as closely as hospital personnel in terms of hand hygiene training and compliance. Their ever-changing work environment is less favorable to traditional hospital-based aseptic techniques and education. METHODS: This study aimed to determine the current state of hand hygiene practices among EMS providers and to provide recommendations for improving practices in the emergency health services environment. This study was a prospective, observational prevalence study and survey, conducted over a 2-month period. We selected participants from visits to three selected hospital emergency departments in the mid-Atlantic region. There were two data components to the study: a participant survey and hand swabs for pathogenic cultures. RESULTS: This study recruited a total sample of 62 participants. Overall, the study revealed that a significant number of EMS providers (77%) have a heavy bacterial load on their hands after patient care. All levels of providers had a similar distribution of bacterial load. Survey results revealed that few providers perform hand hygiene before (34%) or in between patients (24%), as recommended by the Centers for Disease Control and Prevention guidelines. CONCLUSION: This study demonstrates that EMS providers are potential vectors of microorganisms if proper hand hygiene is not performed properly. Since EMS providers treat a variety of patients and operate in a variety of environments, providers may be exposed to potentially pathogenic organisms, serving as vectors for the exposure of their patients to these same organisms. Proper application of accepted standards for hand hygiene can help reduce the presence of microbes on provider hands and subsequent transmission to patients and the environment.

Incidence of health care-associated extended-spectrum ß-lactamase-positive patients before and after discontinuation of contact precautions.

BACKGROUND: Isolation of patients with multidrug-resistant organisms has been recommended in several guidelines. Recent evidence has suggested potential negative effects of isolation on patient well-being and facility throughput. Published literature shows a difference in transmission risk of extended-spectrum ß-lactamase (ESBL)-producing organisms, suggesting that contact precautions may not be necessary for all ESBL-positive organisms. METHODS: Incidence rates of health care-associated ESBL organisms were measured before and after eliminating the use of contact precautions for patients with only ESBL-positive organisms. The National Healthcare Safety Network surveillance methodology was used to measure incidence. Surgical site infections and carbapenem-resistant Enterobacteriaceae were excluded from the surveillance incidence. RESULTS: The incidence of health care-associated ESBL infections from January 2014 through November 2015 was 3.71 per 10,000 patient days. The incidence from December 2015 through August 2017 was 3.00 per 10,000 patient days. This rate change was statistically significant (P = .022) CONCLUSIONS: This study found that discontinuing the use of contact precautions for patients colonized or infected with ESBL-positive organisms did not lead to an increased rate of health care-associated ESBL-positive infections or colonization.

Assessment of operating room airflow using air particle counts and direct observation of door openings.

BACKGROUND: The role of the operating room (OR) environment has been thought to contribute to surgical site infection rates. The quality of OR air, disruption of airflow, and other factors may increase contamination risks. We measured air particulate counts (APCs) to determine if they increased in relation to traffic, door opening, and other common activities. METHODS: During 1 week, we recorded APCs in 5-minute intervals and movement of health care workers. Trained observers recorded information about traffic, door openings, job title of the opener, and the reason for opening. RESULTS: At least 1 OR door was open during 47% of all readings. There were 13.4 door openings per hour during cases. Door opening rates ranged from 0.19-0.28 per minute. During this time, a total of 660 air measurements were obtained. The mean APCs were 9,238 particles (95% confidence interval [CI], 5,494- 12,982) at baseline and 14,292 particles (95% CI, 12,382-16,201) during surgery. Overall APCs increased 13% when either door was opened (P < .15). Larger particles that correlated to bacterial size were elevated significantly (P < .001) on door opening. CONCLUSIONS: We observed numerous instances of verbal communication and equipment movement. Improving efficiency of communication and equipment can aid in reduction of traffic. Further study is needed to examine links between microbiologic sampling, outcome data, and particulate matter to enable study of risk factors and effects of personnel movement.