MRSA screening in ICUs

Sarah Simmons, MPH CIC

Abstract

Is selective use of MRSA screening effective?

Tracked HA-MRSA rates from January 2007-December 2009

PCR Screening was done for all ICU admissions

Background

Mandatory house-wide screening mandatory in several states

Results are delayed 48 hours for clinical cultures

ResultsICU Hospitl Acquired MRSA Rate 2007- 2009

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep-0

7

Nov-0

7

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep-0

9

Nov-0

9

Month

ICU

Ho

sp

ita

l Ac

qu

ire

d M

RS

A r

ate

p

er

10

00

pa

tie

nt

da

ys

ICU Hospital AcquiredMRSA Rate

Pre-Screening Post Screening

Rate decreased from 3.19 to 1.66 (p=0.005)

ResultsHospital Acquired MRSA Rate 2007- 2009

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep-0

7

Nov-0

7

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep-0

9

Nov-0

9

Month

Ho

sp

ita

l Ac

qu

ire

d M

RS

A r

ate

pe

r 1

00

0

pa

tie

nt

da

ys

Hospital Acquired MRSARate

Pre-Screening Post Screening

Rate decreased from 0.80 to 0.38 (p=0.0003)

Conclusion

It works!! Additional populations

– PAT– Nursing Home– Dialysis– Long term indwelling devices

Lessons from Publishing

I already had the data Focus on a simple question Start early Stay Organized!!

What does ESBL mean and why does my patient require contact isolation?

Denise Langford, BS, MT(ASCP), CIC

AbstractThe purpose of the article was: To educate the reader on Extended-spectrum

beta-lactamase (ESBL) producing bacteria. Explain why contact isolation practices are

necessary within a healthcare facility, especially Intensive care units, to prevent the spread of these bacteria, which can potentially cause life-threatening infections.

Discussed recommendations from the Centers for Disease Control (CDC) including Isolation Practices utilized at Baptist Healthcare System.

What is an ESBL bacteria?

ESBL = Extended-spectrum beta-lactamase

It is an enzyme some of the Enterobacteriaceae family of bacteria produce to inactivate beta lactam antibiotics like the penicillins, cephalosporins and aztreonam

The first ESBL isolate was discovered in Western Europe in the mid 1980s and within a few years it arrived in America

Most common ESBL

Klebsiella pneumoniae

Escherichia coli (E.coli)

ESBLs have also been found in other family members such as Salmonella, Proteus, Enterobacter, Citrobacter, and Serratia but not as frequently.

Scary fact!

These enzymes are encoded on plasmids, which can be easily transferred from bacteria to bacteria

The carbapenems represent the only antibiotics active against ESBLs.

Resistance to carbapenems are popping up!

How does Baptist Health handle ESBL?Contact Precautions (In addition to Standard

Precautions)

1. Wash Hands or use hand sanitizer before entering and when leaving room

2. Wear gloves and gown when entering room3. Use patient dedicated equipment or single-

use disposable equipment. 4. Clean and disinfect all equipment before

removing from environment.

Why did I write about ESBL?

I love Microbiology Educate myself.

– Personally interested in increasing my knowledge on ESBL and CDC guidelines.

– A person retains 90% of new information by teaching it!

Educate others– From my experience, most Nurses still don’t know what to do

when their patient has an ESBL– Healthcare facilities are just beginning to add other MDROs to

patient and nursing education.– Provide reader with Evidence-Based references

Challenges / Preparation

Literature seaches/references– Get help from Hospital Librarian

Lots of reading

Being creative and making it interesting

Deadlines! Deadlines! Deadlines!

Surprises

Opportunity to collaborate with critical care nursing and gain their perspective on ESBL and isolation practices, as well educate them!

Infection Preventionists have tons of free time on their hands so why not write an article

Legionella – Every IP’s Dream – Or Is It?

CCNQ Experience

Kris Chafin, RN, BA, MBA, CIC

Infection Preventionist

Legionella - History This disease (Legionnaire’s Disease) is due to

legionella causing a biofilm in plumbing, shower heads and water storage tanks or wherever there is stagnant water. It is everywhere in the environment.

We have all probably been exposed to the bacteria at some point.

8,000 – 18,000 people are hospitalized with Legionnaires’ Disease in the U.S. 5 – 40% of cases will be fatal.

The disease was first identified at the 1976 convention of the American Legion.

Transmission

Inhalation - of mist, aerosols or fine spray into the lungs.

Aspiration – while drinking, swallowing or choking.

Incubation period is 2-10 days.

IT IS NOT SPREAD PERSON TO PERSON!

Signs and Symptoms

Rapidly rising fever and chillsNon-productive coughNausea and diarrhea

Diagnostic Testing Legionella Urinary Antigen – urine test with results

within 15 minutes. This test can remain positive for up to one year, so in essence, the patient could have had legionella at some point from one year ago to present.

Legionella DFA – sputum test which shows growth of legionella.

Legionella Antibodies – blood test which shows type of legionella.

Chest X-Ray – indicative of pneumonia.

Why Hospitals?

Immunocompromised patients are susceptible to Legionnaires’ Disease, including chemo patients, transplant patients, patients on long term steroid therapy and heavy smokers.

Why Hospitals?

Sources: Potable water systems Spray misters Decorative fountains Cooling tower drift Irrigation Systems RT Equipment Whirlpools and Spas Therapy pools

Why San Antonio Hospitals?

Water supply – legionella usually cannot withstand cold water but San Antonio’s cold water temperature is 82-84 degrees. Legionella thrive in water temperatures of 65 – 124 degrees. Texas law requires that the hospital’s hot water not be hotter than 110 degrees!

Construction – the threat of legionella grows as construction occurs due to disruption of water/soil.

Chronology of Events 5/5/2006 – 1st case 5/8/2006 – 2nd caseAt this point, I panicked!I called my Plant Ops director and said we

needed to test the water and he said I was crazy; no one recommends water testing but we did it anyway!

5/10/2006 – 3rd case We had 10 cases between 4/22 and 6/12/06

(community acquired vs. hospital acquired?)

Chronology of Events 5/11/2006 Water tested – results showed no growth. 5/12/2006 Superheated and flushed water. 5/12/2006 Department Leader Notification.

We continued to get cases – didn’t know if they were CA or HA.

CDC definition of HA legionella – if a patient has been in the hospital for 10 straight days or more and then develops Legionnaires’ Disease. CDC tested our water and found growth!

Legionella Task Force Purpose

Investigate Immediately Communicate with Board, Medical Staff,

hospital leadership, staff and visitors. Identify high risk patients and if

necessary limit admissions.

Waterborne Pathogen Plan

Identify corrective actions that will occur once a nosocomial case has been identified.

IC and Plant Ops with the assistance of the LTF revised the current plan.

Waterborne Pathogen Plan - Contents Legionella notification process. Convening LTF. Identification of high risk patients. Potential restriction of water use. Education, rounding,read and sign. Collaboration with local health dept. Water testing/site. Remediation. Preventative Maintenance. Visitor Signage.

Legionella Hotline Manned 24/7 by Infection Control/Employee

Health/Education We offered free urine testing to anyone who

had recently been a patient in our hospital. Crazy phone calls:“I was driving by your hospital and got

Legionnaires’ Disease.”“My grandson was in your ER and I washed my

hands and got Legionnaires’ Disease.”

Initial Restrictions

Ice Machine Use Water fountains

Mass quantities of hand sanitizers and bottled water distributed

Long Term Solution – What We Chose Implementation of Chlorine Dioxide

System in January, 2007. There must be a trained person to

monitor chlorine levels daily. We continue to test our water with

results of no legionella growth.

Lessons Learned Always err on the side of caution – go with your gut! I

had many sleepless nights! Become best friends with your Plant Ops director. Get leadership support. Keep a timeline. Form a task force and meet regularly. Develop/continuously review the Waterborne

Pathogens Plan. EDUCATE and COMMUNICATE! Know that YOU are the expert!

Why Did I Write This For CCNQ? I had already written it. Want to get published. Share the experience with others. Expose the disease and plan.

What Were The Obstacles To Writing This?

Accepting criticism from the editors. Editors sometimes wanted to change

verbage when the wording had to stay that way to make sense with legionella.

Time Frame. Two Authors – one didn’t know how to

write for a journal.

Lessons Learned From Writing

Meet deadlines. References must be exact – some

references come from other references so verification for accuracy must be done.

Accept the editors’ revisions. Know your co-author’s strengths; you

can benefit from that.

Lessons Learned: Managing a Pandemic in a Multi-hospital SystemElizabeth Curnow, MPH, Med, CIC;

Robert E. Wiles, MS, CHEP, CHSP, and

Melissa Wyatt, RN, BS, COHN-S

Scrub the Hub

Sarah Simmons, MPH CIC

Celestina Bryson, DNP, ACNP-BC, CCNS, MSN, MBA, CCRN

Susan Porter, MT ASCP

Abstract

There is no clear guidance for length of time to “Scrub the Hub”

56% of nurses do not disinfect the hub Compared 3 seconds, 10 seconds and

15 seconds

Methods

Contaminated hubs and allowed the to dry for 24 hours

Disinfected hubs and flushed with saline Used a calibrated loop to plate bacteria Counted colonies

Results

Conclusion

No statistical difference between scrub times

HOWEVER, a larger study would have more power

This study does NOT say that a 3 second scrub is acceptable

Lessons from Publishing

Team work is critical

Allow time for editing each others work

Does Proper Design of an Intensive Care Unit Affect Compliance With Isolation Practices? Maria Rodriguez RN BSN CIC, Dennis Ford CHFM,CHSP, CHEP, Sheila Adams RN, BSN, MSN, MHA

In this article, we propose that unit design may have an indirect potential to affect patient outcomes. The design of a unit or patient room, the type of surfaces chosen, accessibility to supplies or medications, affect staff’s ability to provide care to their patients quickly and efficiently. A poorly constructed patient room or unit may decrease efficiency and affect staff’s ability to comply with isolation practices.

Without the input of the end user, the end result is often a less than efficient new unit. The unit is finished and staff is expected to function or in other words, care for their patients in an efficient manner. Nurses are resourceful and great at creating work arounds in order to make their new environment functional. These types of work arounds may meet the immediate need of the nurse but they aren’t always in the patient’s best interest and may sometimes result in negative outcomes otherwise known as a healthcare associated infection (HAI) for patients.

The article supports that planners, end-users and infection preventionists commit to working as a team in order to create units that are clinically functional and safer for the patient.

Lessons Learned: Managing a Pandemic in a Multi-hospital System

Elizabeth Curnow, MPH, Med, CIC;

Robert E. Wiles, MS, CHEP, CHSP, and

Melissa Wyatt, RN, BS, COHN-S

Partnership(s) Internal (primary):

–Employee Health–Safety–IPs

External:–APIC Chapter–City wide STRAC calls with ID–Other regulatory and guidance providing

agencies

Pandemics

History of Flu and PandemicsPRID

–Development with APIC group (Avian Flu Scare) and maturation in health system.

Challenges–Early availability of guidelines and

recommendations.

H1N1 Pandemic Interventions

– Isolation• Special Precautions for Emerging Pathogens (Fluid)

– Communication• Best way to turn around key information quickly • Website

– Visitation• Limit or not?

– Vaccination• Mandatory or not?

– Employee Illness• Rescreens, return to work, mask utilization

– Materials Management• Stockpile• Availability of things like goggles

What we learned:

Plans were updated to include a low mortality pandemic with a novel virus

Decision to use existing plans and not wait for outside guidance that may or may not come

Keep Materials Management in the loopMaintain a stockpile of some critical needs

items

Infection Prevention Data Web

MARTHA MONTANO-PANIAGUA BA QUALITY ANALYST

BHS San Antonio- 5 Facility system with 1700+ Licensed beds offering a wide range of services

6 Facility based Infection Preventionists 1 Regional Director of Infection Prevention

1 Regional Data Analyst

The collection, aggregation, analysis, and dissemination of infection prevention data is crucial to the collaborative relationship shared by the Infection Preventionist and the Critical Care Nurse. There now exists an increasingly data driven environment in which nursing and quality departments are mandated by state and oversight organizations to make data available to the staff as well as the public at large. The infection preventionist is challenged to conduct surveillance, analyze, and report findings quickly, cohesively and accurately.

IP data are requested from and overseen by a wide variety of organizations e.g. National Healthcare Safety Network (NHSN), Centers for Medicare & Medicaid Services (CMS), and Hospital Quality Alliance (HQA) to name a few.

Data will be publicly reported beginning this year.

Regional Quality Regional Committees System Committee reports Facility “O’s”, Directors, employees

In a multi-facility system with many individuals, interpretation of definitions and processes becomes important.

Electronic Data Mining programs are becoming indispensable in the present environment of “real time” surveillance. Information systems have traditionally been purchased with little regard to system integration making the process of aggregation difficult at best.

Quality concerns regarding data are valid given time constraints placed on clinicians.

Meeting all regulatory requirements for aggregation and reporting data.

Post-op letters to physicians for SSI follow up. Algorithms for ready reference by IP’s so that

all data is managed in the same manner. IP representation in facility as well as regional

committees. Regular intradepartmental meetings for IP

collaboration. IP as a resource for nursing. Collaboration with ancillary departments.e.g.

Facilities, Environmental Services.