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MRSA screening in ICUs Sarah Simmons, MPH CIC MRSA screening in ICUs Sarah Simmons, MPH CIC

Abstract n Is selective use of MRSA screening effective? n Tracked HA-MRSA rates from Abstract n Is selective use of MRSA screening effective? n Tracked HA-MRSA rates from January 2007 -December 2009 n PCR Screening was done for all ICU admissions

Background n Mandatory house-wide screening mandatory in several states n Results cultures are delayed Background n Mandatory house-wide screening mandatory in several states n Results cultures are delayed 48 hours for clinical

Results Rate decreased from 3. 19 to 1. 66 (p=0. 005) Results Rate decreased from 3. 19 to 1. 66 (p=0. 005)

Results Rate decreased from 0. 80 to 0. 38 (p=0. 0003) Results Rate decreased from 0. 80 to 0. 38 (p=0. 0003)

Conclusion n It works!! n Additional populations – PAT – Nursing Home – Dialysis Conclusion n It works!! n Additional populations – PAT – Nursing Home – Dialysis – Long term indwelling devices

Lessons from Publishing n. I already had the data n Focus on a simple Lessons from Publishing n. I already had the data n Focus on a simple question n Start early n Stay Organized!!

What does ESBL mean and why does my patient require contact isolation? Denise Langford, What does ESBL mean and why does my patient require contact isolation? Denise Langford, BS, MT(ASCP), CIC

Abstract The purpose of the article was: n To educate the reader on Extended-spectrum Abstract The purpose of the article was: n To educate the reader on Extended-spectrum beta-lactamase (ESBL) producing bacteria. n 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. n Discussed recommendations from the Centers for Disease Control (CDC) including Isolation Practices utilized at Baptist Healthcare System.

What is an ESBL bacteria? n ESBL = Extended-spectrum betalactamase n It is an What is an ESBL bacteria? n ESBL = Extended-spectrum betalactamase n It is an enzyme some of the Enterobacteriaceae family of bacteria produce to inactivate beta lactam antibiotics like the penicillins, cephalosporins and aztreonam n The first ESBL isolate was discovered in Western Europe in the mid 1980 s and within a few years it arrived in America

Most common ESBL Klebsiella pneumoniae Escherichia coli (E. coli) ESBLs have also been found 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! n These enzymes are encoded on plasmids, which can be easily transferred Scary fact! n These enzymes are encoded on plasmids, which can be easily transferred from bacteria to bacteria n The carbapenems represent the only antibiotics active against ESBLs. n Resistance to carbapenems are popping up!

How does Baptist Health handle ESBL? Contact Precautions (In addition to Standard Precautions) 1. How does Baptist Health handle ESBL? Contact Precautions (In addition to Standard Precautions) 1. 2. 3. 4. Wash Hands or use hand sanitizer before entering and when leaving room Wear gloves and gown when entering room Use patient dedicated equipment or singleuse disposable equipment. Clean and disinfect all equipment before removing from environment.

Why did I write about ESBL? I love Microbiology Educate myself. – Personally interested 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 n Literature seaches/references – Get help from Hospital Librarian n Lots Challenges / Preparation n Literature seaches/references – Get help from Hospital Librarian n Lots of reading n Being creative and making it interesting n Deadlines!

Surprises n Opportunity to collaborate with critical care nursing and gain their perspective on Surprises n Opportunity to collaborate with critical care nursing and gain their perspective on ESBL and isolation practices, as well educate them! n 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, 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 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. n We have all probably been exposed to the bacteria at some point. n 8, 000 – 18, 000 people are hospitalized with Legionnaires’ Disease in the U. S. 5 – 40% of cases will be fatal. n The disease was first identified at the 1976 convention of the American Legion. n

Transmission n Inhalation - of mist, aerosols or fine spray into the lungs. n Transmission n Inhalation - of mist, aerosols or fine spray into the lungs. n Aspiration – while drinking, swallowing or choking. n Incubation period is 2 -10 days. IT IS NOT SPREAD PERSON TO PERSON!

Signs and Symptoms n Rapidly rising fever and chills n Non-productive cough n Nausea Signs and Symptoms n Rapidly rising fever and chills n Non-productive cough n Nausea and diarrhea

Diagnostic Testing Legionella Urinary Antigen – urine test with results within 15 minutes. This 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. n Legionella DFA – sputum test which shows growth of legionella. n Legionella Antibodies – blood test which shows type of legionella. n Chest X-Ray – indicative of pneumonia. n

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

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

Why San Antonio Hospitals? Water supply – legionella usually cannot withstand cold water but 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! n Construction – the threat of legionella grows as construction occurs due to disruption of water/soil. n

Chronology of Events 5/5/2006 – 1 st case n 5/8/2006 – 2 nd case Chronology of Events 5/5/2006 – 1 st case n 5/8/2006 – 2 nd case At 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! n 5/10/2006 – 3 rd case n We had 10 cases between 4/22 and 6/12/06 (community acquired vs. hospital acquired? ) n

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

Legionella Task Force Purpose n Investigate Immediately n Communicate with Board, Medical Staff, hospital Legionella Task Force Purpose n Investigate Immediately n Communicate with Board, Medical Staff, hospital leadership, staff and visitors. n Identify high risk patients and if necessary limit admissions.

Waterborne Pathogen Plan n Identify corrective actions that will occur once a nosocomial case Waterborne Pathogen Plan n Identify corrective actions that will occur once a nosocomial case has been identified. n IC and Plant Ops with the assistance of the LTF revised the current plan.

Waterborne Pathogen Plan Contents n n n n n Legionella notification process. Convening LTF. Waterborne Pathogen Plan Contents n n n n n 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 n We offered free urine testing Legionella Hotline Manned 24/7 by Infection Control/Employee Health/Education n We offered free urine testing to anyone who had recently been a patient in our hospital. n 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. ” n

Initial Restrictions n Ice Machine Use n Water fountains n Mass quantities of hand Initial Restrictions n Ice Machine Use n Water fountains n Mass quantities of hand sanitizers and bottled water distributed

Long Term Solution – What We Chose n Implementation of Chlorine Dioxide System in Long Term Solution – What We Chose n Implementation of Chlorine Dioxide System in January, 2007. n There must be a trained person to monitor chlorine levels daily. n We continue to test our water with results of no legionella growth.

Lessons Learned n n n n Always err on the side of caution – Lessons Learned n n n n 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? n. I had already written it. n Why Did I Write This For CCNQ? n. I had already written it. n Want to get published. n Share the experience with others. n Expose the disease and plan.

What Were The Obstacles To Writing This? n Accepting criticism from the editors. n What Were The Obstacles To Writing This? n Accepting criticism from the editors. n Editors sometimes wanted to change verbage when the wording had to stay that way to make sense with legionella. n Time Frame. n Two Authors – one didn’t know how to write for a journal.

Lessons Learned From Writing n Meet deadlines. n References must be exact – some Lessons Learned From Writing n Meet deadlines. n References must be exact – some references come from other references so verification for accuracy must be done. n Accept the editors’ revisions. n Know your co-author’s strengths; you can benefit from that.

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

Scrub the Hub Sarah Simmons, MPH CIC Celestina Bryson, DNP, ACNP-BC, CCNS, MSN, MBA, Scrub the Hub Sarah Simmons, MPH CIC Celestina Bryson, DNP, ACNP-BC, CCNS, MSN, MBA, CCRN Susan Porter, MT ASCP

Abstract n There is no clear guidance for length of time to “Scrub the Abstract n There is no clear guidance for length of time to “Scrub the Hub” n 56% of nurses do not disinfect the hub n Compared 3 seconds, 10 seconds and 15 seconds

Methods n Contaminated hubs and allowed the to dry for 24 hours n Disinfected Methods n Contaminated hubs and allowed the to dry for 24 hours n Disinfected hubs and flushed with saline n Used a calibrated loop to plate bacteria n Counted colonies

Results Results

Conclusion n No statistical difference between scrub times n HOWEVER, a larger study would Conclusion n No statistical difference between scrub times n HOWEVER, a larger study would have more power n This study does NOT say that a 3 second scrub is acceptable

Lessons from Publishing n Team work is critical n Allow time for editing each Lessons from Publishing n Team work is critical n Allow time for editing each others work

Does Proper Design of an Intensive Care Unit Affect Compliance With Isolation Practices? Maria 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, MHA n 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. n 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. n 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; 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) n Internal (primary): – Employee Health – Safety – IPs n External: – Partnership(s) n Internal (primary): – Employee Health – Safety – IPs n External: – APIC Chapter – City wide STRAC calls with ID – Other regulatory and guidance providing agencies

Pandemics n History of Flu and Pandemics n PRID – Development with APIC group Pandemics n History of Flu and Pandemics n PRID – Development with APIC group (Avian Flu Scare) and maturation in health system. n Challenges – Early availability of guidelines and recommendations.

H 1 N 1 Pandemic n Interventions – Isolation • Special Precautions for Emerging H 1 N 1 Pandemic n 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: n Plans were updated to include a low mortality pandemic with What we learned: n Plans were updated to include a low mortality pandemic with a novel virus n Decision to use existing plans and not wait for outside guidance that may or may not come n Keep Materials Management in the loop n Maintain a stockpile of some critical needs items

Infection Prevention Data Web MARTHA MONTANO-PANIAGUA BA QUALITY ANALYST Infection Prevention Data Web MARTHA MONTANO-PANIAGUA BA QUALITY ANALYST

OVERVIEW BHS San Antonio- 5 Facility system with 1700+ Licensed beds offering a wide OVERVIEW BHS San Antonio- 5 Facility system with 1700+ Licensed beds offering a wide range of services n 6 Facility based Infection Preventionists 1 Regional Director of Infection Prevention 1 Regional Data Analyst n

n The collection, aggregation, analysis, and dissemination of infection prevention data is crucial to n 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.

Data Requests IP data are requested from and overseen by a wide variety of Data Requests 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. n Data will be publicly reported beginning this year. n

SYSTEM DATA REQUESTS Regional Quality n Regional Committees n System Committee reports n Facility SYSTEM DATA REQUESTS Regional Quality n Regional Committees n System Committee reports n Facility “O’s”, Directors, employees n

Data Collection Challenges In a multi-facility system with many individuals, interpretation of definitions and Data Collection Challenges In a multi-facility system with many individuals, interpretation of definitions and processes becomes important. n 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. n Quality concerns regarding data are valid given time constraints placed on clinicians. n Meeting all regulatory requirements for aggregation and reporting data. n

Data Strategy n n n Post-op letters to physicians for SSI follow up. Algorithms Data Strategy n n n 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.