Hospital Infection Control

SHEA joins suit against California SSI reporting law

May 31, 2011 – 11:29 am | By Gary Evans | No comments yet

  The Society for Healthcare Epidemiology of America (SHEA) is joining a lawsuit against the California Department of Public Health (CDPH), arguing that new reporting requirements for surgical site infections (SSIs) could have a “devastating impact on patient care.” Effective June 1, 2011, the All Facilities Letter issued by the CDPH requires hospitals to collect and report data on 29 different surgical procedures and resulting site infections to CDC’s NHSN, including denominator data for each procedure. The state is requiring SSI reporting through the through the Centers for Disease Control Prevention National Healthcare Safety Network (NHSN). The CDPH mandate states: “Each health facility shall report quarterly to the department all health-care-associated surgical site infections of deep or organ space surgical sites, health-care-associated infections of orthopedic surgical sites, cardiac surgical sites, and gastrointestinal surgical sites designated as clean and clean-contaminated, and the number of surgeries involving deep or organ space, and orthopedic, cardiac, and gastrointestinal surgeries designated clean and clean-contaminated.” The California Hospital Association (CHA) filed a lawsuit on Thursday, May 26, 2011 against the CDPH to halt the implementation of the new SSI public reporting requirements “SHEA strongly supports the CHA position and intends to file an amicus brief with the court,” the epidemiology group stated. “The amicus brief will outline the significant burden that will be imposed on SHEA members and potentially devastating impact on patient care if the mandate is allowed to stand. … [We have] a well-established and long-standing dedication to working toward the elimination of HAIs and to the important role that public reporting plays in providing high-quality care to patients.”

PA says reporting law cuts HAIs: Skeptics left at the station

May 25, 2011 – 11:59 am | By Gary Evans | No comments yet

In 2003, when Pennsylvania was first in the vanguard of states enacting laws requiring public reporting of health care associated infections (HAIs), there was considerable concern and consternation within the infection control community. I was skeptical myself, questioning whether such laws — however well intentioned — create disincentives to aggressively pursue and report all infections. The thinking was that rates may go down, but is it because reporting laws spur higher quality care or because they discourage full reporting of all HAIs? We’ve heard the anecdotal stories of arguments within the hospital walls about whether a given case meets the definition of an HAI. The stakes are higher now, and there are so many infections coming in from the community. Could there be a chilling effect on HAI surveillance? Still, with all due homage to  healthy skepticism, I’m starting to wonder if mandating HAI rate reporting is indeed a path to improved quality. In any case, it became a reality in so many states so quickly, that our academic arguments were left like baggage on the station platform as the train departed. Now Pennsylvania, the state that started it all, has released a report detailing impressive HAI reductions as the results of its legislative requirements, which in 2007 included an additional provision requiring health care facilities to develop internal infection control plans based on evidence-based practices. This was apparently an answer to the criticism that such reporting laws create “data graveyards” that inspire little real change. Key findings summarized in the Pennsylvania report include:

• Hospitals have reduced catheter-associated urinary tract infections by 26%, central line-associated bloodstream infections by 44%, and ventilator-associated pneumonia by 27%.
• Central line-associated bloodstream infection rates are below the national average.
• Hospitals reduced HAIs overall by 12.5%.

IP Newbie: The new kid at the cool lunch table

May 24, 2011 – 10:21 am | By Gary Evans | No comments yet

Stacey Taylor RN,BSN, entered her job as a rookie infection preventionist with much more enthusiasm than experience, ready to take on a new role she saw as both interesting and important. Then, like some shunned geek in high school, she realized that most unpleasant of surprises: infection control was, in a word, unpopular. “I didn’t realize that people viewed infection control so negatively, in a sense,” says the IP at North Hills Hospital in North Richland Hills, TX. “So that was hard to overcome and make it more of a positive thing. It has become that now. Now, people are more apt to ask me questions because I am out on the floor all the time, getting involved in stuff. But that was a huge thing to overcome.” That’s right, Taylor got caught in the long held perception that infection preventionists are the “police” of hand hygiene and a few million other things. No wonder people scattered when she walked down the halls. Nothing if not resilient, she decided to keep walking the walk, being present and patient, talking to any who would listen. “Really, just being accessible made all the difference in the world,” Taylor says. “Most people were resistant , but eventually I got to know them by name, to know about their lives, and I just made it very personal. It should be.” Thus without really knowing the history of the field, she overcame one of its biggest obstacles: the silo, where too many IPs have sat too long, crunching infection rate numbers and mastering the technical aspects of the job. “The office takes a lot of time too — don’t get me wrong,” she says. “Believe me, I can get stuck in here all day if I let myself. But I can’t. I can’t see what’s going on if I am not out there.” And yes, there is a little “policing” that goes on, but with a human touch by a member of a team. “I do look for hand washing and PPE compliance,” she says “I have created an isolation form that goes in the chart — with a sticker on the outside of the chart. That helps communication so I always make sure that is being met. And I just talk to the charge nurses, people along the floors, and ask them how they are doing. Do they have any concerns or questions?” As she got to know the staff, the questions and comments came more frequently. “I’m involved with everybody, and we all work together as a team,” she says. “So a lot of it is just me being there because I make rounds everyday — everybody knows me. That has made the biggest impact.” For the rest of this profile and similar articles see the IP Newbie supplement in Hospital Infection Control & Prevention.

Do 400,000 people a year die of infections in LTC?

May 23, 2011 – 8:47 am | By Gary Evans | No comments yet

In reviewing the literature, studies of infections in long term care sometimes cite  staggering mortality figures like  “nearly 400,000 deaths annually.” Is the mortality of infections in long term care really four-fold that of the 100,000 patients who die annually of health care associated infections(HAIs) in hospitals? Or unbelievably enough, could it actually be higher? A recently published study found that 15% of all U.S. nursing homes receive deficiency citations for infection control per year, with many of those breaches tied to staffing issues.¹ In reviewing the historical data, the authors note that “between 1.6 and 3.8 million infections occur each year in these nursing homes, with almost 388,000 deaths attributed to these infections.”² On further investigation, we find that these numbers reflect extrapolated mortality estimates from data that are now about a decade old. They have been preserved in the literature like amber because there is no national surveillance system for long term care infections — let alone their morbidity and mortality. One of the studies frequently cited for the death toll was published in 2000, says Nimalie Stone, MD, MS, a medical epidemiologist specializing in long term care at the Centers for Disease Control and Prevention. Moreover, Stone says even that work drew on some studies that date back to the 1980s and 1990s.³ “I would say we don’t have a current estimate of the number of infections and outcomes [in long term care], but we know it is a very vulnerable group of people,” she says. “They have a lot of reasons to have greater risks for infections and worse outcomes, and some of that is driven by the natural waning of the immune system that happens with age.” As infection prevention in long term care becomes a national priority and the CDC increases surveillance by expanding its existing hospital sentinel system, the toll of infections in long term care may come into better focus. The longstanding perception in hospitals that infections were an inevitable consequence of increasingly invasive care has been shattered by dramatic “zero infections” success stories in recent years. However, the old dogma may still apply in long term care, where as many people may die with infections as do because of them. It remains an open question how many HAIs in long term care can be prevented, and correspondingly, how much that grim death estimate could be reduced. Given the frequently cited lack of resources in long term care, one would think the increasing national emphasis could yield some dramatic results in nursing homes. On the other hand, the old mortality estimates were certainly based on resident populations with less acuity than those in long term care today. By that logic, the death toll may even be higher than the literature estimates. References 1. Castle NG, Wagner LM, Ferguson-Rome J, et al. Nursing home deficiency citations for infection control. Am J Infect Control 2011;39:263-9 2. Richards C. Infections in residents of long term care facilities: an agenda for research report of an expert panel. J Am Geriatr Soc 2002;20:570-576. 3. Strausbaugh LJ, Joseph CL. The burden of infection in long term care. Infect Control Hosp Epidemiol 2000; 21:674-679  n

Game on: Don a mask and play your role

May 16, 2011 – 8:57 pm | By Gary Evans | No comments yet

  How do you think you would fare in game where you assume the identity of a character in a computer-based video simulation that calls for key decisions to ensure infection prevention? Find out by playing Partnering to Heal. Based upon your avatar’s decisions, the training branches to different pathways and patient outcomes. The training is designed and developed for use by groups in facilitated training sessions and by individuals as a self-paced learning tool. Drawing upon expert consultation, the Department of Health and Human Services (HHS) developed the computer-based, interactive learning tool for clinicians, health professional students, and patient advocates. The training highlights effective communication about infection control practices and what it means to help create a “culture of safety” in healthcare institutions. Trainees follow five main characters and make decisions about preventing health care associated infections (HAIs). These include a physician, a nurse, an infection preventionist, a patient family member and a medical student. The training includes information on basic protocols for isolation precautions to protect patients, visitors, and practitioners from the most common HAIs.  In addition to communication and teamwork, the interactive sessions promote key hand hygiene and proper insertion, use, and removal of catheters and ventilators.

CDC posts new norovirus outbreak guidelines

May 13, 2011 – 12:34 pm | By Gary Evans | No comments yet

The Centers for Disease Control and Prevention has posted new guidelines on prevention of norovirus infections, compiling the latest information on the bane of cruise ships and hospitals alike. Created by the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), http://www.cdc.gov/hicpac/ the document is entitled “Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, 2011" A series of outbreaks in the last few years seems to have lulled, but no doubt norovirus will be a problem in some hospital or nursing home all too soon. "These things tend to come in waves and every season is not the same," says Michael Bell, MD, HICPAC, executive secretary and deputy director of the CDC Division of Healthcare Quality Promotion. "I have no doubt that with the amount of long-term care facilities, day care facilities and other communal living situations — not to mention the growth of the cruise ship industry — that we will continue to see plenty of norovirus outbreaks." Though rarely including fatal infections, norovirus outbreaks are extremely disruptive and expensive to control. Long-term care settings are particularly vulnerable to outbreaks due to the low infectious dose of norovirus (fewer than 10 viral particles), its persistence in the environment, and the close quarters and interaction typical among residents. Many of the outbreaks have been associated with breaches in infection control measures, which include frequent hand disinfection, contact precautions with known patients and use of bleach or another appropriate disinfectant for environmental cleaning. Outbreaks have also been preceded by symptomatic illness in food handlers, reminding that norovirus can be a foodborne pathogen as well as transmitted through direct fecal-oral contact and through the environment. Transmission also goes the other way too, as outbreaks may include health care workers — some infected severely enough to be hospitalized. "In this document there is a lot of emphasis on containment and environmental hygiene and cleaning," Bell says. "This is one of those things that is persistent in the environment, so there are several recommendations beyond routine cleaning to bring an outbreak to a close. The other issue is to make sure that the outbreak is promptly reported to state health authorities because it may not be purely hospital based. It's often a reflection of something happening in the community."

Achieving zero: Central line BSIs on endangered list

May 11, 2011 – 4:47 pm | By Gary Evans | No comments yet

The more some infection rates are driven down to absolute zero, the more disturbingly quaint appear all those old conversations about the inevitably of HAIs. The only thing inevitable about central line-associated bloodstream infections [CLABSIs] is that they are being driven to near extinction. Well, at least in the ICU. The latest evidence comes from the Agency for Healthcare Research and Quality (AHRQ), which reports that ICUs in both large and small hospitals stopped CLABSIs for up to two years. They used a targeted quality improvement initiative known as the Comprehensive Unit-based Safety Program (CUSP) as part of the now famous Keystone Intensive Care Unit Project in Michigan hospitals. Joining other peer-reviewed reports on this effort is a new study , “The Ability of Intensive Care Units to Maintain Zero Central Line–Associated Bloodstream Infections” published in the current issue of the Archives of Internal Medicine. Researchers found that 60% of the 80 ICUs evaluated went one year or more without an infection, and 26% achieved two years or more. Smaller hospitals sustained zero infections longer than larger hospitals, the researchers found. “Previous research has shown that using CUSP to reduce healthcare-associated infections works,” said AHRQ Director Carolyn M. Clancy, M.D. “This study gives us even better news – that results from efforts to eliminate these deadly and costly infections can be sustained.” The Keystone Project used a comprehensive approach that included promoting a culture of patient safety; improving communication among ICU staff teams; and using a checklist to promote implementation of practices based on guidelines from the CDC. AHRQ continues to support the nationwide implementation of CUSP through a contract with the Health Research & Educational Trust, an affiliate of the American Hospital Association, by reaching more hospitals and other settings in addition to ICUs and applying the approach to various HAIs.

APIC to FDA: Put glove warning in ‘plain language’

May 10, 2011 – 10:00 am | By Gary Evans | No comments yet

  Though conceding that powdered latex gloves pose little risk of causing patient infections, the nation’s largest infection prevention group is joining the chorus of those urging the Food and Drug Administration to ban the gloves i n favor of safer alternatives. In comments submitted to the FDA, the Association for Professionals in Infection Control and Epidemiology (APIC) “finds very limited scientific evidence that powder on medical gloves, specifically surgeon’s gloves, may act to promote infection. However, APIC cannot cite any instance in which powdered gloves offer a unique benefit over powder-free gloves. ... Indeed, the elimination of powdered gloves will significantly lower the risk of allergic reactions.” By making powder-free gloves the standard, the FDA will reduce the incidence of allergic reactions from airborne protein particles carried to the medical staff using them and to the patient. Further, because the protein level in powder-free gloves is much lower, the gloves are less subject to hydration and, hence, retain their barrier qualities, APIC noted. The generally cited merits of powdered gloves include that they are easier to don, absorb perspiration from surgeons’ hands, and are less expensive. However, new cases of latex allergy among health care workers have dropped dramatically with the use of low-protein and powder-free gloves, as well as the increased popularity of latex alternatives. Thus, three separate petitions have been filed, citing the risks to patients and health care workers in calling for an FDA ban on powdered gloves. Going farther, Public Citizen -- a Washington, DC-based advocacy group -- has issued a petition calling for a ban on all latex gloves. Some of the petitions raise the issue of patient safety and powdered gloves, primarily allergic reactions but also a possible risk of wound infections. Balking at an outright ban, the FDA has instead proposed a warning label that would read: “Warning: Powdered gloves may lead to foreign body reactions and the formation of granulomas in patients. In addition, the powder used on gloves may contribute to the development of irritant dermatitis and Type IV allergy, and on latex gloves may serve as a carrier for airborne natural latex leading to sensitization of glove users.” The FDA’s proposed warning has been widely criticized by the petitioners as an insufficient intervention. For its part, APIC advised the FDA to put the warning in “plain language,” noting that health care workers may benefit from more “plainly-stated guidance.”

`Grime Scene Investigators’ in South Carolina

May 6, 2011 – 2:40 pm | By Gary Evans | No comments yet

  It is encouraging to see the spontaneous, creative combustion that seems to be occurring everywhere in the area of hand hygiene improvement. The bane of infection prevention is no longer accepted with unwashed hands thrown in the air. Rather, it being increasingly targeted by infection preventionists emboldened by the recent run of success in the battle against health care associated infections. Exhibit A today is a blog recently posted by Dixie Roberts, APRN, MPH, Healthcare Associated Infections Coordinator South Carolina Department of Health and Environmental Control In 2007, with the knowledge that hand hygiene compliance is directly related to hospital (HAIs), the South Carolina Hospital Association (SCHA) launched the first statewide hand hygiene campaign in alignment with the World Health Organization’s (WHO) international hand hygiene campaign, Roberts notes. Among those joining the effort was a group called “Mothers Against  Medical Error.” You gotta love it. “This campaign had to be engaging in order to be successful,” Roberts writes. “We selected the theme “Grime Scene Investigators: South Carolina” (GSI:SC), a parody on the popular television series CSI.” The bit included sending out a “summons” to hospital infection prevention and marketing departments, calling them in for training in Grime Scene Investigation. “Each hospital received a GSI:SC kit with everything needed to set up a “grime scene” to create awareness while educating people on proper hand hygiene and its importance,” she notes.

And the Golden Glove goes to…HHS awards for IPs

May 4, 2011 – 5:37 pm | By Gary Evans | No comments yet

Too often a thankless job practiced in relative secrecy -- with only bad outcomes likely to come to public light – hospital infection prevention is finally being duly recognized. The latest evidence comes in the form of awards by the Department of Health and Human Services (HHS), which has recognized 37 hospitals and health care facilities for their infection prevention programs. The organizations are the first to be honored as part of a new national awards program to highlight successful and sustained efforts to prevent healthcare-associated infections (HAIs), specifically infections in critical care settings. This initial set of awards recognizes critical care professionals and health care institutions for their efforts to reduce, and eventually eliminate, ventilator-associated pneumonia and bloodstream infections associated with central intravenous lines. HHS partnered with the Critical Care Societies Collaborative (CCSC) to develop the awards program. CCSC is a multidisciplinary organization that promotes the exchange of ideas about critical care practice and ICU patient care among leaders from medicine, nursing, pharmacy and respiratory therapy. Ten recipients were recognized this week at the American Association of Critical-Care Nurses’ (AACN) National Teaching Institute & Critical Care Exposition in Chicago. The remaining 27 recipients will be recognized throughout the year at the conferences of CCSC member societies. The initial awards, which have a certain "Academy" resonance in their wording, are for Achievements in Eliminating Ventilator-Associated Pneumonia and Central Line-Associated Bloodstream Infections. Kudos to these organizations, and for all the infection preventionists in them: It’s a good time to ask for a raise. Check out the winners list at: http://1.usa.gov/mqds7g