Wouldn't it be great if you could stop the spread of C. difficile at the front door? Since carriers can be asymptomatic it can be challenging to initiate the correct precautions without first identifying carriers. A new study attempted to identify whether carriers could actually be identified at the door - upon admission.
Researchers from the Mayo Clinic in Rochester, Minn., identified independent predictors of C. difficile colonization to be recent hospitalization, chronic dialysis and corticosteroid use. They found one or more of the three independent risk factors were present in 48% of their study participants (320 patients), and screening only those with one or more of these factors would have identified 74% of the carriers.
Their findings are published in the May issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC). The authors were careful to note limitations of the study: only 22% of all eligible patients provided stool for C. difficile testing, and the study population was not representative of all patients admitted to the hospital.
"Our objective was to estimate the burden of asymptomatic C. difficile carriers at admission because that constitutes an important checkpoint where risk factors can be assessed and infection prevention measures instituted," said the authors. "This is the first study to demonstrate the feasibility of performing C. difficile surveillance on hospitalized patients at admission.
"While more research needs to be conducted on the transmission of C. difficile infection from colonized patients, this study may help institutions with persistently high rates of transmission develop an expanded strategy for targeted C. difficile surveillance," added APIC 2013 President Patti Grant, RN, BSN, MS, CIC.
On Tuesday, I led a workshop with 50 healthcare workers from 4 different facilities. There were nurses, attendants, transporters, environmental services workers and infection preventionists. They came from critical care units, nurseries, clinics and med surg units.
The workshop was aimed at reducing healthcare acquired infections via cleaning equipment - both stationary and rolling stock.
The second focus was on hand hygiene. I was trying to make the point that alcohol base hand rubs (ABHR) have several advantages over the soap, sink and water method. The ABHR have effective antimicrobial activity. And they are quick and easy to use. The pumps or portable bottles can be used in places where sinks are not accessible.
Of course, soap and water is preferred when your hands are visibly soiled and when caring for certain patients, e.g. a patient with c. difficile.
Even though this seemed like a mundane topic, I was delighted at the lively discussion that the participants had about products used for hygiene hand. Obviously, you can't have this discussion without someone mentioning skin irritation from ABHR but the passion that some staff had for the soap and water method was what really surprised me. Some members just wouldn't use the ABHRs. I wondered if this was a group of traditionalist based on their age or the unit where they worked. But there was no pattern - some people prefer the soap and water and others swear by the ABHRs.
So what's your preference? The CDC has an extensive section on hand hygiene but I bet that won't settle it either.
Since the median age of nurses in the United States is estimated to be 46 years, many of us are familiar with American Association of Retired Persons (AARP)-even if we are not members. This month's journal had an article titled The Top Hospitals for Safety. The article list 66 superstar hospitals across the country- both large and small - which have achieved super safe patient outcomes. They also give a reference to the Leap Frog Group to find other hospitals with an A rating (like the restaurant ratings in New York City).
Of course, infection prevention played a key role in determining a safe hospital. The other elements included medication safety, surgical and ICU safety. The nursing staff played a major role as did design of the facility. It was the last element - design - that caught my attention.
There's an interactive "room of the future" on the AARP website.
The room had 16 features that will enhance patient and worker safety. Five of the features directly impact your infection prevention efforts: hand hygiene station AND an electronic monitoring system to make sure all staff uses it. Three features were designed to improve room cleanliness and air quality. One more component, the use of a checklist was mentioned; checklists have been shown to reduce IV infections.
And only one patient occupies this demo room!
Take a look and tell us how this compares to your facility.
Linda had a great yet possibly scary post on March 7 about resistant gram-negative bacteria. The post referred to the organisms as super bugs, although the technical term is CRE. It referenced the likelihood that once people are colonized with these organisms they may have them for several months. This clearly creates a problem for patients who are frequent fliers in the healthcare system.
If you have not cared for a patient with this organism, you should expect to soon- these organisms have been seen in patients from the Northeast United States. You should check you hospital's protocol for handling these patients- do you place them on contact precautions immediately, collect surveillance cultures?
I've received several calls from staff, patients and visitors about CRE.
The Association for Professionals in Infection Control and Epidemiology has prepared a flyer that highlights key points about CRE bacteria. It's aimed at the consumer but can certainly be adapted for healthcare workers.
Today, John Haberstock and I headed to Dufort, Haiti, to work with the two volunteer doctors from the United States and Dr. Louie, the Haitian clinician who works with Heart to Heart. We drove to the clinic through an area that looked like a jungle with lush vegetation on roads that were really just a dirt path.
There were mango and papaya trees along the way, as well as goats, roosters, mules and oxen. While we may not always have what we need, we follow the Haitian saying, "dégagé," which means to do the best with what you have. Most of the time we have no running water nor electricity, but are able to treat people with what we have available to us. We are seeing some Malaria, hypertension, dehydration and multiple infections. I can not stress how reassuring it is to have our Welch Allyn equipment with us, knowing that the devices are reliable, and the amazing group of interpreters who've become like family after years of working side-by-side.
|The Welch Allyn team worked with the two volunteer doctors from the United States and Dr. Louie, the Haitian clinician. |
The team that has been helping Heart to Heart construct a new healthcare clinic has also been very busy. They are determined to finish what they set out to do-get the clinic as close to being ready for use as possible.
The team has completely finished painting the outside of the building, installed celings in five rooms, painted all five rooms and built the patient waiting area. All of this work was done in extreme heat and humidity with the help of the Haitian construction crew. Jim Colvin said how grateful he was to be working with the Haitian crew, who were incredibly skilled, because they made it that much easier for our team to work together and complete this task. Steve Hower, director of corporate relations at Heart to Heart, was also a key participant and was willing to tackle any task at hand.
|The team that has been helping Heart to Heart construct a new healthcare clinic painted inside and out, installed in the rooms and built the patient waiting area. |
Today we worked at a clinic in Bel Air, one of the poorest neighborhoods in Port-au-Prince, which is close to the former palace. I was struck by the progress and poverty in the region. First the progress: When I first came to Haiti in January 2010, one month after the 7.0 magnitude earthquake that affected an estimated 3 million people and killed 220,000 more, and then my second trip here one year later in February 2011, the area looked as though it was a war zone. So many homes and government buildings, including the palace, were destroyed and there was rubble everywhere.
People were living in tents as far as the eye could see-not much had changed from January 2010 to February 2011.
|John Haberstock trained Haitians to use the iExaminer and they were thrilled to use the donated device. |
During this trip, I immediately noticed a significant change on the drive to the clinic. Where the collapsed palace once stood, for a full year without any change, was now a clean open space. The tents that surrounded the palace for more than a year were now all gone. While there are still some tents scattered in the area, there is a significantly less than in 2011.
|Welch Allyn donated equipment to the clinics in Haiti. To make sure these clinics will get the most out of the devices, we have been training the Haitian triage nurse, the nurse manager and the Haitian family physician. |
There were also drastic improvements made to the clinic in Bel Air. Where we see patients on the second floor of a church that experienced some damage from the quake, was far from the same. We once saw patients in makeshift exam areas, sometimes out in the open. We now have real exam rooms. And, where we used to dispense meds from a crude set up, they now have a small pharmacy. Finally, we previously had to send patients requiring blood work away, but now there is a small lab at the clinic to run tests.
Welch Allyn is donating equipment to the clinics here in Haiti. To make sure these clinics will get the most out of the devices, we have been training the Haitian triage nurse, the nurse manager and the Haitian family physician to use the Spot Vital Signs® Lxi that we left behind. The triage nurse was thrilled to have a device that could capture all the vital parameters she was currently capturing manually (with the exception of thermometry using a Braun ear thermometer) in such a short time.
After visiting the the clinic in the morning, we went to a nearby hospital that also has a teaching program for residents. We met up with several ophthalmology residents and the chief resident, along with Dr. Frantz, the Codio Medical Logistics Director for Heart to Heart who coordinated the visit. This hospital is in the middle of the poorest area of Haiti and the residents came to learn about the iExaminer and Spot Lxi. John Haberstock did a great job of training the residents on the iExaminer and they were thrilled to use the donated device. I spoke to them about the value of acquiring vital signs, regardless of specialty, while Winsome Graham provided training on the donated Spot Lxi. Each resident wanted to use the products and were also very grateful for the donation to their program.
All in all, it was another great day in Haiti. The team commented on how quickly the week was going and how hard it is to believe it is our last day in clinic tomorrow. We head up to the mountains in Fondwa, about a three hour drive. It will by my second trip to this clinic and I'm looking forward to the day!
The Welch Allyn crew had another full day in Léogâne. We split up and my colleague from Beaverton, Ore., Carolyn Pace, came with me to the clinic in Place d'or, which means, "The place of gold." We set up inside a partially completed church with two American doctors and one Haitian clinician. As I have always experienced, the Haitians are very grateful, humble and appreciative of the care we can provide.
They always wait, sometimes for hours, to be seen by a clinician. And, despite coming from homes made of tin and any scraps that can be found, people are always clean, well-groomed and dressed up for their visit.
|Welch Allyn employees set up a clinic in Place d’or, Haiti, inside a partially completed church with two American doctors and one Haitian clinician.|
When we arrived at the clinic, there were nearly 50 patients already waiting in the 90+ degree heat to be seen. Having more than 50 patients waiting for you may seem like a daunting task, but our Welch Allyn diagnositc equipment allowed me to take their vital signs and document why they were there incredibly easy and quick. I saw patients with a variety of diseases, such as typhoid, cancer and severe hypertension. Overall, it was a very rewarding experience and was much easier than it would seem to be. It was extrememely comforting to know the equipment I was using is fast and durable, even in harsh Haitian conditions.
But, most importantly, the equipment is reliable because most of these patients have little opportunity for healthcare and coming back another day is not an option. I know the Welch Allyn equipment we are leaving with the Haitian clinicians will be put to good use. Heart to Heart, has done a phenomenal job providing a system to bring much-needed healthcare to the most destitute in the world.
|Despite coming from homes made of tin and any scraps that can be found, the Haitian people who come to the clinics are always clean, well-groomed and dressed up for their visit. |
The rest of the Welch Allyn team has been workin side-by-side with local Haitians to finish construction on a new clinic-"Place of Gold." Because of the destruction that occurred in Léogâne, which was the epicenter of the quake, they're now using more solid and reliable construction techniques that include lighter roofing matierials and welded steel structures. The team worked tirelessly with their new-found friends in the extreme heart with local children constantly by their side.
The children were always eager to help and were extremely happy to join our team for a delicious peanut butter sandwich for lunch. Additionally, some of the locals offered to help and thanked us. They told us that without the help of the Americans, they never could have recovered from the disaster. Carolyn and I did have time to meet up with the construction team later in the day. All in all it was an exhausting, but very rewarding day.
|Some from the Welch Allyn team worked with local Haitians to finish construction on a new clinic. Even after seeing patients all day, Sue and Carolyn found some energy to join them. |
For the past 3 days, we've had 12 people in a small "house" (and I use that term loosely), only cold water for showers, Haitian construction workers sleeping on the floor, no electricity and no A/C until the evening! In all seriousness, while its not ideal, the work here is seriously rewarding. I am always touched and inspired by the grace, perseverance and humble nature of the people in this country. We are our on our way to a third remote clinic back in Port-au-Prince tonight.
Our team in Léogâne consists of 10 amazing people who, despite not having any hot running water and sharing only one bathroom, continue to give all they can to help the Haitian people. Jim Colvin and some other members of our group are helping to finish construction of a new healthcare clinic being built to serve rural area-Léogâne. They are painting, putting in the ceiling and varnishing that building.
I will have more details about their work for you later.
|Some families bought chickens and fruit trees after the quake so they would have essentials in case of another disaster. |
|Two school girls are seen at the clinic.|
Today I saw more than 60 patients of all ages at a clinic. I used the Welch Allyn equipment we brought with us to leave at the clinic and trained staff members there how to use the devices. The stories of how people here are still dealing with the aftermath of earthquake continue to amaze me. For example, one Haitian doctor who I worked with had just finished a c-section in his clinic on the second floor of the building when the quake hit and the building collapsed. Not only did he lose his clinic, but he also lost his home along with his sister and brother's homes which were on the same property. Today, he and his family live in the clinic, which Heart to Heart helped him rebuild. The family also bought chickens and fruit trees after the quake so they would have essentials in case of another disaster.
|The author saw more than 60 patients in one day at the clinic in Léogâne. |
|Susan Dubay, MPA, BSN, RN, checks the temperature of a young Haitian patient. |
When I arrived in Haiti on Sunday (March 17, 2013), I began to think about the experience I had when I was here a few years ago, one month after the earthquake. There was total devastation and destruction in a country that had already suffered many blows from poverty, war, corruption and natural disasters.
And, as I've said in the past, being in Haiti right after the quake, which killed so many, and having the opportunity to help out during this time made me feel like I was part of something much bigger. I quickly realized the importance of helping others in life and the small, trivial things I tended to worry about at home became somewhat irrelevant. My perspective changed and it had an almost immediate transformational impact on me.
|Since my last trip, the airport has been transformed into a modern facility. |
Immediately after we landed I noticed a major change. The first time I came to Haiti the airport was probably one of the worst I've ever experienced, if not the worst, and I've traveled to many countries. But now it is a new and modern facility. Previously when you landed you walked into an area that was open and all flights exited into this common area. Every piece of luggage was tossed into one common area where you and hundreds of others tried to rifle through to find your own bags; it was mass chaos. This time, however, you walked into a brand new modern facility with a local band playing, real luggage carousels and duty free shops. It was a striking difference compared to my last visit. The entire process, including customs, was now fairly quick and much more efficient than before.
|A local band plays to greet travelers in the new airport.|
In addition to the airport, it was clear during our drive to meet up with Heart to Heart that much had changed for the better in Haiti. The streets were, for the most part, clear from rubble and while there are still tents, there are far fewer than before.
|The streets of Haiti are now mostly clear of ruble.|
The buildings I saw were unlike anything that I had seen before. It was heartwarming to see construction on new homes and buildings. Heart to Heart is doing what they do best: bringing their expertise in providing medical care to people of the world during a crisis and then helping them to take back care and responsibility. I look forward to going to Léogâne, the epicenter of the quake where I worked before. I am hoping to see as much there in the way of progress as I have so far.
Who was that masked man?!
Maybe just someone hoping not to get sick.
Within the healthcare system, employees, and sometimes visitors, wear facemasks if they will encounter someone who is highly contagious with a serious airborne illness. This is a proven way to avoid the spread of infection to healthcare employees.
But there are a lot of contagious people outside of the healthcare system. Should the general public take the same precautions?
In a January 2013 article in The Journal of Infectious Diseases, "Exposure to Influenza Virus Aerosols During Routine Patient Care," the authors reported, "influenza viruses may spread as far as six feet from a person coughing or sneezing." Think about that next time you're in the grocery store and hear "achoo." But as a society are we ready to ask people with the sniffles to wear a facemask for infection source control? Or do facemasks become part of our daily attire as primary protection?
If the latter, imagine the fashion industry getting a hold of that. Whether plain or with bling, they are sure to be a hot-ticket number, according to the two U.S.-based medical mask manufacturers.
According to Matt Conlon, VP of Research and Policy at Cantel Medical (one of the two companies), "... face masks are recommended for use by the general public during pandemic events, yet the government has no supply preparedness plan to fulfill the demand that may come as a result of that recommendation."
Mike Bowen, executive VP of surgical mask manufacturer Prestige Ameritech, commented, "We saw it firsthand during the H1N1 pandemic. U.S. manufacturers were at full capacity within two weeks. Hospitals that normally depend on foreign sources were calling for masks, and we couldn't help them. Government officials have acknowledged very clearly that they couldn't create or support a policy for the use of face masks by the general public because there just isn't enough domestic manufacturing capacity even for healthcare needs."
The manufacturers admit they can make more masks - if they know somebody will buy them - which means they need to convince the public that wearing a facemask is the way to go to prevent the spread of illness.
"We need a bigger effort to include research and clear policy that can help the general public; cough and sneeze etiquette promoting the use of elbow containment, tissues, and handwashing simply isn't enough," claims Conlon.
Research, yes. And what manufacturer wouldn't want scientific evidence as part of its business plan? But if we're having a hard time getting healthcare workers to wash their hands and get vaccinated, what is the likelihood of making face masks the next great fashion statement?
Two surveys released recently, one from APIC and one conducted at AORN, illustrate the need for more effort to reduce the risk of infection in various settings.
C. Diff Prevention Efforts Not Enough
According to a nationwide survey of infection preventionists released from the Association for Professionals in Infection Control and Epidemiology (APIC), 70% of infection preventionists have adopted additional interventions in their healthcare facilities to address C. difficile infection (CDI) since March of 2010, but only 42% have seen a decline; 43 percent have not seen a decline. While CDI rates have climbed to all-time highs in recent years, few facilities (21% of respondents) have added more infection prevention staff to address the problem.
APIC conducted the 2013 CDI Pace of Progress survey in January 2013 to assess activities that have been implemented in U.S. healthcare facilities in the last three years to prevent and control CDI.
"We are encouraged that many institutions have adopted stronger measures to prevent CDI, but as our survey indicates, more needs to be done to reduce the spread of this infection," said Jennie Mayfield, BSN, MPH, CIC, APIC president-elect and clinical epidemiologist at Barnes-Jewish Hospital. "We are concerned that staffing levels are not adequate to address the scope of the problem."
The Pace of Progress survey also noted an inconsistency between cleaning efforts and monitoring. More than nine in 10 respondents (92%) have increased the emphasis on environmental cleaning and equipment decontamination practices since March 2010, but 64% said they rely on observation, versus more accurate and reliable monitoring technologies to assess cleaning effectiveness. Fourteen percent said that nothing was being done to monitor room cleaning.
APIC has released a second, expanded edition of its Implementation Guide on CDI that showcases tools and resources for prevention programs.
OR Nurses Concerned About Infection Rates
A survey at the recent Association of periOperative Registered Nurses (AORN) 60th Annual Congress in San Diego found that 96% of operating room nurses responding cited a concern about surgical site infections (SSIs); 92% noted it's "very important" to develop new and better infection prevention strategies.
In a random sample of 145 operating room nurses responding to the survey conducted at AORN by IrriMax® Corporation, 64% indicate concerns are increasing about SSI in their facility. In addition, 68% think the increase in the incidence of antibiotic-resistant infections, along with the lack of new antibiotics to treat infections (29%) build a case for concern.
While on vacation last week, our hotel served a buffet style breakfast. My husband usually shies away from these buffets because he doesn't trust all the people poking around his food.
But the hotel put a safeguard in place. One of the waiters was stationed so he could see the entire food line. In fact, a teenager dropped a serving spoon on the floor and simply replaced it back by the fruit platter. The waiter quickly removed the contaminated spoon and replaced it - no one was the wiser.
We do procedures every day that can harm patients. Simple ones like IV infusions and complicated ones like surgery. I have seen a nurse drop a syringe on the floor. She was only going to replace the needle before injecting the patient, until I said something to her (politely, of course).
So the "waiter as the safety officer" made me think of what measures do we enact to prevent infections or other harm from occurring?
In many ways the OR safety checklists and the central line insertion checklists are intended to serve this purpose.
Actually, New York State legislature introduced a bill requiring all hospitals to establish and complete a checklist for any procedure done in ICUs.
The goal is to improve health and reduce costs associated with infections. While many hospitals have already adopted this measure, I wonder how making it mandatory will affect care. Tell us how your hospital or ambulatory center uses these types of checklists.
And more interestingly, tell us if you have ever stopped a colleague from continuing with a procedure when there was a break from good technique.
Patients who tested positive for carbapenem-resistant Enterobacteriaceae (CRE) took an average of 387 days following hospital discharge to be clear of the organism, according to a new study published in the March issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).
The study was conducted in the Shaare Zedek Medical Center, a 700-bed university-affiliated general hospital in Jerusalem, Israel. The research team analyzed follow-up cultures from 97 CRE-positive patients who had been discharged from the medical center January 2009-December 2010.
The average time until cultures became negative was 387 days. At three months, 78% of patients remained culture positive; at six months, 65% remained positive; at nine months, 51%, and at one year 39% of patients remained positive, meaning they could potentially become re-infected or transmit the germ to others.
Risk factors for extended carriage included the number of hospitalization days, whether and how often the patient was re-hospitalized, and whether the patient had an active infection as opposed to colonization without signs of active disease.
The authors state, "Patients with multiple hospitalizations or those who were diagnosed with clinical CRE disease should be assumed to have a more extended duration of CRE coverage and should therefore be admitted under conditions of isolation and cohorting until proven to be CRE-negative. These measures will reduce the hospitalization of CRE-positive patients among the general patient population, potentially preventing the spread of CRE."
CRE are extremely difficult-to-treat, multidrug-resistant organisms that are emerging in the U.S. A CRE strain of Klebsiella pneumoniae recently spread through the National Institutes of Health hospital outside Washington, D.C., killing six people. Because of increased reports of these multidrug-resistant germs, the CDC recently alerted clinicians about the need for additional prevention steps to prevent transmission.
Anyone in healthcare is aware of recent initiatives from CMS and CDC to increase the use of medical health records (and use the data) and to decrease infections. And one would image you could use the former to achieve the latter. But a new study from Regenstrief Institute finds that's not being done.
"The Centers for Disease Control and Prevention are encouraging local and state health departments to use health information technologies to improve infectious disease reporting and prevention activities. We found that while hospital-based infection preventionists ... may have access to health information technology, they lack specially designed computer tools needed to sift through the massive amounts of data in electronic medical records," said lead author Brian Dixon, MPA, PhD, Regenstrief Institute investigator and assistant professor in the School of Informatics and Computing at Indiana University-Purdue University Indianapolis.
The study measured the awareness, adoption and use of electronic medical record systems and health information exchange by hospital-based infection preventionists to report and share information. While the majority (70%) of the infection preventionists said they had access to EMR data, just 20% reported being involved in the design of the system; therefore study authors question if the systems offer the right tools and data needed to study infections. Also, just 10% of infection preventionists said their organizations were formally engaged in health information exchange activities.
The study, "Infection Preventionists' Awareness of and Engagement in Health Information Exchange to Improve Public Health Surveillance" was published online on Feb. 18, 2013, in the American Journal of Infection Control. The study was funded by the CDC.
Keep up on infection control issues and take a quiz to test your knowledge on the Infection Control Resource Center.
The Food and Drug Administration along with the CDC recently finalized their report on an outbreak of Salmonella linked to peanut butter - of all things!
The outbreak began in September 2011 and eventually involved 42 people in 20 states both on the East and West coasts.
Salmonellae typically causes fever, diarrhea and abdominal pain. While most people recover completely without any treatment, the very old and the very young are at increased risk for sever illness, dehydration and hospitalization. Not surprisingly, 63% of those afflicted in this case where younger than 10 years old.
This outbreak was traced to a laxity in preventive practices and hygiene standards at the processing plant. The investigators noted poor equipment cleaning, handling raw products with bare hands and lack of handwashing sinks. These practices led to contamination of the peanut butter. The investigation was confirmed by genetic testing that linked the organism in the peanut butter to equipment and material at the plant.
Thankfully, the outbreak was halted. Imagine the difficulty of not being able to send your child to school with a PB&J sandwich.