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Background: Rates of ventilator-associated events (VAEs), including infection-related ventilator-associated complications (IVACs) and probable ventilator-associated pneumonia (PVAPs) have increased nationwide since the onset of the COVID-19 pandemic. In December 2021, our health system adopted a new electronic medical record (EMR), which changed the way surveillance for VAEs is performed. We reviewed surveillance criteria, COVID-19 status, and culturing practices in attempts to understand why VAE rates continue to be elevated. Methods: We collected data on VAE type, culture data, COVID-19 status, and surveillance criteria for all patients meeting NHSN definitions for VAE from 2018 through November 2022. For all patients in 2022 (post-EMR transition), 2 physicians (A.D. and M.D.) manually reviewed documented ventilator settings from flow sheets to validate the automated EMR data, and they evaluated culture data for appropriateness. Cultures were defined as appropriate unless they were included in “pancultures” for leukocytosis without concern for pneumonia documented. Rates were compared using an interrupted time series (ITS) analysis before and after the onset of the COVID-19 pandemic and the EMR transition. Patient level data were compared across periods using the χ2 test. All analyses were performed using SAS version 9.4 software. Results: COVID-19 has been implicated in the increasing number of VAEs since the pandemic began: 6% of patients in 2020, 18% in 2021, and 23% in 2022 (P < .001). The percentage of patients meeting criteria for VAE by positive end-expiratory pressure (PEEP) decreased from 2018 to 2022 (92%, 95%, 93%, 85%, 85%, respectively; P = .0004). Patients meeting criteria for VAE by fraction of inspired oxygen (FiO2) increased from 2018 to 2022 (9%, 6%, 11%, 17%, 19%, respectively; P = .0002). Manual review of 2022 data indicated opportunities for test stewardship in 8 of 65 patients with cultures (12%). ITS analysis revealed that IVAC+ rates were climbing prior to the onset of the COVID-19 pandemic (Fig. 1). We observed a marked increase in rates with the implementation of our new EMR and the changes to our surveillance process (0.32 cases per 100 ventilator days). Manual review of records from 2022 revealed 5 patients in which documentation of ventilator settings to meet VAE diagnosis could not be retrieved from flow sheets. Conclusions: COVID-19 continues to affect VAE despite vaccine availability and may partially account for elevated rates nationwide. However, changes in EMR-automated VAE surveillance may also affect rates. Our findings suggest that automated surveillance captures transient or spurious changes in ventilator machine settings that do not accurately represent clinical status. These data may contribute to spurious increases in VAE. More studies are needed to better understand the impact of both COVID-19 and automated surveillance on VAE.
We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs).
Retrospective observational study.
Tertiary-care, academic medical center.
Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded.
Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service.
In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04).
Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.
The use of an electronic hand hygiene monitoring system (EHHMS) decreased due to the coronavirus disease 2019 (COVID-19) pandemic. We analyzed dispenser use, hand hygiene (HH) badge use, and HH compliance to determine the effect of COVID-19 on EHHMS use and HH compliance. HH product shortages and other pandemic-induced challenges influenced EHHMS use.
Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.
Disclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.
Background: Quantification of the magnitude of CRE both within a facility and regionally poses a challenge to healthcare institutions. Periodic point-prevalence surveys are recommended by the CDC CRE tool kit as a facility-level prevention strategy. A 2016 point-prevalence survey of 2 high-risk units at a tertiary-care center in the United States for CRE colonization found that all patients surveyed were negative for CRE. The infection prevention (IP) team repeated the study in 2019 to reassess the prevalence of CRE in the healthcare facility. Methods: A point-prevalence survey was performed in November 2019 on the same 2 high-risk units surveyed in 2016. A perirectal flocked swab was collected from all patients unless a patient refused and/or a contraindication to rectal swab was present. Swabs were inoculated onto HardyChrom TM CRE agar for incubation in ambient air at 35°C for 24 hours. Organism identification was performed using MALDI-TOF mass spectrometry on a MBT Smart by Bruker. Results: None of the patients on either high-risk unit was known to be colonized or infected with CRE at the time of the point-prevalence survey. Of 41 perirectal swabs collected, 4 (9.8%) were positive for CRE. None (0 of 20) were surgical ICU patients and 4 of 21 (19%) were medical ICU patients. All positive swabs revealed different organisms identified as follows: Escherichia coli, Enterobacter cloacae, Enterobacter kobai, and Enterobacter aerogenes. All 4 positive patients had had recent contact with multiple acute-care hospitals. Also, 2 had been transferred for liver transplant evaluation. None of these patients had received a carbapenem during their admission to the facility. Conclusion: CRE are increasingly identified in healthcare centers in the United States. Centers previously classified as low prevalence will need to maintain preventive strategies to limit transmission risks as colonized patients arrive in the facility for care. Adoption of a robust horizontal infection prevention program may be an effective strategy to avoid the spread of CRE.
Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Background: Central-line–associated blood stream infections (CLABSIs) are linked with significant morbidity and mortality. A NHSN laboratory-confirmed bloodstream infection (LCBSI) has specific criteria to ascribe an infection to the central line or not. The criteria used to associate the pathogen to another site are restrictive. This objective to better classify CLABSIs using enhanced criteria to gain a comprehensive understanding of the error so that appropriate reduction efforts are utilized. Methods: We conducted a retrospective review of medical records with NHSN-identified CLABSI from July 2017 to December 2018 at 2 geographically proximate hospitals. Trained infectious diseases personnel from tertiary-care academic medical centers, the University of Virginia Health System, a 600-bed medical center in Charlottesville, Virginia, and Virginia Commonwealth University Health System with 865 beds in Richmond, Virginia, reviewed charts. We defined “overcaptured” or O-CLABSI into different categories: O-CLABSI-1 is bacteremia attributable to a primary infectious source; O-CLABSI-2 is bacteremia attributable to neutropenia with gastrointestinal translocation not meeting mucosal barrier injury criteria; O-CLABSI-3 is a positive blood culture attributable to a contaminant; and O-CLABSI-4 is a patient injecting line, though not officially documented. Descriptive analyses were performed using the χ2 and the Fisher exact tests. Results: We found a large number of O-CLABSIs on chart review (79 of 192, 41%). Overall, 56 of 192 (29%) LCBSIs were attributable to a primary infectious source not meeting NHSN definition. O-CLABSI proportions between the 2 hospitals were statistically different; hospital A identified 34 of 59 (58%) of their NHSN-identified CLABSIs as O-CLABSIs, and hospital B identified a 45 of 133 (34%) as O-CLABSIs (P = .0020) (Table 1). When comparing O-CLABSI types, hospital B had a higher percentage of O-CLABSI-1 compared to hospital B: 76% versus 64%. Hospital A had a higher proportion of O-CLABSI-2: 21 versus 7%. Hospitals A and B had similar proportion of O-CLABSI-3: 15% versus 18%. These values were all statistically significant (P < .0001). Discussions: The results of these 2 geographically proximate systems indicate that O-CLABSIs are common. Attribution can vary significantly between institutions, likely depending on differences in incidence of true CLABSI, patient populations, protocols, and protocol compliance. These findings have implications for interfacility comparisons of publicly reported data. Most importantly, erroneous attribution can result in missed opportunity to direct patient safety efforts to the root cause of the bacteremia and could lead to inappropriate treatment.
Disclosures: Michelle Doll, Research Grant from Molnlycke Healthcare
To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.
Interrupted time series.
The study was conducted in an 865-bed academic medical center.
Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).
Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).
Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.
The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
Interest in electronic hand hygiene monitoring systems (EHHMSs) is now widespread throughout the infection control community. We tested 2 types of EHHMS for accuracy. The type B EHHMS captured more HH events with superior accuracy. Hospitals considering an EHHMS should assess the technology’s ability to accurately capture HH performance in the clinical workflow.
We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.
We investigated the impact of discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus infected or colonized patients on central-line associated bloodstream infection rates at an academic children’s hospital. Discontinuation of contact precautions with a bundled horizontal infection prevention platform resulted in no adverse impact on CLABSI rates.
To investigate the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI). DESIGN. Single-center, quasi-experimental study conducted between 2011 and 2016.
We employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.
The rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.
The discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.