Background: The phenomena of emerging infectious diseases accelerating once they reach healthcare facilities have been well documented. Outbreaks of MERS-CoV, SARS-CoV, and COVID-19 have led to in-hospital transmission where the initial patient infects healthcare workers, patients, visitors, etc., with infection control policies unable to curtail the spread early on. We refer to this phenomenon as nosocomial amplification. Nosocomial amplification causes an undue burden on a hospital that’s already strained from the pandemic. We aimed to understand which hospital-level parameters impact the community most and vice versa. Methods: We adapted an SEIR compartmental model to have two interconnected units, a community unit and a hospital special care unit, to determine the number of COVID-19 acquisitions in each of them over a hypothetical year. The model was stochastically simulated using Gillespie’s Direct Method for 1000 iterations. A parameter sensitivity analysis assessed the effects each parameter had on the model. The original values of all parameters were allowed to vary +/- 50%. The number of simulation acquisitions was normalized as a percent change from the original model’s mean acquisition. Results: Our analysis found that parameters impacting the community had a disproportionate impact on COVID-19 acquisitions in the hospital as compared to the special care unit, as did the parameters governing the level of asymptomatic transmission. Transmission between healthcare workers facilitated within-hospital transmission even when strict patient-based cohorting and testing were in place. Extensive community-level transmission was also found to readily overwhelm hospital-level infection control at realistic levels of effectiveness and compliance. Conclusion: These findings illustrate that hospitals and the community are tightly linked systems. Hospitals may reintroduce infection into the community that might have contained or mitigated ongoing outbreaks or introduce the disease into a disease-free population; community transmission puts tremendous pressure on infection control. In the future, we can model policies to curb an existing COVID-19 outbreak or subsequent outbreaks to avoid or minimize nosocomial amplification, thus improving the disproportionate burdens on the healthcare system.

Understanding the impact of mpox-related hospitalizations for medical versus infection control indications in New York City Background: New York City (NYC) accounted for 15-20% of new mpox infections at the peak of the 2022-2023 United States outbreak. Globally, 8% of mpox patients required hospitalization. We investigated the proportion of mpox hospitalizations for medical versus infection control indications at two large healthcare systems in the New York metropolitan area. Methods: We included all patients admitted to NYU Langone Health or NYC Health + Hospitals for laboratory-confirmed mpox between May 1, 2022, and April 28, 2023. We analyzed demographic information, reasons for hospitalization, length of stay, number and type of co-infections, healthcare encounters, complications, and treatments received. Results: Sixty-five patients were hospitalized for mpox, with 8 (12%) admitted primarily for infection control isolation (Table 1). Median age was 35 years (IQR=31-40), 69% were cisgender men, and 38% were Black. Those hospitalized primarily for isolation were more likely to reside in a homeless shelter (50% vs. 9%, p < 0 .01) and less likely to have a private residence (25% vs. 81%, p < 0 .01) than those hospitalized for medical indications. Those hospitalized for medical indications were more likely to have HIV (63% vs. 25%, p=0.04), secondary bacterial infections (67% vs. 25%, p=0.02), and to receive antibiotics (82% vs. 25%, p < 0 .01) (Tables 2 and 3). There was no significant difference in median cumulative length of stay per patient (p=0.69) between those hospitalized for medical versus isolation purposes. Most admissions for medical indications were for soft tissue superinfection (40%), severe pharyngitis and/or proctitis (28%) and pain management (20%). There was no significant difference in the proportion of tecovirimat receipt (65% vs. 38%, p=0.14) between those hospitalized for medical versus isolation purposes. Conclusion: Infection control isolation accounted for a significant proportion (12%) of mpox hospitalizations and was associated with a similar median length of stay per patient as hospitalization for medical indications. Our small cohort limits statistical power for comparison between groups. However, our findings argue for increased community-based isolation capacity. This may reduce unnecessary hospitalizations during future outbreaks, particularly amongst unsheltered individuals or those living in congregate settings.

Disclosure: Madeline DiLorenzo: Stocks - Abbvie, Amgen Inc., Becton Dickinson, Biogen Inc., Bristol Myers and Squibb, CVS Health, Davita Inc., Elevance Health, Gilead, Henry Schein, Hologic Inc., Humana Inc., Jazz Pharmaceuticals, Laboratory Corp, Merck and Co., Quest Diagnostics, ResMed Inc., Teladoc Health, Vertex Pharmaceuticals, West Pharmaceuticals

Background: In September 2022, UNC Hospitals was awarded a Regional Emerging Special Pathogens Treatment Center (RESPTC) grant by the U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response (ASPR) to care for up to two patients with viral hemorrhagic fever, or similar pathogen, and up to ten patients with novel respiratory pathogens. Intensive infection prevention efforts and timely multidisciplinary commitment was required to develop the Space, Strategy, Staff, and Stuff needed to care for patients with a special pathogen. Methods: Multiple space needs assessments were undertaken to acquire spaces for the care of patients, simulation training, and a dedicated laboratory. Strategies for developing the response plan required collaboration with hospital executives, nursing leadership, public health leaders, and regional partners. Staff were recruited across various disciplines to join the response team and were provided hands-on skills training which was assessed by post-training surveys. Specialized ‘stuff’ (i.e., PPE, training equipment, and waste management devices) were researched and procured for use by the team. Results: Patient care and dedicated laboratory space was identified within existing infrastructure, and renovation plans were developed to adapt the space for these specialized activities. A waste management plan that benefits the hospital for routine waste and allows for Category A waste management was approved. Fifty-three staff members were recruited from 3 main disciplines (RNs, MDs, Paramedics), and across numerous settings (Medicine Acute Care & ICU, Pediatric ICU & Stepdown, Air Care/Transport, Burn ICU, Surgery Stepdown, Emergency Medicine, Infection Prevention, Infectious Disease) were trained during five 4-hour training sessions, culminating in an exercise involving transporting a rule–out Ebola patient to the hospital’s special pathogens unit. Post-training evaluations demonstrated a very high level of confidence (‘strongly agree’) in staffs’ knowledge about the RESPTC site (92.3%), special pathogens (80.8%), collaboration needed for managing patient care (80.8%), and in their comfort with special PPE donning and doffing (73.1%). Conclusions: Using a systematic approach to develop Space, Strategy, Staff, and Stuff, a large academic hospital readied itself to become a new RESPTC site. Key lessons learned include the importance of a multidisciplinary response team; local, state, and regional coordination for care planning and delivery; and early community partnership development. Logistical infrastructure and waste management challenges continue to require partnership with hospital leadership to optimize workflows and patient care. Holistic decision-making around infrastructure has led to changes that benefit all hospital patients and offer efficiencies to

Disclosure: William Fischer: Consultant - Roche, Merck, Inhalon Biopharma; Speaker for ACGME - IMG. David J Weber: Consultant on vaccines: Pfizer; DSMB chair: GSK; Consultant on disinfection: BD, GAMA, PDI, Germitec

Background: Thorough cleaning and disinfection of high-touch surface areas in hospital inpatient rooms remain vital parts of effective strategies in reducing hospital-acquired infections (HAIs). Currently, Methodist Specialty & Transplant Hospital (MHST) inconsistently utilizes fluorescent marking for terminal cleaning validation. Without quantitative results, it’s difficult to measure the effectiveness of cleaning. To ensure MHST is maintaining a safe and clean environment for patients & staff, MHST implemented a comprehensive cleaning verification program to include adenosine triphosphate (ATP) technology. We aimed to establish the program with baseline readings, and an overall weekly passing score of 95% for all tested inpatient rooms. Methods: To achieve sustained improvement, we needed to monitor, educate, and have periodic performance feedback to individuals and stakeholders. Key stakeholders (IP, EVS, Operations Leadership, Nursing Leadership representative) were identified, and a weekly meeting was established to discuss the planning and implementation of the ATP program. Some key actions included: standardization of brand of luminometer- device to measure ATP for microbial contamination; establishment of 16 high surface touch points to be tested; partnership with IT to create a database & dashboard for ATP results & data analysis; training of ATP device to all personnel who will be utilizing ATP device; establishment of a threshold for a “pass” clean (relative light unit [RLU] less than or equal to 45). Summary of Results: After baseline testing, the average weekly pass score met goal at 95 percent for all tested rooms. The bedside table located on the 2W floor was the location that failed the most (3 instances). Conclusions: Our program implementation project aimed to improve terminal cleaning validation utilizing ATP technology in inpatient rooms, was successfully implemented. Equipped with quantitative results, the MHST team, was able to verify cleaning quickly and efficiently without any confusion, as it may have been with the previous verification method of fluorescent marking. The partnership between Infection Prevention (IP) & Environmental Services (EVS) was crucial in the implementation of this process improvement- from participating in training together to understanding and sharing ATP pass/fail score data.

Background: Candida auris (CA) is an urgent threat per Centers for Disease Control and Prevention with rapidly increasing cases across the US. Patient rooms recontaminate with CA within hours after daily cleaning due to skin shedding, persistence on environmental surfaces and resistance to commonly used disinfectants. Continuous dry hydrogen peroxide (cDHP) is a novel environmental technology augmenting daily room disinfection. cDHP reduces CA organism counts based on environmental cultures. Adenosine triphosphatase (ATPase) testing offers rapid results to monitor surface cleanliness. ATPase Testing Protocol: Upon identification of CA, cDHP was activated in the patient’s room. ATPase surface testing was performed in rooms of CA infected inpatients and nearby control rooms of inpatients without CA and thus no cDHP. Group A surfaces near the patient were nurse call handheld devices and/or bed rail. Group B surfaces were horizontal counter and/or computer keyboard, located >3 feet away from the patient. ATPase testing was to occur within one hour of daily room disinfection for CA patient Day0 (day of cDHP activation), Day1, Day7 and Day14 and controls. Daily room disinfection using quaternary disinfectants was replaced with EPA Class P chemicals upon CA identification. Nursing spot disinfects with Class P ready to use disinfectant wipes in all rooms. Results: Testing occurred among 13 CA and 22 control patients in 5 hospitals. In Table 1, pass rates are displayed by cumulative (Day0+1+7+14) test days for surfaces and patient room groups. Analysis applied Pearson’s Chi-squared test with Yates’ continuity correction. Conclusions: Surfaces further from the patient in rooms of CA patients exposed to cDHP had higher ATPase pass rates than controls. Surfaces close to the patient have a high ATPase failure rate, regardless of CA or cDHP. Strategies are needed to ensure disinfection occurs on high touch surfaces near patients. cDHP may have value in supplementing room disinfection. Contributing failure factors include surfaces missed for disinfection, delays in timely testing and known limitations with ATPase methods.

Background: Surgical site infections (SSIs) are associated with increased morbidity, monetary loss and mortality. The physical aspects of the operation room (OR) including airflow, humidity, pressure, and particulate counts are essential part of SSI prevention. Humidity control is vital to avoid static electricity buildup.Temperature control helps prevent hypothermia. Limiting OR traffic and door opening are essential to prevent airflow disturbance and minimze particles in OR environment. We have recently studied electronic monitoring of OR traffic and the traffic was higher than what was expected. Our aim was to evaluate our real-life measurement of these OR parameters as part of SSI prevention bundle. Methods: This is a prospective study focused on the OR physical environmental factors as part of operative SSI prevention bundle. The study was conducted for 4 weeks at an academic medical center. The study was conducted in two different generations of OR for neurosurgical and ophthalmologic procedures. We performed direct observation of OR traffic as well as environmental parameters (temperature, humidity, pressure, and particulate count) for the entire length of the procedure. We used both directly measured data as well as automated data generated by facilities. Results: The study showed that temperature, humidity, and pressure wer tightly controlled in the OR. This observation was consistent between manual data and automatically generated data. The OR traffic was not easily monitored by the current automatic data and was measured by direct observation. The correlations between particulate count and OR traffic was strongest for 0.3μm (0.7370, and weakest for 1.0μm ( 0.087). The 5.0μm particulate size had a moderate positive correlation of 0.344, Additionally, shorter procedures had less particulate matter in the OR environment. Automated data were only available in the new ORs but could not predict traffic without automated door monitors. But the automated data could easily portray the temperature, humidity and pressure minute by minute. Conclusion: OR traffic increases the particle count particularly the small size. Other physical aspects of the OR environment were tightly controlled. The ability to automatically monitor OR parameters could be extremely helpful for assuring patient safety as well as reviewing OR factors in SSI cases.

Background: Healthcare-acquired infections (HAIs) continue to be a major challenge. In fact, an increased risk of HAIs has been linked to high-touch surfaces contaminated with multidrug-resistant organisms (MDROs), and enhanced environmental disinfection is linked to reduced HAI rates. Recently, more focus has been placed on emerging disinfection technologies, such as UV light-producing portable device that emits light at a wavelength of 222 nm, which has previously demonstrated germicidal capabilities at short contact times. In this study, we aim i) to evaluate the efficacy of a filtered far-UV-C handheld device (FFUHH) to reduce bacterial loads on high-touch surfaces in clinical workrooms in a cancer center, and ii) to isolate, identify and establish a genetic relationship between these environmental clinically significant pathogens and the ones recovered from patients. Methods: Samples were collected weekly on a rotating schedule over a 24-week period from five high-touch items (dictation device, mouse, armchair, desk, and keyboard) in multiple clinical work rooms on hematologic malignancy and stem cell transplant units. Contact plates for colony count and swabs were collected pre- and post-intervention with the FFUHH on standardized adjacent areas respectively for each surface. The swabs were enriched and cultured on selective media to isolate clinically significant pathogens. Whole genome sequencing (WGS) was then performed on environmental pathogens validated by MALDI-TOF as well as clinical samples collected from patients in the same unit around the time of environmental sample collection. Results: A total of 440 plates, 220 pre- and 220 post-interventions, were collected and analyzed. The highest mean colony count pre-treatment was detected from the armchairs and the lowest for the keyboards. The mean reduction of colony forming units (CFUs) ranged between 53% for the keyboard and 83% for the mouse. The reduction was statistically significant across all surfaces with P values < 0.05, except for the keyboard (Figure 1). We isolated many pathogens of the human microbiota identified by MALDI-TOF such as Micrococcus luteus, S. capitis as well as methicillin-resistant S. epidermidis, S. haemolyticus and S. hominis. We also identified several Candida parapsilosis, Pseudomonas stutzeri, one Listeria grayi and one Acinetobacter baumanni. Finally, WSG allowed us to further characterize an environmental multi-drug resistant S. epidermidis ST5 strain associated with patient bacteremia, and ST16 strains detected on surfaces both pre- and post-FFUHH treatment. Conclusion: The FFUHH effectively reduced the microbial burden on high-touch surfaces in clinical workrooms on hematologic malignancy and stem cell units.

Background: Environmental sampling and detection methods for fungi in healthcare settings are not well-established. We previously refined methods for fungal sampling and detection in a controlled laboratory environment and aimed to validate them in a real-world healthcare setting. Methods: We performed a microbiological analysis of air and surfaces in three inpatient units at a tertiary care center. Surface samples were obtained with foam sponges from 3 locations in patient rooms (Patient bedrails, bathroom floor, HVAC export) and 5 locations in units (HVAC exports 3x, clean linen storage, soiled linen storage). Air samples were taken with an active air sampler directly below HVAC exports. Sponges were processed using the stomacher technique. Samples underwent DNA extraction followed by qPCR with FungiQuant primers targeting the 18S rRNA gene. Amplicons from positive samples were sequenced (NextSeq 1000, 300bp PE) and SmartGene databases were used to interpret sequence data. For comparison to culture methods, samples were also plated onto Sabouraud and HardyCHROM Candida + auris medias. Fungal growth underwent DNA extraction, 18S PCR and Sanger sequencing for genus and species identification. Results: A total of 85 samples were obtained, from 15 patient rooms and three units resulting in 61 surface and 24 air samples. Patients in study rooms had a median age of 53, 9 (60%) were male, and no patients had an invasive fungal infection during their hospital encounter. 44 (53%) and 39 (46%) samples were positive for fungi via qPCR and culture, respectively. Of the 44 positive qPCR samples, microbiome analyses identified at least one fungi to the species, genus and family levels in 43 (98%), 28 (64%), 18 (41%) samples, respectively (Table 1). 114 total isolates were identified of which the most common were Mallassezia restricta (30 [26%]), Malassezia globose (29 [25%]), and Pennicillium paradoxum (4 [4%]). 39 genera were identified of which the most common were Mucor (19 [49%]) and Candida (8 [21%]). Of the 39 culture positive samples, 90 total isolates were recovered. The most common species were Paradendryphiella arenariae (19 [21%]), Aspergillus niger (12 [13%]) and Penicillium commune (12 [13%]). Conclusion: These results demonstrate the presence of diverse fungal species in both air and surface samples across inpatient units. Higher sensitivity was noted utilizing qPCR, however, identified genera and species were markedly different between qPCR and culture methods. Larger studies are needed to assess the efficacy of qPCR for fungal detection in the healthcare environment.

Background: The World Health Organization launched ‘Your 5 moments for hand hygiene’ to identify when healthcare workers should perform hand hygiene to reduce healthcare-associated infections (HAIs). Performing hand hygiene correctly is necessary to decrease pathogen transfer, though little research has assessed the effectiveness of all 5 moments. Methods: Registered nurses (n=42) participated in a standardized, one-hour high-fidelity patient care simulation that were recorded via a head-mounted camera. The simulation involved two patients, each requiring four clinical care tasks (e.g., indwelling Foley catheter insertion, stool sample collection). Transmission data was obtained from the simulations using four genetic variants of bacteriophage λ. Before each simulation, variants were applied to unique locations on two manikins: patient A’s wound, patient A’s stool, patient B’s groin, and patient B’s stool. After each simulation, we sampled the patients, nurse, and high-touch environmental surfaces to determined bacteriophage identity of positive samples. For each moment, hand hygiene performance was the total time the nurse practiced hand hygiene across opportunities over the total recommended time (15 seconds per opportunity). Positive samples were categorized as 1) nurse contamination, 2) patient critical site(s) contamination, 3) high touch surface contamination from the same patient, or 4) high touch surface contamination from the other patient. To compare nurse’s performance of each of the 5 moments, we used a Friedman test and then a Wilcoxon test for pairwise comparisons. To assess the relationship between the four types of transmission outcomes and hand hygiene performance of the 5 moments, we performed linear regressions and calculated 95% confidence intervals by bootstrapping the original cases. Results: Performance of moments 1 (Before patient contact: 9.49%), 4 (After patient contact: 13.11%), and 5 (After contact with patient’s surroundings: 13.66%) were significantly higher than moments 2 (Before clean or aseptic task: 2.72%) and 3 (After bodily fluid exposure: 4.22%; p < 0 .05). Moment 2 perfomance, furthermore, was significantly lower than moment 3 (Figure 1). Only moment 2’s performance was significantly related to transmission; specifically, performance was negatively related to critical site contamination (B= -0.03, CI 95%: -0.06 – -0.01); Table 1. Conclusions: Moment 2performance was the lowest of all 5 moments and was the only moment that demonstrated evidence of relationship with pathogen transmission, specifically critical site contamination. Of all the 5 moments, this moment is most directly related to HAIs. Further research should investigate why moment 2 performance is so low.

Background: Proper hand hygiene is the most important practice to reduce the transmission of infections in healthcare settings. Despite this, healthcare institutions continue to struggle to achieve and maintain high rates of hand hygiene compliance among healthcare workers with some studies estimating national healthcare worker hand hygiene compliance to be approximately 50%. Methods: We conducted an anonymous one-time survey of our Lifespan Hospital System employees to evaluate barriers and facilitators to performing hand hygiene as well as interventions to improve hand hygiene compliance. The survey was designed with guidance from the Consolidated Framework for Implementation Research and input from Lifespan infection prevention staff. Result: Over four weeks 985 (6%) Lifespan employees completed the survey. Figure 1 shows the aggregate results of the first 4 survey questions which focused on hand hygiene infrastructure at Lifespan, including availability of sanitizer, staff to manage hand hygiene supplies, and educational materials/reminders. One significant finding was >70% of respondents reported that they either did not know if their unit/department has a person assigned to replace/monitor hand hygiene supplies, or if so, who that person is. We also asked employees to rate how effective different interventions would be at improving hand hygiene compliance. Figure 2 shows of five proposed interventions, three were rated as either “moderately effective” or “very effective” by >50% of respondents. These included displaying hand hygiene instructions, making hand hygiene data available to employees, and displaying materials/reminders promoting hand hygiene. There were also 977 free-text responses regarding “barriers or facilitators to proper hand hygiene”. Major barriers identified were a lack of staff to monitor and refill supplies, slow replacement of hand hygiene products, lack of sanitizer dispensers and sinks, inconsistency of sink location and dispenser placement, lack of hand hygiene reminders/educational materials, time constraints, skin irritation from sanitizer, and an inability to have dispensers in behavioral health units. Survey responses led us to enhance the following: educational materials and reminders in work areas; staff education; leadership involvement in hand hygiene initiatives; routine auditing and feedback; conveniently placed sanitizer dispensers and sinks at the point of care; and making hand hygiene compliance data readily available to staff. Conclusion: This survey identifies important barriers and facilitators to achieving high rates of hand hygiene compliance among healthcare workers and provides the basis for interventions aimed at improving hand hygiene compliance in a large multicenter academic hospital system.

Background: For United States healthcare programs to be fully compliant with Joint Commission National Patient Safety Goal (NPSG) #7, organizations must implement and maintain a hand hygiene (HH) program that follows either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) HH guidelines. Joint Commission standard IC.03.01.01 requires these organizations to provide metrics that evaluate the effectiveness of their program and program goals. Our center utilizes the direct observation method with the use of over 550 Hand Hygiene Observers (HHO) to collect our HH compliance. HHO are trained with a computer-based course that requires passing a post-education test. During fiscal year 2023 (FY23), Infection Control surveillance noted an increase in hospital-acquired infections (HAI) Clostridioides difficile infections (CDI), catheter-associated urinary tract infections (CAUTI), and multidrug-resistant organisms (MDRO) on our hematologic malignancy units (HM), which initiated an Infection Control (IC) investigation into possible causes. Increased rounding by our Infection Preventionist (IP) observed that HH compliance was much lower than unit HHO reported rates. Inquiries into this data discrepancy revealed barriers to accurate reporting, including HHO having low confidence in identifying and reporting non-compliant behavior. To that end, we conducted mandatory re-training of all HM HHO with the primary goal of improving the quality of our HH compliance data and addressing barriers with non-compliance reporting. Our secondary goal was to identify areas of improvement in institutional HH rates. Methods: In August 2023, 252 HM staff and HHO received detailed, in-person retraining by the HM IP. Training included reviewing the discrepancy in HHO and IP observations, potential causes of discrepancy, most commonly missed HH opportunities, examples of correct and incorrect HH practices, and addressing staff questions. Results: Following mandatory re-training of HM HHO, HH compliance for our HM units from September 2023 – December 2023 ranged from 89% to 98%, with increased reporting of non-compliance (Figure 1). A detailed dashboard was created that focused on HM HH compliance, containing the HHO observations and non-compliant reports. Conclusion: A one-time in-person retraining of HM HHO by our IP has led to an improvement in data quality, which is imperative for future quality improvement initiatives. Improving our HH data quality allowed IC to identify and provide actionable feedback to HM leaders, create targeted interventions to improve HAI rates, and improve patient safety. Future goals include retaining of all HHO and a HH campaign to ensure patient safety across our institution.

Background: Alberta Health Services (AHS) measures hand hygiene compliance through direct observations performed by trained site-based reviewers (SBRs) and facilitated by the Infection Prevention and Control (IPC) program. Within AHS there are >100 acute care facilities, ranging in bed size from four beds to more than 1,000, with catchment populations ranging from one million. A time-in-motion study using trained AHS IPC staff was proposed to validate the completeness and accuracy of data being collected by the SBRs. Methods: The AHS IPC staff performed direct observations at pre-selected facilities across all five zones and four different unit types (emergency, medical, surgical, and intensive care) for four 30-minute periods during weekdays between June and September 2023. An iPad app was used to capture results from all four moments of hand hygiene. The reviewer indicated the day and time of the review and captured as many representative hand hygiene moments and healthcare providers as possible. The distributions of the four moments of hand hygiene, healthcare provider group and overall compliance were compared at the unit type and facility level (tertiary, large urban, regional, pediatric, and small sites) between this time-in-motion study and SBR data collected June-September 2023. Results: The study collected 175 reviews and 4,683 observations from 14 facilities and 48 units. Between June and September 2023, SBRs collected 2,625 reviews and 61,506 observations from these same facility and unit types. Across all facility and unit types, the distribution of the four moments was similar between the study and SBRs. Similar proportions of healthcare providers were also observed. However, the overall hand hygiene compliance collected in the study was approximately 10% lower across all unit types as compared to that collected by the SBRs (study: 63%-84%; SBRs: 75%-92%). Conclusions: In public health surveillance, completeness and accuracy are two characteristics of high-quality data. A time-in-motion study identified that the hand hygiene observations collected by SBRs were complete, as the range of healthcare providers observed, and the distribution of their moments, mirrored that collected in the study. However, the SBRs reported higher compliance than the study participants and the true hand hygiene compliance is likely lower than what is currently being reported. Since this difference was seen consistently across all unit and facility types, trending data over time should still identify areas in need of improvement and may help to suggest causes of the over-reporting.

Background: Hand hygiene (HH) is fundamental to preventing the transmission of pathogens between patients. Unfortunately, adherence to HH is suboptimal and monitoring adherence is challenging. Electronic HH monitoring systems (EHHMS) are emerging potential solutions to increase the number of HH observations and eliminate the potential for observation bias. This aim of this study is to assess the impact of improved HH adherence after the introduction of an EHHMS on the rates of healthcare facility-onset multidrug-resistant organisms and Clostridioides difficile (HO-MDRO). Methods: We performed a retrospective, quasi-experimental study to evaluate the impact of HH on HO-MDROs across 4 acute care facilities (59 hospital units, 14 of which were ICUs) from January 2021 - September 2022 after implementing an EHHMS in a large academic healthcare system. Clinical cultures from all sources were included; routine surveillance cultures were not collected during this period. HO determination was made using National Healthcare Safety Network (NHSN) definitions. The association between monthly unit-level HH adherence (%) and HO-MDRO rate per 1000 patient-days was assessed using mixed-effects Poisson regression using rate ratios (RR), which accounts for unobserved heterogeneity between units while controlling for number of tests ordered per month per hospital unit. HH adherence was stratified in quartiles (Q1: 24-43%, Q2: 43-51%, Q3: 52-61%, Q4: 61-84%). Results: During the study period, there were 23 million HH opportunities and 1875 MDROs in 772,930 patient-days. HH adherence increased from 41% January 2021 to 57% September 2022. ESBL, MSSA, and CDIFF accounted for most MDROs (Figure 1). The mean monthly HH adherence rate was 52% per unit, with a median of 1.66 (IQR: 0-3.5) MDROs/1000 patient-days. Mixed-effects Poisson regression suggested no significant overall relationship between HH adherence and MDRO rate (Figure 2). A close to null association was observed when comparing quartile two to quartile one (RR: 0.97, 95% CI: 0.82, 1.15), quartile three to quartile one (RR: 0.96, 95% CI: 0.79, 1.17), and quartile four to quartile one (RR: 1.05, 95% CI: 0.86, 1.28). Results were similar across hospitals (Figure 3). Conclusions: Although implementing an EHHMS led to an improvement in HH adherence, we were not able to demonstrate a resultant decrease in HO-MDROs. Potential explanations include the relatively rare outcomes of interest, unrecognized confounders, and the complex interaction between HH and HO-MDROs, since poor HH adherence on a unit may lead to increased attention from infection prevention and therefore increased focus on other MDRO prevention measures.

Background: Significant focus has been placed on healthcare worker hand hygiene, but little attention is has been assigned to the role of patient hand hygiene (HH) in reducing hospital acquired infections. Therefore, in this quality improvement study, we examined the impact of providing patients with hand hygiene products around mealtime on increasing patient HH adherence and on reducing acquisition of nosocomial antibiotic resistant organisms. Methods: Patients on two inpatient leukemia units at a tertiary oncologic center were provided with a single use pre-packaged alcohol wipe on their meal trays prior to every meal (three times daily). Additionally, an information card explaining to patients how and when to use the alcohol wipe was provided on the meal trays three times a week. Both the wipe and instructions were designed with input from patient representatives at the hospital. Two oncologic control units were selected where no specific intervention for patient hand hygiene was conducted. Patient hand hygiene adherence on the control and intervention units were measured through once monthly patient interviews conducted after meals where patients were asked to recall whether they washed their hands prior to eating (using any product). Vancomycin Resistant Enterococcus (VRE) incidence was compared on the intervention and control units during the 7 months prior and 7 months following initiating the intervention. Results: During the seven-month intervention period, more than 15 000 wipes were dispensed to patients on the intervention units. Through interview, 91% of 87 patients on the intervention units reported cleaning their hands before eating a meal using any cleaning product compared to 72% of 68 patients on the control units (X2 = 9.32, p = 0.002). Furthermore, on the intervention units, 30 (38%) patients endorsed using the provided hand hygiene product. During intervention period, the combined incidence rate of VRE the intervention units was 1.85 case/1000 patient-days compared to 5.35 cases/1000 patient-days during the 7 months prior to intervention (t = 3.24, p=0.007)(Figure 1). Conclusions: This patient-centered quality improvement intervention increased patient hand hygiene and potentially reduced VRE incidence in a vulnerable oncologic population. This practical intervention that incorporated the patient perspective provided accessible hand hygiene products with simple instruction and reminders required minimal participation of unit staff. Further application of the intervention in non-oncologic populations is needed to further establish the relationship between patient hand hygiene and the acquisition of nosocomial infections.

Background: This research, part of a doctoral study, aims to examine the impact of managerial factors on the implementation of Infection Prevention and Control (IPC) measures in Israeli hospitals. The study focuses on identifying key facilitators and barriers from the perspectives of physician and nurse managers, with an emphasis on understanding the integration of managerial strategies and theoretical frameworks in IPC implementation. Objective: The objective is to explore specific managerial factors, both facilitators and barriers, influencing the effective implementation of IPC measures. The research investigates these influences through the lens of physicians and nurses managing IPC units in public hospital settings. Methodology: A mixed-method approach was adopted, involving in-depth interviews with ten IPC-Unit managers (five physicians and five nurses) and a comprehensive questionnaire distributed among IPC-Unit heads. The study’s demographic and professional profiles of participants are detailed in Table 1. The data collection process encompassed an Activity Assessment Questionnaire (2-AAQ) and an Organizational Change Implementation Questionnaire (3-OrgChangeImplQ), with the distribution of responses categorized by implementation stages and sociological theories (Tables 2-4). Result: Managerial autonomy emerged as a significant catalyst for IPC implementation, with supportive leadership and resource allocation being critical. Differences in approaches between physician and nurse managers were observed, reflecting diverse strategies in planning, execution, monitoring, and maintenance of IPC measures. The findings also revealed a natural alignment with sociological theories, particularly Normalization Process Theory (NPT) and Diffusion of Innovations (DOI), despite a lack of formal training in these areas. Conclusions: The study underscores the multifaceted nature of IPC implementation, highlighting the importance of managerial autonomy, supportive leadership, and a deep understanding of organizational culture. The inherent alignment of IPC strategies with NPT and DOI theories suggests the potential of these frameworks in guiding IPC implementation. The research advocates for the integration of these theoretical perspectives into formal training programs to enhance the effectiveness of IPC measures in healthcare settings.

Background: Presenteeism when ill in healthcare personnel (HCP) can contribute to the spread of respiratory illness among HCP and patients. However, during the COVID-19 pandemic and now, there are substantial challenges preventing HCP from staying home when ill. We examined these challenges using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Method: As part of a larger anonymous electronic survey between 3/11/2022 and 4/12/2022 at an academic tertiary referral center, in inpatient and ambulatory settings where respondents were asked to describe factors impacting presenteeism when ill, we analyzed free-text responses using the SEIPS categories of tasks, tools/technology, person, organization, and physical environment. Result: 522 comments were received in response to the open-ended survey question asking individuals to describe any factors that would assist them in remaining home and/or help them get tested for COVID-19 when they have symptoms of a respiratory illness; 21 were excluded due to absent or incomplete response. Of the remaining responses (N = 501, Figure 1), 82% were associated with a single SEIPS component such as organization (N = 409), while other responses discussed factors that involved two SEIPS components, in no particular order (N = 92). A majority of the responses (N = 324, 55%) reported organizational barriers, frequently citing a strict sick call-in policy as well as a lack of protected time-off for COVID-19 testing or related absences. The next two most commonly identified components were physical environment (N= 88, 15%) and tasks (N = 72, 12%), mentioning barriers such as far distances to testing centers and prolonged waiting periods for testing Results: The person and tools/technology components were less commonly identified, with a frequency of 9% each. Conclusion: A number of systems level factors were identified that may impact the ability of HCP to stay home when ill. Interventions to help overcome HCP perceived barriers to staying home when experiencing respiratory symptoms should focus on the policies and practices within an organization. Communication from leadership should support staying home with respiratory symptoms by creating plans for coverage and back up consistently across all employee types in direct care.

Background: The 2022 WHO global survey on infection prevention and control (IPC) exposes significant gaps in IPC in the WHO Southeast Asia region. A better understanding of IPC vulnerabilities will inform improvement initiatives. We describe an evaluation of IPC practices known to prevent and contain carbapenem-resistant organisms (CROs) at hospitals participating in the United States Centers for Disease Control Global Action in Healthcare Network –Antimicrobial Resistance in India. Prior hospital evaluations suggest resistance to carbapenems among gram-negative isolates is up to 45%. Methods: We conducted a mixed methods evaluation including cross-sectional surveys, semi-structured interviews, and site observations at five hospitals (one government, two private tertiary care, and two private teaching) located in three cities. The number of hospital beds ranged from 362 to 2,011. Hospital and IPC program characteristics, and CRO prevention and containment activities were examined virtually. Site observations focused on hand hygiene, environmental cleaning, personal protective equipment (PPE), CRO containment practices and use of water for patient care. Results: All sites had IPC programs with established policies and qualified IPC staff. The IPC nurse-to-bed ratio ranged from 1:73 to 1:432 (mean, 1:209). Due to the integral role of microbiology staff in IPC at these hospitals, the two departments had strong communication channels associated with CRO identification. Screening for CRO colonization, if done, targeted patients from outside hospitals. Three of the five hospitals routinely implemented contact precautions for patients with identified CROs, displayed isolation signage at the bedside, and provided adequate PPE at point-of-use; however, all sites reported barriers to effective isolation and/or cohorting patients with CROs. Timely communication of CROs to clinical staff varied and no sites effectively relayed CRO status upon patient discharge to another facility. IPC teams identified gaps in environmental cleaning procedures and practices related to medical devices and equipment. All sites used alternatives to tap water for clinical care and sink etiquette was evident. Each IPC team performed audits of patient isolation and hand hygiene practices. Despite the considerable proportion of IPC resources dedicated to daily education and feedback in clinical areas, the IPC teams reported that improvement was often difficult to achieve. Conclusion: Given the high burden of CROs and limited IPC resources, detailed knowledge of IPC opportunities for improvement will help hospitals target novel interventions for CRO prevention and containment. Further investigation of colonization rates and effective performance improvement methods in these settings is needed.

Disclosure: Patricia Simner: Research Contracts: BD Diagnostics, OpGen Inc., Qiagen Sciences Inc, T2 Diagnostics, Accelerate Diagnostics; Research Collaborators:Ares Genetics, CosmosID, IDbyDNA, Illumina; Consulting: OpGen Inc., BD Diagnostics, Shionogi Inc., GeneCapture, Qiagen Sciences Inc, Entasis, Day Zero Diagnostics, Next Gen Diagnostics

Background: Healthcare-associated infections (HAI) substantially increase hospital costs and lead to poor patient outcomes, particularly when caused by multidrug-resistant organisms (MDRO). To decrease MDRO transmission, isolation of colonized or infected patients in single rooms is recommended. However, single-patient isolation rooms are expensive to build and often unavailable in resource-limited hospitals. In 2023, an intensive care unit (ICU) at a large Brazilian tertiary hospital relocated from a space with an open floor plan to a newly built location with single-patient rooms. We evaluated the impact of this transition on acquisition of carbapenem-resistant Enterobacterales (CRE) colonization, HAI, and compliance with Hand Hygiene (HH) and Contact Precaution (CP) activities. Methods: We compared rates of CRE colonization acquisition, CRE colonization pressure, HAI, and compliance with HH and CP between pre- (March 1, 2022 – Feb 28, 2023) and post-implementation of single-rooms (March 1, 2023 - October 31, 2023) in a 12-bed surgical ICU. All patients were screened for CRE colonization on admission to the unit and weekly until discharge using rectal swab cultures. Colonization pressure was defined as the ratio of CRE-positive patient-days (PDs) to the total number of PDs. Rates of central-line associated blood-stream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were monitored. HH and CP compliance were monitored weekly by infection prevention staff outside of the unit. Poisson regression and multiple linear regression were used to compare rates between pre- and post-implementation periods. Results: Healthcare acquisition of CRE colonization remainedstable between pre- and post-implementation (incidence rate ratio: 0.88 (95%CI, 0.73-1.05; P=0.16) despite an increase in CRE colonization pressure of 8.6% over baseline (from 7.84% pre- to 16.39% post-implementation (95% confidence interval [CI], 4.13-12.96%; P=.001)). The latter was driven by reduced turnover of CRE-colonized patients in the post-implementation period (mean patient-day reduced by 10.33; 95%CI, 3.06-17.61; P=0.006). Incidence of HAIs also remained stable (global incidence 3.12 vs 3.30, pre- and post-intervention, respectively; P=0.2). HH compliance was high prior to the transition (95.7%) and increased slightly but not significantly post-intervention (97.5%; P=0.3). CP compliance improved by 9.83%, especially in gown and glove changes after each patient interaction, from 90.62% pre- to 100% post-implementation (95%CI, 1.52-17.22; P=.02). Conclusion The move to an ICU with exclusively single-patient rooms was associated with increase in CP compliance. This could help explain why HAI incidence and healthcare acquisition of CRE colonization remained stable despite a significant increase in CRE colonization pressure.

Disclosure: Matias Salomao: Speaker - Cepheid

Background: Infection prevention and control assessments in healthcare settings serve as a primary resource for obtaining data and providing recommendations based on safety, compliance, and quality assurance guidelines. In Puerto Rico (PR), surgical site infections are underreported in the Epi Info platform used by the Puerto Rico Department of Health (PRDOH), mainly due to the complexity of their identification. By focusing on evaluating Operating Rooms/Sterile Processing and Distribution (OR/SPD) units in acute care facilities (ACFs), our goal is to generate new data within the Healthcare-Associated Infection/Antibiotic Resistance (HAI/AR) Program, specifically related to patient management throughout preoperative, intraoperative, and postoperative phases, as well as reprocessing practices. Methods: Nineteen evaluations of ACFs' OR/SPDs were conducted from May through December 2023. Direct observations, file reviews, and personnel assessments were performed using an infection control assessment and response (ICAR) tool developed collaboratively by a team from an acute facility in PR and the HAI/AR Program staff. This ICAR Tool was customized based on guidelines from the certified Board for Sterile Processing and Distribution (CBSPD), the Association of periOperative Registered Nurses (AORN), and the Association for the Advancement of Medical Instrumentation (AAMI), among other regulatory agencies. The Division of Health Quality Promotion (DHQP) reviewed and approved the tool for use in these evaluations. Results: Key findings indicate that 32% of Sterile Processing Department (SPD) units restrict access to dedicated personnel with available manufacturer’s instructions, yet only 36% of SPD personnel are certified in CBSPD and packaging practices. Only 10% of facilities had a water treatment system for sterilization and Immediate Use Steam Sterilization (IUSS) policies. Notably, 84% of endoscopy areas require additional equipment for cultivating endoscopes, and no facility possessed a borescope for visually inspecting endoscope lumens. Tray inspection occurred in 21%, and only 31% of staff knew the Spaulding Classification and Class V Indicators. Conclusion: These data underscore the necessity of evaluating OR/SPD units in ACFs to provide updated recommendations and mitigate the incidence of surgical site infections (SSI). They offer insight into the structural and functional status of OR/SPD units in Puerto Rico, aligning reporting with OR/SPD practices to enhance patient care and minimize infection risks.

Background: Current epidemiological methods have limitations in identifying transmission of bacteria causing healthcare-associated infections (HAIs). Recent whole genome sequencing (WGS) studies found that genetically related strains can cause HAIs without meeting standard epidemiologic definitions, but these results could not provide data in a timely fashion needed for intervention. Given recent advances in Oxford Nanopore Technologies (ONT) sequencing, we sought to establish a validated ONT pipeline capable of providing accurate WGS-based comparisons of clinical pathogens within a short time frame that would allow for infection control interventions. Method: Using electronic medical record data, we identified potential healthcare acquisition of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and carbapenem-resistant gram-negative rods. Bacterial genomic DNA was directly extracted from clinical microbiology lab plates. Sequencing was conducted with the ONT MinION sequencer and R10.4.1 flow cell. MINTyper for single nucleotide polymorphism (SNP) calling and Ridom SeqSphere+ for core genome MLST were used to determine genetic relatedness. The main outcome was time from pathogen identification to completed genetic analysis. Result: The weekly workflow, from genomic DNA extraction to complete data analysis, averaged 2.6 days with a standard deviation of 1.3 days. (range: 1 to 6 days). Starting in August 2023, we have sequenced a total of 177 bacterial isolates from 156 unique patients. Isolates came from blood (38%), tissue/wound/body fluid (24%), urinary tract (20%), respiratory tract (16%), and rectal swab (2%). To date, six genetically related clusters have been identified. Three clusters involved ST117 vancomycin-resistant Enterococcus faecium (VREfm), comprising a total of 13 unique patients distributed as 2, 3, and 8 patients in each group, with pairwise SNP differences of 20, 11, and 14. Patients within the same clusters showed epidemiological links through overlapping admissions and temporally shared ICU stays. Additionally, another cluster consisted of five genetically related ST633 Pseudomonas aeruginosa isolates, with a pairwise SNP difference of 57.5. Each patient in this cluster had potential epidemiological links through overlapping admission times, despite the absence of identified shared spaces. The last two clusters involved Klebsiella pneumoniae and Escherichia coli (two cases each), with pairwise SNP differences of 18 and 9, respectively. In both cases, each patient showed potential epidemiological links through overlapping admission times. Conclusion: Our stand-alone ONT pipeline was able to rapidly and accurately detect genetically related AMR pathogens, aligning closely with epidemiological data. Our approach has the potential to assist in the efficient detection and deployment of preventative measures against healthcare-associated infection transmission.