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Background:Candida auris is an emerging pathogen that exhibits broad antimicrobial resistance and causes highly morbid infections. Prolonged survival on surfaces has been demonstrated, and standard disinfectants may not achieve adequate disinfection. Persistent patient colonization and constant environmental recontamination poses an infection risk that may be mitigated by no touch disinfection systems. We evaluated the efficacy of continuous dry hydrogen peroxide (DHP) exposure on C. auris environmental contamination. Methods: The study was conducted in a large tertiary-care center where multiple patients were identified as either infected or colonized with C. auris. DHP-emitting systems were installed in the ventilation systems dedicated to the adult burn intensive care and children’s cardiac intensive care units. Composite surface samples were collected in a sample of patient rooms and shared clinical workspaces among units with current C. auris patients, before and after installation of the DHP system, and from areas with and without exposure to DHP. The samples included “high touch” surfaces near the patient, the general area of the patient room, shared medical equipment for the unit, shared staff work areas, and equipment dedicated to individual staff members (Table 1). Presence of C. auris was determined by polymerase chain reaction (PCR). Association between DHP exposure and C. auris contamination was determined using the Fisher exact test. Results: In the presence of C. auris patients, 5 baseline samples per unit were taken before DHP was installed, and then 5 samples per unit were taken on days 7, 14, and 28 after installation. Prior to initiation of DHP, 7 (70%) of 10 samples were PCR positive for C. auris. After DHP installation, a statistically significant decrease to 5 (16.7%) of 30 samples (P <.05) was observed. In total, 20 samples (5 before installation and 15 after installation) were collected from units without DHP on the same days. At baseline, 2 (40%) of 5 samples were PCR positive for C. auris. During subsequent periods, 4 (27%) 15 samples were positive (P = .66). No adverse effects were reported by patients, visitors, or personnel in association with the operation of the DHP systems. Conclusions: These findings suggest that DHP is effective in reducing surface C. auris contamination in a variety of patient and healthcare worker surfaces.
This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the “SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates,” which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the “knowing-doing” gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the “Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals” published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.
Background: Efficient monitoring of devices to ensure timely removal is an ongoing challenge. There is a need for data visualization products that can aggregate disparate data streams to support device reviews, increase consistency across changes in caregiver teams, and synergize with people and operational processes within and across regional acute-care facilities. Methods: A data display application was developed to provide data from nearly any source in a consistent visual representation that could be used in real time. The infection prevention (IP) overlay combined data related to urinary catheters, central vascular catheters, and femoral vascular catheters from the electronic health record system. Clinical and data experts collaborated to develop data definitions, inclusion criteria, and report components. The application display indicated the current catheter or device status of each patient facility-wide, organized by service unit (Fig. 1). Additional patient information could be accessed from within the application, and a comment feature allowed caregivers to communicate directly through the tool (Fig. 2). Results: Pilot implementation began February 2021, and the NATE IP application was live for all users (unit and facility leaders, providers, infection preventionists, etc) as of July 2021. The tool is currently available for use at 171 acute-care hospitals within the HCA healthcare system, and it accommodated 3 different electronic medical record systems. Usage peaked in August 2021, with an average of 1,700 views per day. Daily utilization maximum ranges from 1,100 to 1,500 views per day, with an average of ~1,300 views per day. The tool is used during daily patient safety rounds, including weekends and holidays. User feedback was overwhelmingly positive, with users reporting an increase in communication, streamlined documentation, improved tracking of reasons to retain, and increased accountability for daily updates. During the proof-of-concept implementation, zero bugs were identified and several feature enhancements were implemented, including addition of port status and device-day reporting counts. Planned enhancements include mupirocin and chlorhexidine bathing use, isolation precaution use, and blood cultures ordered >3 days after admission. Conclusions: The NATE IP tool brings together data related devices into a single view for use by direct caregivers and all levels of leadership. Development of this or similar tools to consolidate various data streams into a central tool facilitates improved communication and consistency between caregiver teams. It also drives operational efficiencies and improves safety. Expansion to incorporate notifications related to potential issue will expand the proactive utility of this tool.
Background: The approval of the first SARS-COV-2 vaccines for COVID-19 were accompanied by unprecedented efforts to provide vaccination to healthcare workers and first responders. More information about vaccine uptake in this group is needed to better refine and target educational messaging. Methods: HCA Healthcare used federal guidance and internal experience to create a systemwide mass vaccination strategy. A closed point-of-dispensing (POD) model was developed and implemented. The previously developed enterprise-wide emergency operations strategy was adapted and implemented, which allowed for rapid development of communications and operational processes. A tiering strategy based on recommendations from the National Academies was used in conjunction with human resources data to determine vaccine eligibility for the first phase of vaccination. A comprehensive data and reporting strategy was built to connect human resources and vaccine consent data for tracking vaccination rates across the system. Results: Vaccination of employed and affiliated colleagues began December 15, 2020, and was made available based on state-level release of tiers. Within the first 6 weeks, in total, 203,544 individuals were eligible for vaccine based on these criteria. Of these, 181,282 (89.1%) consented to and received vaccine, 19,788 (9.7%) declined, and 2,474 (1.2%) indicated that they had already been vaccinated. Of those eligible, the highest acceptance of vaccine was among the job codes of specialists and professionals (n = 7,914 total, 100% consent), providers (n = 23,335, 99.6%,), and physicians (n = 3,218, 98.4%). Vaccine was most likely to be declined among job codes of clerical and other administrative (n = 12,889 total, 80.1% consent), clinical specialists and professionals (n = 22,853, 81.0%,) and aides, orderlies and technicians (n = 17,803, 82.6%,). Registered nurses made up the largest eligible population (n = 56,793), and 89.5% of those eligible consented to receive vaccination. Average age among those who consented was slightly older (48.3 years) than those that declined (44.7 years), as was length of employment tenure (6.9 vs 5.0 years). Conclusion: A large-scale, closed POD, mass vaccination program was able to vaccinate nearly 200,000 healthcare workers for SARS-CoV-2 in 6 weeks. This program was implemented in acute-care sites across 20 different US states, and it was able to meet the various state-level requirements for management of processes, product, and required reporting. The development of a standardized strategy and custom, centralized monitoring and reporting facilitated insight into the characteristics of early vaccine adopters versus those who decline vaccination. These data can aid in the refining and targeting of educational materials and messaging about the SARS-CoV-2 vaccine.
To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients).
Cost analysis using decision modeling.
We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature.
In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions.
A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.
To determine rates of blood culture contamination comparing 3 strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization.
Pragmatic cluster-randomized trial.
Forty-three hospitals with 74 ICUs; 42 of 43 were community hospitals.
Patients admitted to adult ICUs from July 1, 2009, to September 30, 2011.
After a 6-month baseline period, hospitals were randomly assigned to 1 of 3 strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all 3 arms.
During the 6-month baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. Among all individual draws, for arms 1,2, and 3, the contamination rates were 4.1%, 3.9%, and 3.8% for the baseline period and 3.3%, 3.2%, and 2.4% for the intervention period, respectively. When we evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8% (N = 108 sets) in the baseline period and 7.5% (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4% (N = 78) compared to 7.5% (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7% (N = 119) contaminated blood cultures during the baseline period to 5.1% (N = 184) during the intervention period. Logistic regression models demonstrated a significant difference across the arms when comparing the reduction in contamination between baseline and intervention periods in both unadjusted (P = .02) and adjusted (P = .02) analyses. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 (95% confidence interval [CI], 0.044-0.71) and an adjusted OR of 0.55 (95% CI, 0.43-0.71).
In this large cluster-randomized trial, we demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistant Staphylococcus aureus (MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
Misuse and overuse of antimicrobials, primarily involving therapeutic agents used to treat infection in humans, is considered one of the world's most pressing public health problems. Not only does such inappropriate use diminish the therapeutic benefit of essential medications, it also facilitates the development and spread of multidrug-resistant organisms (MDROs). Antimicrobial resistance and the rise in MDROs globally are associated with increased morbidity and mortality, cross-transmission within and between healthcare settings, and increased consumption of limited patient-care resources. Despite elevated awareness, publication of guidelines on antimicrobial stewardship, and several initiatives, the proportion of resistant strains causing both health care- and community-associated infections continues to increase and the number of new antimicrobials continues to decline.
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