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Objectives: Ancillary staff members perform operational support functions and play an active role in enhancing the patient care experience. Infection prevention practices among ancillary staff play a critical role in preventing transmission of microorganisms, which ensures the safety of patients. Low hand hygiene compliance was found among porters in a cross-institutional hand hygiene audit in 2021. A quality improvement team was formed to improve hand hygiene compliance, especially during the COVID-19 pandemic. Methods: A focus-group discussion and survey were conducted to understand hand hygiene knowledge and challenges among porters. Using the findings, the team initiated Glo–germ education tools, pocket alcohol hand-rub agents, pocket moisturizer, poster display, and a toolbox messaging system via conversion of group roll call to satellite-area roll call. Respective satellite teams were sent hand hygiene reminders, and prompt corrective action was taken following noncompliance events. Analytic comparisons of pre- and postsurvey data were performed using the χ2 test, and P < .05 was regarded as statistically significant. Results: In total, 572 ancillary staff participated in the survey. Knowledge of hand hygiene practices improved significantly following the interventions, as shown in the comparison of pre- and postintervention results: knowledge of the hand hygiene steps (P < .001), knowledge of the duration of hand rub (P < .001), and knowledge of duration of handwashing (P < .001). Also, 295 staff members (97.68%) stated that implementation measures increased their awareness of the importance of hand hygiene. Moreover, the hand hygiene compliance rate improved from 77.8% to 100%. There were no significant differences related to sex (P = .089), age group (P = .355), years of working (P = .359), education level (P = .268), or difficulty in reading English (P = .906). Conclusions: Evaluating staff hand hygiene knowledge and understanding the challenges faced among porters helped toward the development of appropriate interventions and assurance of success in project.
Objectives:Streptococcus mitis is a gram-positive coccus and is a common commensal found in the throat, nasopharynx, and mouth. In an immunocompromised host, S. mitis opportunistically multiplies and can translocate to other sites. At baseline, the prevalence of S. mitis remained stable among hematological patients, averaging ~1 case monthly. However, in August–September 2020, 5 S. mitis cases were documented in a hematology ward and included overlapping inpatient stays. In this descriptive cluster report, we sought to identify the reasons for the increased prevalence of S. mitis in our institution. Methods: A literature review was undertaken to gain a better understanding of the bacteriology of S. mitis. Subsequently, geographical mapping was performed to identify epidemiological links. Further culture and sensitivity testing was requested. Hand hygiene compliance, environmental audit, and handling of central lines within the ward were examined for any lapses in practice. Results: Based on geographical mapping, no epidemiological linkages were established between patients; they were admitted to different rooms and did not share any equipment. Moreover, based on the antibiogram, different bacteria sensitivities were recorded across the isolates from these patients. A hand hygiene and environmental audit result showed 100% compliance. Nurses performed care of central lines in accordance with guidelines. However, an investigation of changes in practice revealed that the use of a toothbrush had only recently been permitted as part of streamlining oral care for hematology patients. Because toothbrushes were not provided by the hospital, patients were utilizing their personal toothbrushes with no direct supervision of their oral care regimen. Conclusions: The prevalence of S. mitis in hematological patients was likely due to the neutropenic condition of patients. This report provides valuable information supporting the optimization of oral hygiene in immunocompromised patients while minimizing the risk of opportunistic infections.
Background: In the last 2 years of the COVID-19 pandemic, Singapore has been forced to explore alternative sites to quarantine persons or manage infected cases during surge periods in a national effort not to overwhelm the public healthcare facilities. External quarantine facilities were created at the EXPO and further extended to D’Resort and other hotels in May 2020. Infection prevention (IP) practices were implemented at these external facilities, where training non–healthcare staff to quickly learn and understand these required practices has been challenging. A team of staff from different clinical disciplines was formed to manage the COVID-19 patients at these facilities. The Infection Prevention and Epidemiology (IPE) department was invited to train all staff, including the clinical team, management agency, and security staff, regarding IP measures. We have described the system and approach used in the rapid training of all staff in IP measures where the goal is zero transmission while providing care to COVID-19 patients. Methods: Training materials were developed to facilitate rapid learning by all staff; medical jargon was avoided. Curriculum included precautions to be taken while performing terminal cleaning of patient rooms, serving meals, disinfecting phones and thermometers, as well as donning and doffing personal protective equipment (PPE). “Green” and “red” zones were created to assist staff in remembering appropriate PPE to be used. PPE training was provided using slides and video. Posters were created as a guide for staff at donning and doffing stations. Additionally, the IPE training team utilized an online data collection tool to capture staff completion on IP training and PPE competency for record keeping. We used a ‘soft’ approach because staff members were fearful of the unknown when caring for COVID-19 patients. Daily audits were conducted with immediate concurrent feedback to engage the relevant stakeholders. Infection prevention liaison officers (IPLOs) were appointed to assist in the daily audits. An electronic audit tool was used to facilitate audit and quick analysis. Conclusions: The experience gained in the last 2 years has been useful and may provide a template if new external sites are needed in the future because of the potential surge associated with the ο (omicron) variant.
Sporadic clusters of healthcare-associated coronavirus disease 2019 (COVID-19) occurred despite intense rostered routine surveillance and a highly vaccinated healthcare worker (HCW) population, during a community surge of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) B.1.617.2 δ (delta) variant. Genomic analysis facilitated timely cluster detection and uncovered additional linkages via HCWs moving between clinical areas and among HCWs sharing a common lunch area, enabling early intervention.
To describe OXA-48–like carbapenem-producing Enterobacteriaceae (CPE) outbreaks at Singapore General Hospital between 2018 and 2020 and to determine the risk associated with OXA-48 carriage in the 2020 outbreak.
Outbreak report and case–control study.
Singapore General Hospital (SGH) is a tertiary-care academic medical center in Singapore with 1,750 beds.
Active surveillance for CPE is conducted for selected high-risk patient cohorts through molecular testing on rectal swabs or stool samples. Patients with CPE are isolated or placed in cohorts under contact precautions. During outbreak investigations, rectal swabs are repeated for culture. For the 2020 outbreak, a retrospective case–control study was conducted in which controls were inpatients who tested negative for OXA-48 and were selected at a 1:3 case-to-control ratio.
Hospital wide, the median number of patients with healthcare-associated OXA-48 was 2 per month. In the 3-year period between 2018 and 2020, 3 OXA-48 outbreaks were investigated and managed, involving 4 patients with Klebsiella pneumoniae in 2018, 55 patients with K. pneumoniae or Escherichia coli in 2019, and 49 patients with multispecies Enterobacterales in 2020. During the 2020 outbreak, independent risk factors for OXA-48 carriage on multivariate analysis (49 patients and 147 controls) were diarrhea within the preceding 2 weeks (OR, 3.3; 95% CI, 1.1–10.7; P = .039), contact with an OXA-48–carrying patient (OR, 8.7; 95% CI, 1.9–39.3; P = .005), and exposure to carbapenems (OR, 17.2; 95% CI, 2.2–136; P = .007) or penicillin (OR, 16.6; 95% CI, 3.8–71.0; P < .001).
Multispecies OXA-48 outbreaks in our institution are likely related to a favorable ecological condition and selective pressure exerted by antimicrobial use. The integration of molecular surveillance epidemiology of the healthcare environment is important in understanding the risk of healthcare–associated infection to patients.
Background: The ongoing COVID-19 pandemic tests the healthcare system in many ways. The scarcity of resources poses challenges to infection prevention (IP) practices. We describe our experience in managing such scarcity in our care of COVID-19 patients in the hospital as well as community settings. Methods: The hospital pandemic plan traditionally included only plans for healthcare delivery management within the hospital. However, on March 25, 2020, a decision was made by the Ministry of Health to set up swab isolation (SIFs) and community care facilities (CCFs) to meet the growing demand for isolation beds for migrant workers infected by COVID-19. The CCFs were located in convention halls and resort centers and the SIFs were located in facilities previously functioning as hotels. Mobile medical teams were activated to run clinics at the dormitories housing 200,000 migrant workers. The IP team of an acute- and tertiary-care hospital in Singapore was activated to oversee IP measures at facilities managed by medical teams from the hospital, with the goal of zero healthcare-associated COVID-19 cases among staff. Two IP leaders were set up to oversee the IP program at 8 dormitories, 4 SIFs, and 2 CCFs. In total, 12 IP staff and 15 infection prevention liaison officers (IPLOs) were deployed from 2 acute-care hospitals and 3 specialty centers to conduct training in hand hygiene and the use of personal protective equipment, and to conduct daily audits of compliance to practice guidelines. Education on personal hygiene was also given to patients in these facilities in at least 7 languages. In the SIFs and dormitories, IPLOs were recruited to perform daily audits and feedback to the IP team on issues related to IP at the sites. Results: Since our first COVID-19 patient on January 23, 2020, there has been no report of healthcare-associated COVID-19 within the hospital nor among the medical, administrative, and support service staff working in the external operation facilities. Daily audits showed an average of 99.4% compliance to IP guidelines. Conclusions: IPLOs or IP champions play a significant role in ensuring compliance to IP guidelines. This compliance allows the IP professional to focus on the evaluation of the IP program, managing IP consultations, and planning and implementation of the IP program in nontraditional healthcare settings. The key success factors of the program included the ability to contextualize the planning and implementation of IP programs in various settings, strong leadership support, cohesive teamwork, and effective communication at various levels.
Background: The optimal prevention of healthcare onset Clostridium difficile infection (CDI) has been a challenging one in an acute tertiary-care hospital with limited number of single rooms. Asymptomatic patients with CDI are nursed in open wards but tagged with a green sticker to alert staff of their status. This signal prompts cleaning staff to use 5,000 ppm sodium hypochlorite to clean environmental surfaces in the multibed room and to continue with modified contact precautions. Methods: We conducted a survey on infection prevention measures used in the management of CDI patients over 2 weeks among senior nurse managers, clinicians, and registered nurses in 38 inpatient wards. We categorized the survey results into 4 types of practices: established practices, nonestablished practices (easy implementation), nonestablished practices (lack of resources), and nonestablished practices (staff resistance). We then identified barriers to determine reasons for resistance to nonestablished practices before the implementation of the CDI bundle in May 2019. The bundle comprised the following components: contact precautions, antimicrobial stewardship, isolation of CDI patient with diarrhea in single room, environment, and equipment hygiene. Following the survey, we enhanced the signage for CDI patients to be more obvious. Monthly, we monitored the incidence of HO-Clostridium difficile to assess effectiveness of implementation measures. Results: Nonestablished practices (easy implementation) included uncertainty of diarrhea definition and the recommended environmental hygiene disinfectant, lack of understanding of the importance of complying to personal protective equipment (PPE), and inconsistency in conveying CDI status. Among nonestablished practices (lack of resources), shortage of isolation beds for CDI patients with diarrhea and unavailability of electronic alert system for CDI patients within the institution are the major issues faced by clinical staff. Unavailability of CDI indicator stickers, contact precaution posters, and sporicidal wipes were noted in 6 medical and surgical wards. Nonestablished practices (staff resistance) were related to the time taken to don full PPE and reluctance to arrange for an isolation bed due to increased workload and unavailability of isolation beds. A shift was noted in the control chart for HO-Clostridium difficile after the implementation of the CDI bundle in May 2019. Conclusions: The categorization of practices into established and nonestablished practices can help to identify barriers that may interfere with successful implementation of an infection prevention bundle.
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