Download Slide 1

MRSA screening in
ICUs
Sarah Simmons, MPH CIC
Abstract
Is selective use of MRSA screening
effective?
 Tracked HA-MRSA rates from January
2007-December 2009
 PCR Screening was done for all ICU
admissions

Background

Mandatory house-wide screening
mandatory in several states

Results are delayed 48 hours for clinical
cultures
Results
ICU Hospitl Acquired MRSA Rate 2007- 2009
ICU Hospital Acquired MRSA rate
per 1000 patient days
Pre-Screening
Post Screening
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
7
8
9
7
8
9
7
8
9
7
8
9
7
8
9
7
8
9
-0 n-0
-0 n-0
-0
-0 y-0
-0 y-0
-0 y-0
-0
-0 p-0
-0 p-0
-0 p-0
l
l
l
r
r
r
v
v
v
n
a
a
a
o
o
o
a
a
a
Ju Se
Ju Se
Ju Se
Ja
Ja
Ja
M
N
M
N
M
N
M
M
M
ICU Hospital Acquired
MRSA Rate
Month
Rate decreased from 3.19 to 1.66 (p=0.005)
Results
Pre-Screening
Post Screening
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
Hospital Acquired MRSA
Rate
Month
Rate decreased from 0.80 to 0.38 (p=0.0003)
9
ov
-0
N
p0
9
9
Se
l-0
Ju
-0
9
M
ay
-0
9
M
ar
n09
8
Ja
ov
-0
N
Se
p0
8
8
l-0
Ju
-0
8
M
ay
-0
8
M
ar
n08
7
Ja
ov
-0
N
p0
7
7
Se
l-0
Ju
-0
7
M
ay
M
ar
Ja
-0
7
0.0
n07
Hospital Acquired MRSA rate per 1000
patient days
Hospital Acquired MRSA Rate 2007- 2009
Conclusion
It works!!
 Additional populations

– PAT
– Nursing Home
– Dialysis
– Long term indwelling devices
Lessons from Publishing
I already had the data
 Focus on a simple question
 Start early
 Stay Organized!!

What does ESBL mean and
why does my patient
require contact isolation?
Denise Langford, BS, MT(ASCP),
CIC
Abstract
The purpose of the article was:
 To educate the reader on Extended-spectrum
beta-lactamase (ESBL) producing bacteria.
 Explain why contact isolation practices are
necessary within a healthcare facility,
especially Intensive care units, to prevent the
spread of these bacteria, which can potentially
cause life-threatening infections.
 Discussed recommendations from the Centers
for Disease Control (CDC) including Isolation
Practices utilized at Baptist Healthcare System.
What is an ESBL bacteria?
ESBL = Extended-spectrum betalactamase
 It is an enzyme some of the
Enterobacteriaceae family of bacteria
produce to inactivate beta lactam
antibiotics like the penicillins,
cephalosporins and aztreonam
 The first ESBL isolate was discovered in
Western Europe in the mid 1980s and
within a few years it arrived in America

Most common ESBL
Klebsiella pneumoniae
Escherichia coli (E.coli)
ESBLs have also been found in other family
members such as Salmonella, Proteus,
Enterobacter, Citrobacter, and Serratia but
not as frequently.
Scary fact!
These enzymes are encoded on
plasmids, which can be easily
transferred from bacteria to bacteria
 The carbapenems represent the only
antibiotics active against ESBLs.
 Resistance to carbapenems are
popping up!

How does Baptist Health handle
ESBL?
Contact Precautions (In addition to Standard
Precautions)
1.
2.
3.
4.
Wash Hands or use hand sanitizer before
entering and when leaving room
Wear gloves and gown when entering room
Use patient dedicated equipment or singleuse disposable equipment.
Clean and disinfect all equipment before
removing from environment.
Why did I write about ESBL?
I love Microbiology 
Educate myself.
– Personally interested in increasing my knowledge
on ESBL and CDC guidelines.
– A person retains 90% of new information by
teaching it!
Educate others
– From my experience, most Nurses still don’t know what to do
when their patient has an ESBL
– Healthcare facilities are just beginning to add other MDROs to
patient and nursing education.
– Provide reader with Evidence-Based references
Challenges / Preparation

Literature seaches/references
– Get help from Hospital Librarian

Lots of reading

Being creative and making it interesting

Deadlines! Deadlines! Deadlines!
Surprises
Opportunity to collaborate with critical
care nursing and gain their perspective
on ESBL and isolation practices, as well
educate them!
 Infection Preventionists have tons of
free time on their hands so why not
write an article 

Legionella – Every IP’s
Dream – Or Is It?
CCNQ Experience
Kris Chafin, RN, BA, MBA, CIC
Infection Preventionist
Legionella - History
This disease (Legionnaire’s Disease) is due to
legionella causing a biofilm in plumbing, shower
heads and water storage tanks or wherever there is
stagnant water. It is everywhere in the environment.
 We have all probably been exposed to the bacteria at
some point.
 8,000 – 18,000 people are hospitalized with
Legionnaires’ Disease in the U.S. 5 – 40% of cases
will be fatal.
 The disease was first identified at the 1976
convention of the American Legion.

Transmission
Inhalation - of mist, aerosols or fine
spray into the lungs.
 Aspiration – while drinking, swallowing
or choking.
 Incubation period is 2-10 days.

IT IS NOT SPREAD PERSON TO
PERSON!
Signs and Symptoms
 Rapidly
rising fever and chills
 Non-productive cough
 Nausea and diarrhea
Diagnostic Testing




Legionella Urinary Antigen – urine test with results
within 15 minutes. This test can remain positive for
up to one year, so in essence, the patient could have
had legionella at some point from one year ago to
present.
Legionella DFA – sputum test which shows growth of
legionella.
Legionella Antibodies – blood test which shows type
of legionella.
Chest X-Ray – indicative of pneumonia.
Why Hospitals?

Immunocompromised patients are
susceptible to Legionnaires’ Disease,
including chemo patients, transplant
patients, patients on long term steroid
therapy and heavy smokers.
Why Hospitals?
Sources:
 Potable water systems
 Spray misters
 Decorative fountains
 Cooling tower drift
 Irrigation Systems
 RT Equipment
 Whirlpools and Spas
 Therapy pools
Why San Antonio Hospitals?
Water supply – legionella usually cannot
withstand cold water but San Antonio’s cold
water temperature is 82-84 degrees.
Legionella thrive in water temperatures of 65
– 124 degrees. Texas law requires that the
hospital’s hot water not be hotter than 110
degrees!
 Construction – the threat of legionella grows
as construction occurs due to disruption of
water/soil.

Chronology of Events
5/5/2006 – 1st case
 5/8/2006 – 2nd case
At this point, I panicked!
I called my Plant Ops director and said we
needed to test the water and he said I was
crazy; no one recommends water testing but
we did it anyway!
 5/10/2006 – 3rd case
 We had 10 cases between 4/22 and 6/12/06
(community acquired vs. hospital acquired?)

Chronology of Events
5/11/2006 Water tested – results showed no growth.
 5/12/2006 Superheated and flushed water.
 5/12/2006 Department Leader Notification.
We continued to get cases – didn’t know if they were CA
or HA.
CDC definition of HA legionella – if a patient has been in
the hospital for 10 straight days or more and then
develops Legionnaires’ Disease. CDC tested our
water and found growth!

Legionella Task Force Purpose
Investigate Immediately
 Communicate with Board, Medical Staff,
hospital leadership, staff and visitors.
 Identify high risk patients and if
necessary limit admissions.

Waterborne Pathogen Plan
Identify corrective actions that will occur
once a nosocomial case has been
identified.
 IC and Plant Ops with the assistance of
the LTF revised the current plan.

Waterborne Pathogen Plan Contents










Legionella notification process.
Convening LTF.
Identification of high risk patients.
Potential restriction of water use.
Education, rounding,read and sign.
Collaboration with local health dept.
Water testing/site.
Remediation.
Preventative Maintenance.
Visitor Signage.
Legionella Hotline

Manned 24/7 by Infection Control/Employee
Health/Education
 We offered free urine testing to anyone who
had recently been a patient in our hospital.
 Crazy phone calls:
“I was driving by your hospital and got
Legionnaires’ Disease.”
“My grandson was in your ER and I washed my
hands and got Legionnaires’ Disease.”
Initial Restrictions
Ice Machine Use
 Water fountains


Mass quantities of hand sanitizers and
bottled water distributed
Long Term Solution – What We
Chose
Implementation of Chlorine Dioxide
System in January, 2007.
 There must be a trained person to
monitor chlorine levels daily.
 We continue to test our water with
results of no legionella growth.

Lessons Learned
Always err on the side of caution – go with your gut! I
had many sleepless nights!
 Become best friends with your Plant Ops director.
 Get leadership support.
 Keep a timeline.
 Form a task force and meet regularly.
 Develop/continuously review the Waterborne
Pathogens Plan.
 EDUCATE and COMMUNICATE!
 Know that YOU are the expert!

Why Did I Write This For
CCNQ?
I had already written it.
 Want to get published.
 Share the experience with others.
 Expose the disease and plan.

What Were The Obstacles To
Writing This?
Accepting criticism from the editors.
 Editors sometimes wanted to change
verbage when the wording had to stay
that way to make sense with legionella.
 Time Frame.
 Two Authors – one didn’t know how to
write for a journal.

Lessons Learned From Writing
Meet deadlines.
 References must be exact – some
references come from other references
so verification for accuracy must be
done.
 Accept the editors’ revisions.
 Know your co-author’s strengths; you
can benefit from that.

Lessons Learned:
Managing a Pandemic in
a Multi-hospital System
Elizabeth Curnow, MPH, Med, CIC;
Robert E. Wiles, MS, CHEP, CHSP, and
Melissa Wyatt, RN, BS, COHN-S
Scrub the Hub
Sarah Simmons, MPH CIC
Celestina Bryson, DNP, ACNP-BC, CCNS, MSN, MBA, CCRN
Susan Porter, MT ASCP
Abstract
There is no clear guidance for length of
time to “Scrub the Hub”
 56% of nurses do not disinfect the hub
 Compared 3 seconds, 10 seconds and
15 seconds

Methods
Contaminated hubs and allowed the to
dry for 24 hours
 Disinfected hubs and flushed with saline
 Used a calibrated loop to plate bacteria
 Counted colonies

Results
Conclusion
No statistical difference between scrub
times
 HOWEVER, a larger study would have
more power
 This study does NOT say that a 3
second scrub is acceptable

Lessons from Publishing

Team work is critical

Allow time for editing each others work
Does Proper Design of an Intensive Care Unit Affect
Compliance With Isolation Practices?
Maria Rodriguez RN BSN CIC, Dennis Ford CHFM,CHSP, CHEP, Sheila Adams RN, BSN, MSN, MHA

In this article, we propose that unit design may have an indirect potential to affect patient
outcomes. The design of a unit or patient room, the type of surfaces chosen, accessibility to
supplies or medications, affect staff’s ability to provide care to their patients quickly and
efficiently. A poorly constructed patient room or unit may decrease efficiency and affect
staff’s ability to comply with isolation practices.

Without the input of the end user, the end result is often a less than efficient new unit. The
unit is finished and staff is expected to function or in other words, care for their patients in an
efficient manner. Nurses are resourceful and great at creating work arounds in order to
make their new environment functional. These types of work arounds may meet the
immediate need of the nurse but they aren’t always in the patient’s best interest and may
sometimes result in negative outcomes otherwise known as a healthcare associated
infection (HAI) for patients.

The article supports that planners, end-users and infection preventionists commit to working
as a team in order to create units that are clinically functional and safer for the patient.
Lessons Learned:
Managing a Pandemic in a
Multi-hospital System
Elizabeth Curnow, MPH, Med, CIC;
Robert E. Wiles, MS, CHEP, CHSP, and
Melissa Wyatt, RN, BS, COHN-S
Partnership(s)
 Internal
(primary):
–Employee Health
–Safety
–IPs
 External:
–APIC Chapter
–City wide STRAC calls with ID
–Other regulatory and guidance providing
agencies
Pandemics
 History
of Flu and Pandemics
 PRID
–Development with APIC group (Avian Flu
Scare) and maturation in health system.
 Challenges
–Early availability of guidelines and
recommendations.
H1N1 Pandemic
 Interventions
– Isolation
• Special Precautions for Emerging Pathogens (Fluid)
– Communication
• Best way to turn around key information quickly
• Website
– Visitation
• Limit or not?
– Vaccination
• Mandatory or not?
– Employee Illness
• Rescreens, return to work, mask utilization
– Materials Management
• Stockpile
• Availability of things like goggles
What we learned:
 Plans
were updated to include a low
mortality pandemic with a novel virus
 Decision to use existing plans and not wait
for outside guidance that may or may not
come
 Keep Materials Management in the loop
 Maintain a stockpile of some critical needs
items
Infection Prevention
Data Web
MARTHA MONTANO-PANIAGUA BA
QUALITY ANALYST


BHS San Antonio- 5 Facility system with
1700+ Licensed beds offering a wide
range of services
6 Facility based Infection Preventionists
1 Regional Director of Infection Prevention
1 Regional Data Analyst

The collection, aggregation, analysis, and
dissemination of infection prevention data is
crucial to the collaborative relationship
shared by the Infection Preventionist and
the Critical Care Nurse. There now exists an
increasingly data driven environment in
which nursing and quality departments are
mandated by state and oversight
organizations to make data available to the
staff as well as the public at large. The
infection preventionist is challenged to
conduct surveillance, analyze, and report
findings quickly, cohesively and accurately.


IP data are requested from and
overseen by a wide variety of
organizations e.g. National Healthcare
Safety Network (NHSN), Centers for
Medicare & Medicaid Services (CMS),
and Hospital Quality Alliance (HQA) to
name a few.
Data will be publicly reported
beginning this year.




Regional Quality
Regional Committees
System Committee reports
Facility “O’s”, Directors, employees

In a multi-facility system with many individuals,
interpretation of definitions and processes
becomes important.
 Electronic Data Mining programs are becoming
indispensable in the present environment of
“real time” surveillance. Information systems
have traditionally been purchased with little
regard to system integration making the
process of aggregation difficult at best.
 Quality concerns regarding data are valid given
time constraints placed on clinicians.
 Meeting all regulatory requirements for
aggregation and reporting data.






Post-op letters to physicians for SSI follow up.
Algorithms for ready reference by IP’s so that
all data is managed in the same manner.
IP representation in facility as well as regional
committees.
Regular intradepartmental meetings for IP
collaboration.
IP as a resource for nursing.
Collaboration with ancillary departments.e.g.
Facilities, Environmental Services.