New Document Guides Hospitals in Responding to Infectious Disease Outbreaks
Healthcare epidemiologists play key role in emergency preparedness and response
New expert guidance document for hospitals to use in preparing for and containing outbreaks was published today by the Society for Healthcare Epidemiology of America, with the support of the Centers for Disease Control and Prevention. The guide was published in Infection Control and Hospital Epidemiology.
“This guidance details the role of the healthcare epidemiologist as an expert and leader supporting hospitals in preparing for, stopping, and recovering from infectious diseases crises,” said David Banach, MD, co-chair of the writing panel and Assistant Professor of Medicine at the University of Connecticut and Hospital Epidemiologist at UConn Health. “Armed with the resources to develop and support key activities, healthcare epidemiologists can utilize their skills and expertise in investigation and response to infectious disease outbreaks within a hospital’s incident command system.”
SHEA and CDC collaborated in 2016 to form the Outbreak Response Training Program to guide healthcare epidemiologists in how to maximize their facilities’ preparedness and response efforts to combat outbreaks such as Ebola, Zika, pandemic influenza, and other infectious diseases. The new document, Outbreak Response and Incident Management: SHEA Guidanceand Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals, leads epidemiologists through how to apply, use, and interact with emergency response structures, groups, and frameworks from the institutional to the federal levels, and provides an overview of essential resources. The principles in the guidance are intended for acute care hospitals, but may apply to other types of healthcare facilities, such as free-standing emergency departments and long-term care facilities.
According to the guidance document, during a crisis the epidemiologist provides medical and technical expertise and leads infection prevention and control efforts, coordinates with institutional stakeholders, and provides input into internal and external communications.
“We will always be faced with new and re-emerging pathogens,” said Lynn Johnston, MD, co-chair of the writing panel and professor of medicine and infectious diseases at Dalhousie University, Halifax, Canada. “This guidance is part of an ongoing effort to develop tools and strategies to prevent and manage contagious diseases to ensure patient and public safety.”
The document is part of a partnership between SHEA and CDC to prepare for emerging and re-emerging infections by providing training, educational resources, and expert guidance for dealing with outbreaks in healthcare facilities. The program is designed to train U.S. healthcare epidemiologists, who oversee infection control programs, to have the skills, abilities, and tools available to implement infection control practices and provide a leadership voice in responding to infectious threats.
To operationalize the guidance, SHEA will conduct an outbreak response workshop in January, develop and post toolkits based on the recommendations, and provide online training modules and webinars.
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Hand-Washing aka hand hygiene Remains #1 In Infection Prevention In Every Setting.
“Despite evidence to suggest that [hand hygiene] is important in preventing infection, hospitalized patients are often not provided the opportunity to clean their hands,” due to mobility and cognitive obstacles as well as lack of education, investigators wrote.
Education on patient hand hygiene significantly reduced the incidence of Clostridium difficile infection at University of Pittsburgh Medical Center Mercy Hospital.
First, they conducted baseline surveys to assess patient hand hygiene, which showed patients needed more opportunities to wash their hands. Then nurse educators provided staff with an educational presentation on the importance of patient hand hygiene for preventing infection, which included specific times they should encourage and assist patients with hand hygiene. Staff then provided education and assistance to newly admitted patients, and researchers conducted additional surveys after implementation of this intervention.
During the first phase of the study involving just four medical-surgical nursing units, patient hand hygiene education increased significantly after the intervention (P < .0001). Overall, 97 follow-up surveys showed the proportion of those who received hand hygiene education increased from 34% to 64%, the opportunities provided for hand hygiene increased from 60% to 86%, and the average number of times hand hygiene was performed daily increased from 2.7 to 3.75.
After expanding the intervention to the whole hospital in the second phase of the study, 189 follow-up surveys showed that patient hand hygiene education increased from 48% to 53%. Meanwhile, overall opportunities for hand hygiene remained unchanged from 68%, and daily frequency of patient hand hygiene did not change significantly (mean, 2.4 vs. 2.6 times per day).
Notably, CDI rates dropped significantly during the 6 months following hospital-wide implementation.
“[Standardized infection ratio] P values for Q2 and W3 (0.0157 and 0.0103, respectively) were significantly lower than expected (P .05),” investigators wrote. “The Q4 SIR, however, showed an increase to 0.3844 over the 2 preceding quarters.”
They concluded that these findings showed patient hand hygiene “should be considered a potential addition to CDI prevention measures in hospitalized patients.” – by Adam Leitenberger
Infection Control Today (ICT) asked board members of the Healthcare Laundry Accreditation Council (HLAC) for their perspectives on key issues relating to infection prevention and healthcare textiles management.
Q: What are the gaps in research that are needed to advance healthcare textile science?
A: We view gaps as opportunities for advancements in healthcare textile science, and these opportunities are in large part being driven by infection prevention’s changing landscape. Growing drug resistance, the threat of pandemics and the cost of healthcare-associated infections (HAIs) require that we gain a much better understanding of the morphology of organisms as it relates to their resistance and the chain of transmission. The list of infectious agents continues to grow and include prions, Clostridium difficile (C. diff.), Severe Acute Respiratory Syndrome (SARS), Ebola, etc. Each is unique and presents its own challenges for healthcare textiles, including the need to protect patient and staff from exposure situations (e.g., via personal protective equipment), assisting in patient-care activities (from exam gowns to incontinence products), and ultimately the need for them to be effectively cleaned/sanitized for reuse. The emergency guidelines issued by the Centers for Disease Control and Prevention (CDC) for Ebola highlight the point: all items including textiles exposed to an Ebola patient must be incinerated. Though it is a very pragmatic and understandable decision, it is not an effective or sustainable one.
A better understanding of these infectious agents will allow for:
– The development of barrier fabrics that include chemical finishes that offer better and more specialized protection for the wearer
– Optimized cleaning and sanitizing conditions in the reprocessing of reusable products
– The use of scientifically based guidelines (not emotional ones) that effectively mitigate (not displace) infection risk in the handling contaminated textiles – (i.e., exposure of waste handlers vs. handling by trained reprocessing professionals). — Bradley J. Bushman, vice president of technical affairs, Standard Textile Co. Inc., Cincinnati, Ohio
Q: What are the imperatives about proper healthcare laundry processes that infection preventionists (IPs) must know?
A: IPs must be well-versed in the end-to-end healthcare laundry process, especially in the context of potential infection risks from contaminated healthcare textiles (HCTs). Contamination risks extend well beyond the actual wash process. While it is imperative to have a validated wash process that consistently produces hygienically safe and clean textiles, close attention must be paid to the many contamination risks after the wash process. HCT contamination after the wash process is just as dangerous as contamination from improperly washed HCTs.
Key areas to look for potential HCT contamination include:
– Dirty finish surfaces that may touch clean HCTs
– Carts, after being loaded, that are improperly stored outside on a loading dock
– HCT transfer carts that are not protected from the environment via fluid-proof covers or doors
– Dirty hands of laundry workers handling clean HCTs
– Dirty/linty equipment used to process HCTs
– The presence of dirty/soiled HCTs in an area with clean HCT
– Contaminated air flowing into a clean HCT area.
Also, it’s imperative to ensure that laundry workers are well-trained in hygiene concepts such as proper hand hygiene; proper environmental cleaning; the importance of functional separation of soiled and clean; and proper HCT sorting, washing, drying, and finishing. — Gregory Gicewicz, HLAC immediate past president; president, Sterile Surgical Systems, Tumwater, Wash.
Q: How important is it for healthcare laundry personnel to work with IPs and other stakeholders to achieve good outcomes?
A: It is very important. It’s essential to have open communication and collaboration between the healthcare IP and the laundry profession. There must be a sharing of knowledge and operational details, both the laundry operations and the healthcare facility operation, for each professional to be able to positively interact with each other.
The IP is involved in and responsible for observation, or surveillance, of aspects relating to both patient safety and infection prevention. This includes the collection and analysis of infection prevention and control data; review of products and procedures; follow-up on infection risk; prevention and control approaches; educational interventions to avoid or mitigate infection; and the application of changes mandated by regulatory and licensing agencies such as the Occupational Health and Safety Administration (OSHA). The more knowledge the IP has concerning the operations of a laundry, the more epidemiological principles can be applied to improve patient care outcomes.
In welcoming the IP, a bond can be established that allows both entities to address ongoing issues with desired outcomes. Utilizing observation to follow the laundry progression of textiles in a step-by-step process will enable the IP to determine if there are perceived breaches in the process and can share these concerns with the laundry operator and personnel. In turn, the healthcare laundry operator may notify the healthcare facility administration and IP of concerns they may encounter in the healthcare laundry. — Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.
Q: What are some ways that IPs can help facilitate dialogue and collaboration with healthcare laundry professionals?
A: We encourage IPs to have a strong, trusted partnership with their healthcare laundry vendor. A good practice is for the hospital IP team members to treat their healthcare laundry professionals as part of their extended team, where there’s an ongoing sharing of updates in infection control and prevention efforts and in the regulatory and licensing arenas. By establishing a working relationship with healthcare laundry personnel, problems that arise with the laundry process or the healthcare facility process can be more readily corrected and unresolved issues can be more directly addressed.
Important to this team-style relationship is for the IP to visit the healthcare laundry to become acquainted with the personnel responsible for administering the laundry. In fact, the laundry should be open to at least yearly visits from their IPs. These visits are more productive when they’re treated collaboratively. The purpose of visits is to ensure that the processes used by the healthcare laundry is safe and supported by research*. Utilizing HLAC’s Standards Checklist (available at www.hlacnet.org) as a guideline during these visits ensures that a thorough over-view of the laundry process is accomplished. — Gregory Gicewicz, HLAC immediate past president; president, Sterile Surgical Systems, Tumwater, Wash.; and Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.
Q: What are the unresolved key issues related to infection prevention and healthcare textiles that remain for the future?
A: Without education and awareness, the same myths about healthcare laundry that have persisted for a long time will continue. For example:
– Myth: The laundry industry is regulated – by someone.
– Myth: The laundry industry is regulated by the government.
– Myth: If the hospital is accredited then so is the laundry.
– Myth: All textiles are washed the same.
– Myth: When it comes to knowing all about laundry matters, the hospital IP is on top of it.
– Myth: Every healthcare laundry is accredited.
Only the education of healthcare professionals, including IPs, can overcome these myths.
Furthermore, in the expanding world of pathogens, we will continue to see more bacteria and viruses developing more lethal strains and antibiotics becoming less and less effective. HLAC believes that going forward we should be striving for a more robust, collaborative effort among healthcare laundries, IPs, environmental services, laundry departments, quality management, and healthcare resource and materials management professionals.
Another point: It’s not unrealistic for hospitals to begin to look at healthcare textiles as an investment in quality patient outcomes and not just an expense. Bear in mind that the processing of healthcare textiles is a reimbursable expense by CMS because healthcare textiles have a direct impact on patient outcomes.
Because of these issues, we believe that every laundry that is providing healthcare textile processing services should be HLAC-accredited. Doing so would ensure that all patients receive textiles that are processed to the highest level, thus safeguarding that three of the four major principles of medical ethics are afforded of all patients: Justice, beneficence, and non-maleficence. We believe that there is a moral and ethical obligation to do the right thing for patients and processing healthcare textiles to the highest level possible helps to fulfill those obligations. We believe that working collaboratively, IPs and laundry operators will be key players in this process. — Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.; and John Scherberger, HLAC board president; president, Healthcare Risk Mitigation, Spartanburg, S.C.
1. Centers for Medicare/Medicaid Services. CMS Hospital Infection Control Worksheet. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf Accessed July 14, 2016.
2. Occupational Safety and Health Administration. Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR § 1030 (2012). Occupational Safety and Health Administration.
3. Siegel JD, Rhinehart E, Jackson M, Chierello L. the Healthcare Infection Control Practices Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007.
4. Accreditation Standards for Processing Reusable Textiles for use in Healthcare Facilities. 2016 ed Frankfort, IL. Health care Laundry Accreditation Council. 2016.
5. Protecting Workers Families—DHHS(NIOSH) Pub No. 1002-113. National Institute for Occupational Safety and Health.
6. AINSI/AAMI ST65 2008/R 2013 Processing of Reusable Surgical Textiles for Use in Healthcare Facilities. 2013. Arlington, VA.: Association for the Advancement of Medical Instrumentation: 2013.
7. Guideline for Surgical Attire. In: Guidelines for Perioperative. Denver, CO: AORN, Inc.: 2016.
Preauthorization of broad-spectrum antibiotics and prospective review after two or three days of treatment should form the cornerstone of antibiotic stewardship programs to ensure the right drug is prescribed at the right time for the right diagnosis. These are among the numerous recommendations included in new guidelines released by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) and published in the journal Clinical Infectious Diseases.
“Initially, antibiotic stewardship was more focused on cost savings, and physicians responded negatively to that, because they often felt it was best to give patients the newest, most expensive drug,” said Tamar Barlam, MD, lead co-author of the guidelines, director of the antibiotic stewardship program at Boston Medical Center and associate professor of medicine at Boston University Medical School. “While these programs do save hospitals money, their most important benefit is that they improve patient outcomes and reduce the emergence of antibiotic resistance. When we say stewardship, we really mean stewardship, and increasingly, doctors are realizing it’s important and necessary.”
The White House has called for hospitals and healthcare systems to implement antibiotic stewardship programs by 2020 to ensure appropriate use of these vital drugs and reduce resistance, an escalating problem that threatens the ability to effectively treat often life-threatening infections.
The new guidelines replace those originally created to help with the development of programs when antibiotic stewardship was in its infancy, and instead focus on specific strategies that the evidence suggests are most beneficial to ensure the program will be effective and sustainable. They also note it is key that these programs tailor interventions based on local issues, resources and expertise. To ensure that, the guidelines recommend the programs be led by physicians and pharmacists and rely on the expertise of infectious diseases specialists.
“We want hospital administrators to understand the importance of giving antibiotic stewardship their full support to ensure its success,” said Sara Cosgrove, MD, MS, lead co-author of the guidelines, president-elect of SHEA and associate professor of medicine and epidemiology at Johns Hopkins University, and director of the antimicrobial stewardship program and associate hospital epidemiologist at The Johns Hopkins Hospital, Baltimore. “Distributing a few brochures or holding grand rounds won’t do it. It’s vital that antibiotic stewardship be integrated into the hospital’s culture and that infectious disease specialists guide strategies that have been shown to work.”
The guidelines note that more research needs to be done to determine how to ensure antibiotic stewardship is most effective. However, the best evidence to date suggests a number of components, including the following, will help ensure the implementation of an effective antibiotic stewardship program.
Preauthorization or prospective audit and feedback – Targeted antibiotics, such as those that treat emerging drug-resistant bacterial infections, should require preauthorization. This means providers need to get approval to use antibiotics before they are prescribed. Prospective audit and feedback can be an alternate strategy or combined with preauthorization. Prospective audit allows antibiotic stewards to engage the prescribing clinician after the antibiotic has been used, typically after two or three days, to optimize antibiotic treatments. Both methods can reduce antibiotic misuse and decrease the development of resistance. Hospitals should choose one or both of these methods as part of their program based on their local resources and expertise.
Syndrome-specific interventions – The guidelines recommend focused multifaceted interventions for the treatment of specific syndromes, rather than trying to improve treatment of all infections at once. For example, Dr. Barlam said those leading a hospital’s antibiotic stewardship program might take a close look at management of pneumonia during winter, including making recommendations to shorten the amount of time people are treated and switching to an oral agent more quickly, and then measuring the results of those interventions. In the fall, the program might focus on urinary tract infections and then several months later, switch to skin and soft tissue infections. “This method makes stewardship more manageable and provides a targeted and clear treatment message rather than trying to disseminate 100 different lessons at the same time,” she said.
Rapid diagnostic testing – The guidelines note that rapid diagnostic testing of respiratory specimens can help determine if the cause is viral and therefore reduce the inappropriate use of antibiotics. They also note that the rapid testing of blood cultures in addition to conventional culture is helpful, but should be guided by the antibiotic stewardship team for maximum benefit to the patient.
Other recommendations include reducing the use of antibiotics associated with Clostridium difficile infection, implementing antibiotic time-outs and other strategies to encourage prescribers to perform routine reviews of regimens and using computerized clinical decision support if possible.
The guidelines do not recommend relying solely on passive educational materials to implement antibiotic stewardship because any improvement likely will not be sustained. Lectures and brochures should be used to supplement strategies such as antibiotic preauthorization and prospective audit and feedback, the authors note.
AT A GLANCE
Preauthorization and prospective review of antibiotics are among the many recommendations to ensure antibiotic stewardship programs are most effective, suggest new guidelines from IDSA/SHEA.
Antibiotic stewardship programs should be led by physicians and pharmacists, including ID specialists, who have the expertise and education to ensure the right drug is being prescribed at the right time for the right diagnosis.
Antibiotic stewardship programs must be based on the specific problems identified by the healthcare facility and a realistic examination of available resources to ensure interventions are performed with consistency.
These programs have been shown to improve patient outcomes, reduce antibiotic resistance and save money.
In addition to Drs. Barlam and Cosgrove, the antibiotic stewardship program guidelines panel includes: Lilian Abbo, Conan MacDougall, Audrey N. Schuetz, Ed Septimus, Arjun Srinivasan, Timothy Dellit, Yngve T. Falck-Ytter, Neil Fishman, Cindy W. Hamilton, Timothy C. Jenkins, Pamela A. Lipsett, Preeti N. Malani, Larissa S. May, Gregory J. Moran, Melinda M. Neuhauser, Jason Newland, Christopher A. Ohl, Matthew Samore, Susan Seo and Kavita K. Trivedi.
IDSA and SHEA individually have published myriad treatment guidelines and together have published several, including the prevention of healthcare-associated infections and antimicrobial prophylaxis in surgery.
As with other IDSA and SHEA guidelines, the antibiotic stewardship guidelines will be available in a smartphone format and a pocket-sized quick-reference edition.
Infection rates decreased significantly at Orlando Health South Seminole Hospital after the hospital began using Xenex’s xenon light Germ-Zapping Robots for room disinfection, according to a new peer-reviewed study published in the American Journal of Infection Control (AJIC). This is the eighth peer-reviewed study that demonstrates how a hospital successfully reduced its infection rates after utilizing Xenex Disinfection Services’ unique Xenon Full-Spectrum Disinfection technology to disinfect its rooms. Xenex Germ-Zapping Robots havebeen credited for helping healthcare facilities in the U.S. decrease their Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C.diff) and Surgical Site infection rates by more than 50, 70 and 100 percent respectively.
Xenex’s xenon light disinfection system is the only disinfection system that uses pulsed xenon to create light that covers the entire germicidal spectrum. The Xenex system is the only ultraviolet light disinfection technology shown, in multiple peer-reviewed published studies, to help hospitals reduce infection rates.
According to the new AJIC study, South Seminole Hospital reported a 61 percent reduction in combined Vancomycin-resistant enterococci (VRE), MRSA and C.diff infection rates in its Intensive Care Unit (ICU), an 87 percent reduction in its ICU VRE infection rate, and a 29 percent reduction facility-wide in combined VRE, MRSA and C.diff infection rates after it began using Xenex’s xenon light technology. The hospital estimates that it saved $730,000 based on the number of C.diff and VRE infections that were avoided.
The study titled “Impact of pulsed xenon ultraviolet light on hospital-acquired infection (HAI) rates in a community hospital” analyzed the efficacy of pulsed xenon light in two different deployment strategies.
The difference in infection rate reduction was associated with the two different utilization strategies, which indicates best practices for pulsed xenon disinfection. ICU discharges and transfers were disinfected with Xenex Germ-Zapping Robots with a goal of all terminal cleans.
As a result, the combined VRE, MRSA and C.diff infection rates decreased 61 percent. Non-ICU discharges and transfers were disinfected with Xenex robots for C.diff cases only, resulting in a 29 percent decrease in VRE, MRSA and C.diff infection rates facility wide.
“This is an exciting study because it demonstrates best practices for pulsed xenon automated disinfection,” said Dr. Mark Stibich, Chief Scientific Officer at Xenex. “Previous studies have shown that the number of rooms disinfected with the Xenex robot correlates to the infection rate reduction the hospital will experience. This study shows that it’s more effective to use the Xenex robot to disinfect as many rooms as possible versus only disinfecting rooms where patients are known to have an infection. Our pulsed xenon robot works in a five-minute disinfection cycle, so they are able to quickly disinfect multiple rooms per day in a facility – leading to dramatic reductions in infection rates.”
Designed for speed, effectiveness and ease of use, hospital cleaning staff operate the Xenex robot without disrupting hospital operations. The robot pulses intense UV light covering the entire UV spectrum, destroying viruses, bacteria and bacterial spores in a five-minute disinfection cycle. Without contact or chemicals, the robot eliminates harmful microorganisms safely and effectively. According to Xenex customers, the robot can disinfect 30-62 hospital rooms per day, including: patient rooms, operating rooms, equipment rooms, emergency rooms, intensive care units and public areas.
Proven to Reduce HAI Rates
MD Anderson Cancer Center, the Central Texas Veterans Health Care System, Cooley Dickinson Health Care, Trinity Medical Center and other hospitals have published 14 studies providing evidence of the robot’s efficacy in highly regarded scientific journals that include the American Journal of Infection Control (AJIC), Journal of Infection Prevention, Infection Control & Hospital Epidemiology (ICHE) and BMC Infectious Diseases.
About Xenex Disinfection Services
Xenex’s patented Full Spectrum pulsed xenon UV room disinfection system is used for the advanced disinfection of healthcare facilities. Due to its speed and ease of use, the Xenex system has proven to integrate smoothly into hospital cleaning operations. The Xenex mission is to save lives and reduce suffering by eliminating the deadly microorganisms that cause HAIs. The company is backed by well-known investors that include Brandon Point, Battery Ventures, Targeted Technology Fund II and RK Ventures. For more information, visit www.xenex.com.