The power of feedback: Implementing a comprehensive hand hygiene observer program.

2023

142-148

02/2023

1527-3296

BACKGROUND: Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses.

METHODS: A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses.

RESULTS: During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses.

DISCUSSION: Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations.

CONCLUSIONS: In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

10.1016/j.ajic.2022.06.003

Am J Infect Control

35691447

Dodging the bundle-Persistent healthcare-associated rhinovirus infection throughout the pandemic.

2022

1140-1144

05/2022

1527-3296

INTRODUCTION: Healthcare-associated viral infections (HAVI) are a common cause of patient harm in the pediatric population. We implemented a HAVI prevention bundle in 2015, which included 6 core elements: caregiver screening, symptom-based isolation, personal protective equipment (PPE), hand hygiene, staff illness procedures, and monitoring of environmental cleanliness. Enhanced bundle elements were introduced at the start of the COVID-19 pandemic, which provided an opportunity to observe the effectiveness of the bundle with optimal adherence to prevention practices, and to measure the impact on respiratory HAVI epidemiology.

METHODS: Respiratory HAVIs were confirmed through review of medical records and application of the National Health Safety Network (NHSN) surveillance criteria for upper respiratory infections (URIs) with predetermined incubation periods for unit attribution. Descriptive statistics of the study population were examined, and comparative analyses were performed on demographic and process metrics. Data analysis was conducted using R statistical software.

RESULTS: We observed an overall decrease in respiratory HAVI of 68%, with prepandemic rates of 0.19 infections per 1,000 patient significantly decreased to a rate of 0.06 per 1,000 patient days in the pandemic period (P < .01). Rhinovirus made up proportionally more of our respiratory HAVI in the pandemic period (64% vs 53%), with respiratory HAVI secondary only to rhinovirus identified during 8 of 16 months in the pandemic period. Compliance with our HAVI prevention bundle significantly improved during pandemic period.

CONCLUSIONS: Enhancement of our HAVI bundle during the COVID-19 pandemic contributed toward significant reduction in nosocomial transmission of respiratory HAVI. Even with prevention practices optimized, respiratory HAVIs secondary to rhinovirus continued to be reported, likely due to the capacity of rhinovirus to evade bundle elements in hospital, and infection prevention efforts at large in the community, leaving vulnerable patients at continued risk.

10.1016/j.ajic.2022.04.016

Am J Infect Control

35588914

The power of feedback: Implementing a comprehensive hand hygiene observer program.

2022

06/2022

1527-3296

BACKGROUND: Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses.

METHODS: A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses.

RESULTS: During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses.

DISCUSSION: Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations.

CONCLUSIONS: In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

10.1016/j.ajic.2022.06.003

Am J Infect Control

35691447

Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Critical Importance of Equipment Cleaning During Inpatient Ophthalmologic Examinations.

2018

2018 Sep 01

1549-4713

<p><strong>PURPOSE: </strong>Outbreaks of adenovirus in neonatal intensive care units (NICUs) can lead to widespread transmission and serious adverse outcomes. We describe the investigation, response, and successful containment of an adenovirus outbreak in a NICU associated with contaminated handheld ophthalmologic equipment used during retinopathy of prematurity (ROP) screening.</p>

<p><strong>DESIGN: </strong>Epidemiologic outbreak investigation.</p>

<p><strong>PARTICIPANTS: </strong>A total of 23 hospitalized neonates, as well as NICU staff and parents of affected infants.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>Routine surveillance identified an adenovirus outbreak in a level IV NICU in August 2016. Epidemiologic investigation followed, including chart review, staff interviews, and observations. Cases were defined as hospital-acquired adenovirus identified from any clinical specimen (NICU patient or employee) or compatible illness in a family member. Real-time polymerase chain reaction (PCR) and partial- and whole-genome sequencing assays were used for testing of clinical and environmental specimens.</p>

<p><strong>RESULTS: </strong>We identified 23 primary neonatal cases and 9 secondary cases (6 employees and 3 parents). All neonatal case-patients had respiratory symptoms. Of these, 5 developed pneumonia and 12 required increased respiratory support. Less than half (48%) had ocular symptoms. All neonatal case-patients (100%) had undergone a recent ophthalmologic examination, and 54% of neonates undergoing examinations developed adenovirus infection. All affected employees and parents had direct contact with infected neonates. Observations revealed inconsistent disinfection of bedside ophthalmologic equipment and limited glove use. Sampling of 2 handheld lenses and 2 indirect ophthalmoscopes revealed adenovirus serotype 3 DNA on each device. Sequence analysis of 16 neonatal cases, 2 employees, and 2 lenses showed that cases and equipment shared 100% identity across the entire adenovirus genome. Infection control interventions included strict hand hygiene, including glove use; isolation precautions; enhanced cleaning of lenses and ophthalmoscopes between all examinations; and staff furlough. We identified no cases of secondary transmission among neonates.</p>

<p><strong>CONCLUSIONS: </strong>Adenovirus outbreaks can result from use of contaminated ophthalmologic equipment. Even equipment that does not directly contact patients can facilitate indirect transmission. Patient-to-patient transmission can be prevented with strict infection control measures and equipment cleaning. Ophthalmologists performing inpatient examinations should take measures to avoid adenoviral spread from contaminated handheld equipment.</p>

10.1016/j.ophtha.2018.07.008

Ophthalmology

30180976

Development of a novel prevention bundle for pediatric healthcare-associated viral infections.

2018

1-7

2018 Jul 20

1559-6834

<p><strong>OBJECTIVE: </strong>To reduce the healthcare-associated viral infection (HAVI) rate to 0.70 infections or fewer per 1,000 patient days by developing and sustaining a comprehensive prevention bundle.</p>

<p><strong>SETTING: </strong>A 546-bed quaternary-care children's hospital situated in a large urban area.PatientsInpatients with a confirmed HAVI were included. These HAVIs were identified through routine surveillance by infection preventionists and were confirmed using National Healthcare Safety Network definitions for upper respiratory infections (URIs), pneumonia, and gastroenteritis.</p>

<p><strong>METHODS: </strong>Quality improvement (QI) methods and statistical process control (SPC) analyses were used in a retrospective observational analysis of HAVI data from July 2012 through June 2016.</p>

<p><strong>RESULTS: </strong>In total, 436 HAVIs were identified during the QI initiative: 63% were URIs, 34% were gastrointestinal infections, and 2.5% were viral pneumonias. The most frequent pathogens were rhinovirus (n=171) and norovirus (n=83). Our SPC analysis of HAVI rate revealed a statistically significant reduction in March 2014 from a monthly average of 0.81 to 0.60 infections per 1,000 patient days. Among HAVIs with event reviews completed, 15% observed contact with a sick primary caregiver and 15% reported contact with a sick visitor. Patient outcomes identified included care escalation (37%), transfer to ICU (11%), and delayed discharge (19%).</p>

<p><strong>CONCLUSIONS: </strong>The iterative development, implementation, and refinement of targeted prevention practices was associated with a significant reduction in pediatric HAVI. These practices were ultimately formalized into a comprehensive prevention bundle and provide an important framework for both patient and systems-level interventions that can be applied year-round and across inpatient areas.</p>

10.1017/ice.2018.149

Infect Control Hosp Epidemiol

30027857

Improving Cardiac Surgical Site Infection Reporting and Prevention By Using Registry Data for Case Ascertainment.

2016

190-9

2016 Jan

1552-6259

<p><strong>BACKGROUND: </strong>The use of administrative data for surgical site infection (SSI) surveillance leads to inaccurate reporting of SSI rates [1]. A quality improvement (QI) initiative was conducted linking clinical registry and administrative databases to improve reporting and reduce the incidence of SSI [2].</p>

<p><strong>METHODS: </strong>At our institution, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and infection surveillance database (ISD) were linked to the enterprise data warehouse containing electronic health record (EHR) billing data. A data visualization tool was created to (1) use the STS-CHSD for case ascertainment, (2) resolve discrepancies between the databases, and (3) assess impact of QI initiatives, including wound alert reports, bedside reviews, prevention bundles, and billing coder education.</p>

<p><strong>RESULTS: </strong>Over the 24-month study period, 1,715 surgical cases were ascertained according to the STS-CHSD clinical criteria, with 23 SSIs identified through the STS-CHSD, 20 SSIs identified through the ISD, and 32&nbsp;SSIs identified through the billing database. The rolling 12-month STS-CHSD SSI rate decreased from 2.73% (21 of 769 as of January 2013) to 1.11% (9 of 813 as of December 2014). Thirty reporting discrepancies were reviewed to ensure accuracy. Workflow changes facilitated communication and improved adjudication of suspected SSIs. Billing coder education increased coding accuracy and narrowed variation between the 3 SSI sources. The data visualization tool demonstrated temporal relationships between QI initiatives and SSI rate reductions.</p>

<p><strong>CONCLUSIONS: </strong>Linkage of registry and infection control surveillance data with the EHR improves SSI surveillance. The visualization tool and workflow changes facilitated communication, SSI adjudication, and assessment of the QI initiatives. Implementation of these initiatives was associated with decreased SSI rates.</p>

10.1016/j.athoracsur.2015.07.042

Ann. Thorac. Surg.

26410159

High proportion of false-positive Clostridium difficile enzyme immunoassays for toxin A and B in pediatric patients.

2012

175-9

2012 Feb

1559-6834

<p><strong>OBJECTIVES: </strong>To determine the frequency of false-positive Clostridium difficile toxin enzyme immunoassay (EIA) results in hospitalized children and to examine potential reasons for this false positivity.</p>

<p><strong>DESIGN: </strong>Nested case-control.</p>

<p><strong>SETTING: </strong>Two tertiary care pediatric hospitals.</p>

<p><strong>METHODS: </strong>As part of a natural history study, prospectively collected EIA-positive stools were cultured for toxigenic C. difficile, and characteristics of children with false-positive and true-positive EIA results were compared. EIA-positive/culture-negative samples were recultured after dilution and enrichment steps, were evaluated for presence of the tcdB gene by polymerase chain reaction (PCR), and were further cultured for Clostridium sordellii, a cause of false-positive EIA toxin assays.</p>

<p><strong>RESULTS: </strong>Of 112 EIA-positive stools cultured, 72 grew toxigenic C. difficile and 40 did not, indicating a positive predictive value of 64% in this population. The estimated prevalence of C. difficile infection (CDI) in the study sites among children tested for this pathogen was 5%-7%. Children with false-positive EIA results were significantly younger than those with true-positive tests but did not differ in other characteristics. No false-positive specimens yielded C. difficile when cultured after enrichment or serial dilution, 1 specimen was positive for tcdB by PCR, and none grew C. sordellii.</p>

<p><strong>CONCLUSIONS: </strong>Approximately one-third of EIA tests used to evaluate pediatric inpatients for CDI were falsely positive. This finding was likely due to the low prevalence of CDI in pediatric hospitals, which diminishes the test's positive predictive value. These data raise concerns about the use of EIA assays to diagnosis CDI in children.</p>

10.1086/663706

Infect Control Hosp Epidemiol

22227987

Risk factors and outcomes associated with severe clostridium difficile infection in children.

2012

134-8

2012 Feb

1532-0987

<p><strong>BACKGROUND: </strong>The incidence and severity of Clostridium difficile infection (CDI) is increasing among adults; however, little is known about the epidemiology of CDI among children.</p>

<p><strong>METHODS: </strong>We conducted a nested case-control study to identify the risk factors for and a prospective cohort study to determine the outcomes associated with severe CDI at 2 children's hospitals. Severe CDI was defined as CDI and at least 1 complication or ≥2 laboratory or clinical indicators consistent with severe disease. Studied outcomes included relapse, treatment failure, and CDI-related complications. Isolates were tested to determine North American pulsed-field gel electrophoresis type 1 lineage.</p>

<p><strong>RESULTS: </strong>We analyzed 82 patients with CDI, of whom 48 had severe disease. Median age in years was 5.93 (1.78-12.16) and 1.83 (0.67-8.1) in subjects with severe and nonsevere CDI, respectively (P = 0.012). All patients with malignancy and CDI had severe disease. Nine subjects (11%) had North American pulsed-field gel electrophoresis type 1 isolates. Risk factors for severe disease included age (adjusted odds ratio [95% confidence interval]: 1.12 [1.02, 1.24]) and receipt of 3 antibiotic classes in the 30 days before infection (3.95 [1.19, 13.11]). If infants less than 1 year of age were excluded, only receipt of 3 antibiotic classes remained significantly associated with severe disease. Neither the rate of relapse nor treatment failure differed significantly between patients with severe and nonsevere CDI. There was 1 death.</p>

<p><strong>CONCLUSIONS: </strong>Increasing age and exposure to multiple antibiotic classes were risk factors for severe CDI. Although most patients studied had severe disease, complications were infrequent. Relapse rates were similar to those reported in adults.</p>

10.1097/INF.0b013e3182352e2c

Pediatr. Infect. Dis. J.

22031485

Reasons Why Physicians and Advanced Practice Clinicians Work While Sick: A Mixed-Methods Analysis.

2015

815-21

2015 Sep

2168-6211

<p><strong>IMPORTANCE: </strong>When clinicians work with symptoms of infection, they can put patients and colleagues at risk. Little is known about the reasons why attending physicians and advanced practice clinicians (APCs) work while sick.</p>

<p><strong>OBJECTIVE: </strong>To identify a comprehensive understanding of the reasons why attending physicians and APCs work while sick.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>We performed a mixed-methods analysis of a cross-sectional, anonymous survey administered from January 15 through March 20, 2014, in a large children's hospital in Philadelphia, Pennsylvania. Data were analyzed from April 1 through June 1, 2014. The survey was administered to 459 attending physicians and 470 APCs, including certified registered nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>Self-reported frequency of working while experiencing symptoms of infection, perceived importance of various factors that encourage working while sick, and free-text comments written in response to open-ended questions.</p>

<p><strong>RESULTS: </strong>Of those surveyed, we received responses from 280 attending physicians (61.0%) and 256 APCs (54.5%). Most of the respondents (504 [95.3%]) believed that working while sick put patients at risk. Despite this belief, 446 respondents (83.1%) reported working sick at least 1 time in the past year, and 50 (9.3%) reported working while sick at least 5 times. Respondents would work with significant symptoms, including diarrhea (161 [30.0%]), fever (86 [16.0%]), and acute onset of significant respiratory symptoms (299 [55.6%]). Physicians were more likely to report working with each of these symptoms than APCs (109 [38.9%] vs 51 [19.9%], 61 [21.8%] vs 25 [9.8%], and 168 [60.0%] vs 130 [50.8%], respectively [P &lt; .05]). Reasons deemed important in deciding to work while sick included not wanting to let colleagues down (521 [98.7%]), staffing concerns (505 [94.9%]), not wanting to let patients down (494 [92.5%]), fear of ostracism by colleagues (342 [64.0%]), and concern about continuity of care (337 [63.8%]). Systematic qualitative analysis of free-text comments from 316 respondents revealed additional reasons why attending physicians and APCs work while sick, including extreme difficulty finding coverage (205 [64.9%]), a strong cultural norm to come to work unless remarkably ill (193 [61.1%]), and ambiguity about what constitutes "too sick to work" (180 [57.0%]).</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>Attending physicians and APCs frequently work while sick despite recognizing that this choice puts patients at risk. The decision to work sick is shaped by systems-level and sociocultural factors. Multimodal interventions are needed to reduce the frequency of this behavior.</p>

10.1001/jamapediatrics.2015.0684

JAMA Pediatr

26146908

Trends in the incidence of methicillin-resistant Staphylococcus aureus infection in children's hospitals in the United States.

2009

65-71

2009 Jul 1

1537-6591

<p><strong>BACKGROUND: </strong>The incidence of and outcomes associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in hospitalized children have been incompletely characterized.</p>

<p><strong>METHODS: </strong>We performed a retrospective, observational study using the Pediatric Health Information System, a database of clinical and financial data from &gt;40 freestanding US children's hospitals. Using discharge coding data, we characterized S. aureus infections in children &lt;18 years of age who were hospitalized during the period from 1 January 2002 through 31 December 2007.</p>

<p><strong>RESULTS: </strong>During this 6-year study period, we identified 57,794 children with S. aureus infection, 29,309 (51%) of whom had MRSA infection. The median age of patients with S. aureus infection was 3.1 years (interquartile range, 0.8-11.2 years), and less than one-third of these patients had complex, chronic medical conditions. Over time, there was a significant increase in cases of MRSA infection (from 6.7 cases per 1000 admissions in 2002 to 21.1 cases per 1000 admissions in 2007; P = .02, by test for trend), whereas the incidence of methicillin-susceptible S. aureus infection remained stable (14.1 cases per 1000 patient-days in 2002 to 14.7 cases per 1000 patient-days in 2007; P = .85, by test for trend). Of the 38,123 patients whose type of infection was identified, 23,280 (61%) had skin and soft-tissue infections. The incidences of skin and soft-tissue infection, pneumonia, osteomyelitis, and bacteremia that were caused by S. aureus increased over time, and these increases were due exclusively to MRSA. The mortality rate for hospitalized children with MRSA infection was 1% (360 of 29,309 children).</p>

<p><strong>CONCLUSIONS: </strong>There has been a recent increase in the number of hospitalized children with MRSA infection. This increase is largely driven by, but is not limited to, an increase in skin and soft-tissue infections. The mortality rate for hospitalized children with MRSA infection is low.</p>

10.1086/599348

Clin. Infect. Dis.

19463065