American Journal of Infection Control

A practicing hospital administrator explores how a risk management program can function effectively in a hospital setting. Risk management is defined and methods of planning, developing, and organizing a practical risk management program are outlined. Certain principles are presented to ensure its effectiveness and the advantages and disadvantages of such a program are discussed in this article.

A quick review of the basics of sample size and power is presented. Readers can participate in an online exercise that introduces them to a power calculator that can be used in their practice, and illustrates the concepts discussed in the article.

Once established in an institution, methicillin-resistant Staphylococcus aureus (MRSA) outbreaks have proved difficult to eradicate, despite intensive infection control measures. This report describes the nosocomial infection with MRSA of 22 male infants in a neonatal nursery during a 7-month period and the infection control procedures that effectively brought this outbreak under control and eliminated recurrence for more than 3 1/2 years. After a single index case of bullous impetigo caused by MRSA in a neonate discharged from the nursery 2 weeks previously, an additional 18 cases of MRSA skin infections were clustered in a 7-week period. Aggressive infection control measures were instituted, including changes in umbilical cord care, circumcision procedures, diapers, handwashing, gloves, gowns, linens, disinfection, placement in cohorts of neonates and staff, surveillance, and monitoring. These measures were not effective in slowing the outbreak. The single additional measure of changing handwashing and bathing soap to a preparation containing 0.3% triclosan (Bacti-Stat) was associated with the immediate termination of the acute phase of the MRSA outbreak. The nursery has remained free of MRSA for more than 3 1/2 years, attesting to the success of our program.

Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Recent exposure to health care facilities is a risk factor for carriage of multidrug-resistant organisms, but identification of hospitalized patients admitted from other health care facilities is often inefficient. At an acute care hospital, we utilized a standard point of origin code from a universal billing form (UB-04) to categorize hospitalized patients as admitted from any health care facility (long-term care facility vs acute care facility). In a prospective study, the point of origin code and information obtained from physician-documented history were validated against patient self-report. Admission source for 523 patients was assessed. For identifying admission from any health care facility, the point of origin code had 86% sensitivity (95% confidence interval [CI]: 77-92) and 98% specificity (95% CI: 97-99). Physician-documented history had 75% sensitivity (95% CI: 65-84) and 98% specificity (95% CI: 96-99). For identifying patients from long-term care facilities, the sensitivities of the point of origin code and physician history were 50% (95% CI: 23-77) and 71% (95% CI: 42-92), respectively. For identifying patients admitted from acute care facilities, the sensitivities of the point of origin code and physician history were 93% (95% CI: 84-98) and 76% (95% CI: 64-85), respectively. The point of origin code is an accurate method of identifying patients admitted from another health care facility that is comparable with physician-documented history.

Annual influenza vaccination is recommended for all persons aged ≥6 months. The objective of this study was to assess trends in racial/ethnic disparities in influenza vaccination coverage among adults in the United States. We analyzed data from the 2007-2012 National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) using Kaplan-Meier survival analysis to assess influenza vaccination coverage by age, presence of medical conditions, and racial/ethnic groups during the 2007-08 through 2011-12 seasons. During the 2011-12 season, influenza vaccination coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites among most of the adult subgroups, with smaller disparities observed for adults age 18-49 years compared with other age groups. Vaccination coverage for non-Hispanic white, non-Hispanic black, and Hispanic adults increased significantly from the 2007-08 through the 2011-12 season for most of the adult subgroups based on the NHIS (test for trend, P < .05). Coverage gaps between racial/ethnic minorities and non-Hispanic whites persisted at similar levels from the 2007-08 through the 2011-12 seasons, with similar results from the NHIS and BRFSS. Influenza vaccination coverage among most racial/ethnic groups increased from the 2007-08 through the 2011-12 seasons, but substantial racial and ethnic disparities remained in most age groups. Targeted efforts are needed to improve coverage and reduce these disparities.

The purpose of this study was to monitor disinfection with 10,000 ppm sodium hypochlorite for decontamination of common hospital spills. Simulated spills deliberately contaminated with 10(8) bacterial challenges were used for the study. Results showed greater than 5 log reduction in the challenge bacteria for all spills (serum, pus, sputum, csf, ascitic fluid, urine, and stool) except blood. Disinfection was satisfactory for blood contaminated with gram-negative bacteria, but not for staphylococci. As a practical procedure, surfaces contaminated from gross spillage of human body fluids should first be contained with absorbent materials, then disinfected with hypochlorite.

According to manufacturers information, the STERRAD 100NX sterilizer-a low temperature H(2)O(2) gas plasma sterilizer-can adequately process single channel stainless steel lumens with an inside diameter of 0.7 mm or larger and a maximum length of 500 mm using standard cycle sterilizing conditions. The aim of this study was to qualify the performance of this H(2)O(2) gas plasma sterilizer under different experimental settings representing worst case conditions. Inoculated carriers were placed at the midpoint position of specified lumens and then submitted to flex scope sterilizing conditions. To simulate insufficient cleaning or crystalline residues, we added organic and inorganic challenges to our inoculated carriers. For experiments done with unchallenged carriers, quantitative analysis reached a log(10) reduction rate of ≥5.71, whereas qualitative results showed no growth in 24 out of 30 biologic indicators tested using flex scope half cycle conditions. Any additional kind of challenge significantly impaired the sterilization outcome. The findings of our current study emphasize the importance of a thorough validated cleaning of medical devices as well as timing for cleaning and decontamination before being exposed to the H(2)O(2) sterilization process and, furthermore, the need for strict adherence to manufacturer's recommendations.

Sterrad sterilizers have been developed for the sterilization of thermolabile materials. The aim of the present study was to challenge the efficacy of this low-temperature hydrogen peroxide-based sterilization system with different carrier materials and wrappings under experimental "clean" and "dirty" conditions. We tested the sporocidal effect of the Sterrad 100NX sterilizer (Advanced Sterilization Products, Irvine, CA) on the carrier materials titanium, polyethylene, and polyurethane with single versus 3 wrappings of inoculated carriers. To simulate insufficient cleaning or crystalline residues, carriers were charged with spore inocula containing organic and inorganic burdens. Our qualitative results show that irrespective of the number of wrappings in the "clean" condition, sterilization by the Sterrad 100NX was equally effective on all 3 carrier materials, reaching a log-10 reduction rate of ≥ 6 under standard half-cycle conditions. Any additional organic or inorganic challenge significantly impaired the sterilization outcome. Results of our current study emphasize the utmost importance of thorough and reliable cleaning of medical devices before being exposed to a subsequent hydrogen peroxide sterilization process. Any institution using this sterilization technology should have a well-established and validated cleaning process and enforce a rigorous quality assurance program for all steps of the presterilization processing of medical devices.

A surgical site infection (SSI) develops in 2% to 5% of patients undergoing operation. We report SSI surveillance at Baystate Medical Center, Springfield, Mass, in coronary artery bypass operation between 1991 and 2001, and demonstrate a substantial decline in SSI rates accomplished with use of multiple intervention strategies. Infection documentation used Centers for Disease Control and Prevention (CDC) criteria and a postdischarge questionnaire. Infections were stratified by risk class. Strategies used to lower SSI rates included active surveillance and provision of authenticated SSI rate plus surgeon-specific rates. Interventions included outbreak analyses and targeted nasal mupirocin plus chlorhexidine showering. The rate of coronary artery bypass-related SSIs declined from >8% to <2%, comparing extremely favorably with CDC national data. Percentage of infections documented by postdischarge questionnaire was variable and did not change during the study period. Most SSIs were at the harvest site. Routine implementation of nasal mupirocin plus chlorhexidine preoperative showering effectively disrupted an outbreak of Staphylococcus aureus, and statistically decreased rates of postoperative infections with this organism. Regular provision of authenticated and verified data, use of postdischarge questionnaires, and careful attention to adverse trends and outbreaks with appropriate actions can substantially decrease rates of infections in coronary artery bypass operation.

For valid comparisons with the published NNIS nosocomial infection rates, hospitals must define data elements in the same way. Definitions for infections, risk factors, and populations monitored are specified in the NNIS System, but thus far only infection definitions and the list of NNIS operative procedure categories have been published. This article defines other key terms used in the NNIS System.

A safe alternative to ethylene oxide for reprocessing heat-sensitive lumen medical devices, such as endoscopes, is needed. The effectiveness of a new, safe, low-cost, and environmentally friendly low-temperature sterilization process using ozone was assessed. Rigid lumen devices were used to assess the maximum length of lumens of different internal diameters that can be sterilized in the TSO(3) model 125L ozone sterilizer. Two inoculation techniques were used. An inoculated wire was placed inside lumens with internal diameters of 0.8 mm and larger, whereas lumens with an internal diameter of 0.5 mm were inoculated directly. Lumens with internal diameters of 0.5 mm, 1 mm, 2 mm, 3 mm, and 4 mm with lengths varying between 45 and 70 cm can be sterilized with ozone. Calculation of the log reduction value for each size demonstrated the achievement of a sterility assurance level of 10(-6). Experimental results demonstrated a linear relationship (with r(2) = 0.990) between the length of lumen that can be sterilized in the 125L ozone sterilizer and its internal diameter. Effective sterilization of an ACMI ureteroscope that is more challenging in terms of sterilant penetration in a small lumen (0.8 mm) compared with the stated lumen claims confirms that the relationship can conservatively be used to predict the length of a lumen device that can be sterilized in the 125L ozone sterilizer for a given diameter. Intermediate sizes of lumen devices that can be sterilized in the 125L ozone sterilizer can be interpolated from the linear relationship between diameter and length found in the present study.

Multicenter studies assessing hand hygiene adherence and risk factors for poor performance are scarce. In an observational study involving 13 hospitals across Ontario, Canada, we found a mean adherence rate of 31.2%, and that adherence was positively associated with nurses, single rooms, contact precautions, and the availability of alcohol hand rub dispensers. Copyright © 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background and aims Appropriate hand hygiene among healthcare workers is the most important infection prevention measure; however, compliance is generally low. Gain-framed messages (i.e. messages that emphasise the benefits of hand hygiene rather than the risks of noncompliance) may be most effective. The aim of this study was to test the impact of gain-framed messages on the frequency of handdisinfection events and compliance with the hand hygiene protocol. Methods The study was conducted in a 27-bed neonatal intensive care unit. We performed an interrupted time series analysis of objectively measured hand disinfection events. We used electronic devices in hand alcohol dispensers, which continuously documented the frequency of hand disinfection events. In addition, hand hygiene compliance before and after the intervention period were directly observed. Results The negative trend in hand hygiene events per patient-day before the intervention (decrease by 2.3 [standard error, 0.5] per week) changed to a significant positive trend (increase of 1.5 [0.5] per week) after the intervention (p < 0.001). The direct observations confirmed these results, showing a significant improved in hand hygiene compliance from 193 of 303 (63.6%) observed hand hygiene events at pretest to 201 of 281 (71.5%) at posttest (p = 0.05). Conclusions We conclude that gain-framed messages concerning hand hygiene presented on screen savers may improve hand hygiene compliance.

One qualified infection control director, reporting directly to administration, was responsible for the Infection Prevention and Control Program of a 150-bed acute care, non-teaching, for-profit hospital. To observe for potential trending, questions (consultations) and determinations related to infectious processes were documented. To explore the possibility of measuring the essential although "hidden" function of the infection control consultation (process), which is a role not formerly linked to infection rates (outcomes). A 7-year retrospective study was conducted of all infection control consultations requiring more than a 5-minute intervention, as part of routine job responsibilities. The XmR Statistical Process Control charts (XmR Charts) and Pearson's Correlation Coefficient were used to analyze the activity of infection control consultations. From January 1, 1998 to December 31, 2004, there were 770 infection control consultations logged for 375.1 hours. Beginning with 2003, the variation in both the number and duration of infection control consultations in the XmR Charts become more standardized and has a smaller moving range between data points. The Pearson's Correlation Coefficient shows statistical significance (P <.05) between the number and duration of consultations. Assessment of infection control consultations at this 150-bed hospital illustrates that this essential component can be measured, and should be formerly tracked to document overall assessment of infection prevention and control interdisciplinary interaction. The consultation process became more efficient over the 7-year study period because, as the number of questions increased, the duration required to achieve closure decreased.

To assess the occurrence of enteric gram-negative bacilli (EGNB) bloodstream infections (BSI) in a neonatal intensive care setting during a 17-year period in which a consistent antibiotic treatment program was in place. To document infections, outbreaks, or epidemics, emergence of antibiotic resistance, clinical correlates, and outcomes of the most prevalent EGNB (Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae). This study analyzed demographic, clinical, and bacteriologic information from 360 infants born 1986-2002 who developed 633 blood culture-proven BSI. A total of 121 EGNB were isolated (E coli, K pneumoniae, and E cloacae). Early-onset BSI were discovered within 48 hours from birth, and late-onset BSI were those that occurred thereafter. Suspected early-onset BSI were treated with ampicillin and gentamicin, suspected late-onset BSI with vancomycin and gentamicin. Antibiotics were changed on the basis of organism antimicrobial susceptibility. Early-onset BSI were noted in 52 of 21,336 (244/100,000) live births (1986-1991), 40 of 20,402 (196/100,000) live births (1992-1997), and 25 of 17,926 (139/100,000) live births (1998-2002). Of these cases, 39 were caused by E coli and 4 by K pneumoniae. Antibiograms for E coli isolated during the last 5 years of the study showed an increase in antibiotic resistance that coincided with obstetric group B streptococcus antepartum antibiotic prophylaxis. Group B streptococcus declined from 41 to 4 cases from the first to the last period. Late-onset BSI increased from 111 to 230 cases from the first to the second 6-year study period and declined modestly (171 cases) during the last. Fifteen percent (78 cases) of late-onset BSI were caused by EGNB, 5% by other gram-negative bacilli, 67% primarily by coagulase-negative staphylococcus, and 13% by fungus. Nonspecific clinical and hematologic signs of late-onset BSI were similar across EGNB species, but necrotizing enterocolitis was often associated with E coli, whereas pneumonia and prolonged thrombocytopenia characterized K pneumoniae infections. No outbreaks or epidemics were observed, and strains of EGNB with evidence of extended spectrum beta-lactamase production were never isolated. Antepartum antibiotic prophylaxis may have increased antibiotic resistance in E coli isolates from early-onset BSI but has dramatically decreased group B streptococcus infections. Late-onset BSI caused by EGNB increased, but without changes in antibiotic susceptibility. In spite of medical advances, E coli, K pneumoniae, and E cloacae remain responsible for significant morbidity and mortality, especially in very low birth weight infants.

Am J Infect Control 2001;29:203-6

To describe and analyze trends in hygiene-related advertisements and examine potential social and regulatory changes that might be associated with these trends. From 1940 to 2000, advertisements in January issues of 2 widely read magazines were analyzed every fifth year, and 2 additional magazines only available from 1960 to 2000 were also analyzed every fifth year. In a content analysis, the total number of advertisements were determined and specific advertisements were grouped into categories (personal hygiene, dishwashing, laundry, and house cleaning) and further examined for the presence of 4 key claims (aesthetics, health effects, time-saving, and microbial effects). From 1940 to 2000 for all magazines combined, 10.4% of the advertisements were devoted to hygiene products. After 1960 there were significantly fewer hygiene advertisements as compared with 1940 to 1955, and there was a significant increase after 1980 (P <.00001). Throughout all 6 decades, most advertisements related to personal hygiene. There were no significant differences over time in the proportion of advertisements that made claims related to health, microbial effects, or aesthetics, but significantly more advertisements before 1960 made time-savings claims (P =.009). This content analysis reflects a cyclical attention in consumer advertising to personal and home hygiene products during the past 6 decades, with a waning of interest in the decades from 1960 to 1980 and an apparent resurgence of advertisements from 1985 to 2000. The potential contributions of federal regulatory bodies and societal changes (e.g., new marketing strategies and options, product development, new and re-emerging infectious diseases, increasing concern about antimicrobial resistance, and increasing recognition that infectious diseases are unlikely to be eradicated) to these marketing trends are discussed.

To determine the prevalence of and risk factors for antibody to the hepatitis C virus in hospital employees. Retrospective testing of serum samples obtained from 1677 hospital employees during a prehepatitis B vaccination program in a private teaching community hospital. Twenty-three employees (1.4%) were found to have antibody to hepatitis C virus. The prevalence of antibody to hepatitis C virus was higher in blacks (3.4%) than in whites (1.1%, p = 0.03) and Hispanics (2.6%, p = 0.88). In a logistic regression model, factors significantly associated with antibody to hepatitis C virus seropositivity included antibody to hepatitis B core antigen (p = 0.002), a history of blood transfusion (p = 0.03), and needlestick injuries (p = 0.04). Although the prevalence of antibody to hepatitis C virus in health care workers was not high, needlestick injuries were associated with an increased risk for acquiring hepatitis C virus infection.

An estimated 4 million patients per year in the United States are subjected to urinary catheterization. Approximately 25% of patients who are hospitalized have an indwelling urinary tract catheter placed at some time during their hospital stay and nosocomial urinary tract infections develop in 5% per day, with associated bacteremia in 4% of patients. We sought to assess the prevalence and the appropriateness of the use of urinary catheters at a community teaching hospital in medical patients age 65 years and older. We randomly selected 285 charts from a total of 2845 patients admitted during the year 2000 who were 65 years and older and had an indwelling urinary tract catheter inserted during the first 24 hours after admission. We excluded patients who had a urinary catheter placed before admission and patients admitted for operation. On chart review we found an appropriate indication for catheterization for 46% of these patients. A physician or nurse explicitly documented the reason for catheter placement in only 13%. No order for catheterization was written in 33% of the charts. Mean duration of catheter use was 3 days. Less than half of urinary catheterizations in this teaching hospital were indicated and even fewer had an explicit indication recorded in the chart. Other investigators have had similar findings at other hospitals. Interventions are needed to decrease the inappropriate use of urinary catheters.

Biomedical research journals are important because peer reviewed research is viewed as more legitimate and trustworthy than non-peer reviewed work. Therefore, it is important to know how knowledge transmitted through academic biomedical journals is produced. This article asks if some organizations are more likely to produce research than others and if organizational setting is linked with an article's impact, as measured by citation counts. Using research on methicillin-resistant Staphylococcus aureus (MRSA) as a case study, we examined the role that hospitals, universities, public health agencies, and other organizations have in shaping an emerging research area. We collected public data on the organizational affiliations of researchers who authored 1,721 articles in general interest and selected specialty journals. MRSA research appears to have evolved in stages that require the participation of different types of organizations. Additionally, our analyses indicate that an author's organizational affiliation predicts citation counts, even when controlling for other factors. Organizations vary greatly in their ability to produce research, and this should be taken into account by those who manage or award funds to research organizations. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

We reviewed the English-language peer-reviewed journals and the Centers for Disease Control's Morbidity and Mortality Weekly Reports between 1970 and 1984 presenting information about infections and infection risk in residents of long-term care facilities. More than 50 articles met review criteria. Approximately one third of the articles were reports of outbreaks, primarily of respiratory and gastrointestinal infections. Seven articles reported rates for several infection sites, but most rates were not directly comparable to one another because numerators and/or denominators were different. Many of the studies have been done in Veterans Administration hospitals with largely male populations, which may limit their applicability to freestanding long-term care facilities with largely female clients. This review establishes the need for high-quality observational studies of infections in long-term care facilities. Such studies are needed before intervention studies can be done to measure the effect of manipulation of risk factors on infection outcome.