MRSA screening in ICUs

1. MRSA screening in ICUs Sarah Simmons, MPH CIC

2. 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

3. Background • Mandatory house-wide screening mandatory in several states • Results are delayed 48 hours for clinical cultures

4. Results Rate decreased from 3.19 to 1.66 (p=0.005)

5. Results Rate decreased from 0.80 to 0.38 (p=0.0003)

6. Conclusion • It works!! • Additional populations • PAT • Nursing Home • Dialysis • Long term indwelling devices

7. Lessons from Publishing • I already had the data • Focus on a simple question • Start early • Stay Organized!!

8. What does ESBL mean and why does my patient require contact isolation? Denise Langford, BS, MT(ASCP), CIC

9. 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.

10. What is an ESBL bacteria? • ESBL = Extended-spectrum beta-lactamase • 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

11. 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.

12. 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!

13. How does Baptist Health handle ESBL? Contact Precautions (In addition to Standard Precautions) • Wash Hands or use hand sanitizer before entering and when leaving room • Wear gloves and gown when entering room • Use patient dedicated equipment or single-use disposable equipment. • Clean and disinfect all equipment before removing from environment.

14. 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

15. Challenges / Preparation • Literature seaches/references • Get help from Hospital Librarian • Lots of reading • Being creative and making it interesting • Deadlines! Deadlines! Deadlines!

16. 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 

17. Legionella – Every IP’s Dream – Or Is It? CCNQ Experience Kris Chafin, RN, BA, MBA, CIC Infection Preventionist

18. 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.

19. 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!

20. Signs and Symptoms • Rapidly rising fever and chills • Non-productive cough • Nausea and diarrhea

21. 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.

22. Why Hospitals? • Immunocompromised patients are susceptible to Legionnaires’ Disease, including chemo patients, transplant patients, patients on long term steroid therapy and heavy smokers.

23. Why Hospitals? Sources: • Potable water systems • Spray misters • Decorative fountains • Cooling tower drift • Irrigation Systems • RT Equipment • Whirlpools and Spas • Therapy pools

24. 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.

25. 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?)

26. 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!

27. 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.

28. 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.

29. 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.

30. 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.”

31. Initial Restrictions • Ice Machine Use • Water fountains • Mass quantities of hand sanitizers and bottled water distributed

32. 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.

33. 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!

34. 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.

35. 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.

36. 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.

37. 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

38. Scrub the Hub Sarah Simmons, MPH CIC Celestina Bryson, DNP, ACNP-BC, CCNS, MSN, MBA, CCRN Susan Porter, MT ASCP

39. 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

40. 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

41. Results

47. 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

48. Lessons from Publishing • Team work is critical • Allow time for editing each others work

49. 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.