North Carolina Division of Public Health Healthcare-Associated Infections Prevention Program: 2012 Highlights

by Jennifer MacFarquhar, R.N., M.P.H., C.I.C.

Key accomplishments and activities of the North Carolina Healthcare-Associated Infections Prevention Program (N.C. HAI Program) in 2012 include the following:

1. Transitioned from a voluntary to a mandatory surveillance program for healthcare-associated infections (HAI) effective January 1, 2012.

• The permanent version of the North Carolina Administrative Code rule specifying requirements for reporting of healthcare-associated infections from North Carolina hospitals was adopted by the Commission for Public Health on September 20, 2012 and became effective October 1, 2012. 

2. Became the third state partner in the One & Only Campaign, a public health campaign led by the CDC and the Safe Injection Practices Coalition that aims to eradicate outbreaks resulting from unsafe injection practices by raising awareness among patients and healthcare providers about safe injection practices.
3. Released first public report on healthcare-associated infections on October 1, 2012, as required by the NC Administrative Code.
4. Participated or consulted in responses to more than 75 outbreaks in healthcare settings.

Decontamination of Hospital Privacy Curtains

by Bill Rutala, M.S., M.P.H., Ph.D. 

Over the past decade, substantial scientific evidence has accumulated that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key healthcare-associated pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile, multidrug-resistant Acinetobacter spp., and norovirus.^{1, 2}  All of these pathogens have been demonstrated to persist in the environment for hour to days (and in some cases months), to frequently contaminate the surface environment and medical equipment in the rooms of colonized or infected patients, to transiently colonize the hands of healthcare personnel (HCP), to be associated with person-to-person transmission via the hands of HCP, and to cause outbreaks in which environmental transmission was deemed to play a role. Furthermore, hospitalization in a room in which the previous patient had been colonized or infected with MRSA, VRE, Clostridium difficile, multidrug-resistant Acinetobacter spp., or multidrug-resistant Pseudomonas has been shown to be a risk factor for colonization or infection with the same pathogen for the next patient admitted to the room.²

Survey of Carbapenem-resistant Enterobacteriaceae (CRE) in North Carolina Hospitals: Key Findings

by Kristin Sullivan, M.P.H.

Carbapenem-resistant Enterobacteriaceae (CRE) are a growing public health concern and the current topic of CDC’s Vital Signs campaign (http://www.cdc.gov/vitalsigns/HAI/CRE/index.html). These organisms are associated with high mortality rates and have the potential to spread widely through transmissible gene segments. Although CRE prevalence is on the rise, the opportunity still exists to prevent widespread transmission.

In the United States, the most common mechanism of carbapenem resistance is the Klebsiella pneumoniae carbapenemase (KPC), which was first identified in North Carolina in 2001.  Although KPC-producing strains of CRE have been identified in our state, other unusual strains with less common resistance mechanisms such as New Delhi metallo-β-lactamase (NDM), Verona integrin-encoded metallo-β-lactamase (VIM), and the imipenemase (IMP) metallo-β-lactamases have not been reported in North Carolina. These unusual strains have been found primarily among patients who received overnight medical treatment outside the United States.

In order to prevent the spread of KPC, as well as to detect and prevent the emergence of unusual forms of CRE, a coordinated, regional effort among providers, healthcare facilities and public health is necessary.

Hospital Surveys. In order to estimate the prevalence of CRE in our state, the North Carolina Division of Public Health (NC DPH) and the North Carolina Statewide Program for Infection Control and Epidemiology (NC SPICE) requested that hospital infection preventionists (IPs) and hospital laboratories provide basic information regarding identification of and response to CRE in their facilities. In July 2012, surveys were sent with questions covering the time period from January 2011-June 2012. The surveys were specifically developed to determine 1) the frequency of CRE identification in NC, 2) current practices for detecting CRE and 3) current practices used to prevent transmission.

CDC Issues Vital Signs Report on CRE

by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.

Carbapenem-resistant Enterobacteriaceae (CRE) (e.g., E. coli, K. pneumoniae) are   The data provided in the CDC report are not surprising, given the international emergence of these “superbugs”, but they are still rather sobering.  In fact, in the press conference held by the Director of the CDC, Dr. Thomas Frieden stated:

CRE… pose a triple threat. First, they’re resistant to all or nearly all antibiotics - even some of our last-resort drugs.  Second, they have high mortality rates.  They kill up to half of people who get serious infections with them.  And third, they can spread their resistance to other bacteria.  So one form of bacteria, for example, carbapenem-resistant Klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also… We only have a limited window of opportunity.

Data from CDC’s National Healthcare Safety Network (NHSN) and The Surveillance Network – USA (TSN) revealed the proportion of Enterobacteriaceae that were CRE rose from 1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN facilities – A four-fold increase over 10 years. In Klebsiella species, the situation is dire with 10.4% classified as CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and 17.8% of long-term acute-care hospitals reported at least one CRE in their facility.   Moreover, healthcare institutions in 42 state have now identified at least one case of CRE. 

Trends in Resistance to Carbapenems and Third-Generation Cephalosporins among Clinical Isolates of Klebsiella pneumoniae in the United States, 1999–2010

So what are the current CDC recommendations for management of the CRE cases?  CDC continues to recommend that facilities follow the CDC guidance for preventing the spread of CRE in healthcare settings (http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html).

Tips and Tricks for Navigating NHSN Group Rights ... Again and Again

by Cindi Snider, Ph.D.
Already enrolled in the NC DPH user group (User ID: 15728)? Great! Never have to deal with granting data access rights again? Not quite… Although the following discussion will focus on the NC DPH user group, keep in mind that it applies to other user groups as well.

Once a member of the NC DPH user group, your hospital will be periodically asked to re-confer data access rights. Why? When reporting requirements change, NC DPH’s access to hospital data will need to change. For example, NC DPH only had access to hospital data for CLABSI and CAUTI (in ICUs) as well as SSI (post abdominal hysterectomy and colon surgery) for 2012. In preparation for the new LabID MRSA bacteremia and C. difficile reporting in January 2013, rights had to be re-conferred in fall 2012. NC DPH led changes to data access rights results in NHSN notices in the “Alerts” page.

But that is not the only type of change that affects NC DPH’s access to hospital data. A common change is when hospitals add or remove reporting units or wards in NHSN for CLABSI and CAUTI. These types of changes do not lead to alerts or notifications sent to NC DPH. NC DPH only becomes aware of these changes when the monthly reconciliation report contains missing data for the unit or ward. Cue the ominous music…

One Hospital's Road to Zero CLABSIs

by Connie Jones, R.N., C.I.C.

Working with the NC Prevent CLABSI Collaborative, the Vascular Access Safety Team (V.A.S.T.) at CaroMont Health in Gastonia has reduced Central Line-associated Bloodstream Infection (CLABSI) rates to zero across all of their ICUs for the past six months with the following strategies:

• Implemented the IHI Central Line Insertion Bundle at high compliance. 
•  Initiated house-wide, extensive staff education and incorporated annual competencies for central lines into all staffs’ job descriptions calling for accessing the vascular system. 
• Implemented a maintenance bundle in 2011 when they recognized that the CLABSIs they did have were occurring, on average, ten days after line insertion, indicating inoculation was most likely happening after line insertion. The bundle included: strict hand hygiene when the central line was entered/manipulated; scrubbing hubs/ports with a sterile 70 percent isopropyl alcohol wipe for at least 15 seconds prior to entering to administer medications, draw blood, etc.; and ensuring all ports were capped at all times. Cap styles were changed and standardized throughout the hospital to promote better disinfection. 
• Ensuring line dressing changes were performed according to policy written based on the most up-to-date published scientific evidence. 

Insulin Pen Reuse Implicated in Potential Bloodborne Pathogen Exposures in NY and NC

by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.

Credit:  One and Only Campaign

At least two Veterans Affairs (V.A.) medical centers in New York and North Carolina, and one general hospital in New York have recently detected potential exposures as a result of improper insulin pen re-use in former inpatients.   Officials in the Buffalo V.A. Medical Center (N.Y.) uncovered several incidents over a two year period where multi-dose insulin pens intended for use by a single patient were reused on more than one patient.  Although the needles were changed, the stored insulin could have been contaminated by a back flow of blood; changing the needle does not make it safe for multi-patient use.  As a result of these unsafe injection practices at least 700 former inpatients were notified and tested.

The case in New York prompted an audit of practices in all V.A. medical centers across the country.  During an audit at the W.G. Hefner V.A. Medical Center in Salisbury, N.C., auditors uncovered insulin pen re-use identical to what was reported in NY.  So far, at least 200 former inpatients have been notified and tested following the potential exposures.  

A similar case to those reported at the V.A.s occurred at Olean General Hospital in New York.  Multiple instances of inadvertent reuse among inpatients from 2009-2013, resulting in notification of more than 2000 former inpatients.  Following notification, at least 3 lawsuits have been filed by former patients alleging contracting hepatitis C as a result of the exposure and a potential class action suit against the hospital, its managing organization, and two pharmaceutical companies who manufactured pens used by the hospital.

All facilities have suspended use of insulin pens.

Insulin Pen Safety Recommendations

Regulatory Update: CMS Issues Clarification of F Tag 441 - Laundry and Infection Control

by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.

Credit:  Reuters

On January 25, 2013, The Centers for Medicare and Medicaid Services (CMS)  released a memo notifying State Survey Agencies of a change.  The memo addressed laundry detergents with and without antimicrobial claims, use of chlorine bleach rinses, water temperatures during the process of washing laundry, maintenance of laundry equipment and items, and ozone laundry cleaning systems.  The summary of changes is as follows:

• Laundry Detergents – New laundry detergents are more effective at removing soil and reducing the presence of microbes.  CMS has determined that facilities may use any detergent designated for laundry in laundry processing, and are not required to have antimicrobial claims.  Facilities should follow manufacturers’ Instructions for Use (IFUs)
• Water Temperatures and Chlorine Bleach Rinses - Laundry processing within facilities occurs at a lower temperature, and many laundry items are made of bleach incompatible materials.  Chlorine bleach rinse is not required for all laundry items processed in low temperature washing environments due to improvements in detergents in producing hygienically clean laundry without bleach.  Chlorine bleach rinse may still be used for items composed of materials like cotton.  Hot water washing at temperatures ≥160°F for 25 minutes and low temperature washing at 71-77°F with a 125 ppm chlorine bleach rinse remain effective ways to process laundry.  For facilities using hot water (≥160°F), the temperature must be maintained for 25 minutes.

Nursing Homes Get Their Very Own Soap!

Behind the Scenes at "Gowns and Gloves"

A partnership between the Centers for Medicare and Medicaid Services and NC Division of Health Service Regulation has provided funding for the development of educational modules to promote infection prevention in nursing homes. During the two year funding period SPICE will develop four modules: management of antibiotic resistant bacteria, isolation precautions, safe injection practices, and environmental disinfection. The modules will be web-based and user-friendly with the aim of reaching a wide array of healthcare personnel. The only proven method to increase compliance with key infection control activities is ongoing, periodic education. The first module, Antibiotic Resistant Organisms, was launched on February 25th. A second module on Isolation Precautions will roll out later this spring.

Gowns and Gloves Soap Opera wins a Telly Award

The Telly Awards has named SPICE and Rucci Productions as an Bronze winner in the 34th Annual Telly Awards for our piece titled Gowns and Gloves. With nearly 11,000 entries from all 50 states and numerous countries, this is truly an honor.

The Telly Awards was founded in 1979 and is the premier award honoring outstanding local, regional, and cable TV commercials and programs, the finest video and film productions, and online commercials, video and films. Winners represent the best work of the most respected advertising agencies, production companies, television stations, cable operators, and corporate video departments in the world.

For its 34th season, The Telly Awards once again joined forces with YouTube to give the public the power to view and rate videos submitted as part of the People’s Telly Awards. In addition to recognition from the Silver Telly Council, the judging panel that selects the Telly Awards winners, the Internet community helps decide the People’s Telly Awards winners.

A prestigious judging panel of over 500 accomplished industry professionals, each a past winner of a Silver Telly and a member of The Silver Telly Council, judged the competition, upholding the historical standard of excellence that Telly represents. The Silver Council evaluated entries to recognize distinction in creative work – entries do not compete against each other – rather entries are judged against a high standard of merit. Less than 10% of entries are chosen as Winners of the Silver Telly, our highest honor. Approximately 25% of entries are chosen as Winners of the Bronze Telly.

“The Telly Awards has a mission to honor the very best in film and video,” said Linda Day, Executive Director of the Telly Awards. “SPICE and Rucci Productions' accomplishment illustrates their creativity, skill, and dedication to their craft and serves as a testament to great film and video production.”

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