ICR: New Collaboration, New Format

The Statewide Program for Infection Control and Epidemiology and the NC Division of Public Health are embarking on a new communication collaboration. Going forward, Infection Control Report will continue to offer up applicable nuggets of knowledge from UNC infection prevention experts and to highlight relevant literature, news, and programming. Added to Infection Control Report will be brief summaries of NC Division

of Public Health reports, NHSN tips, tricks, hints, and lessons learned, NHSN success stories, and information relevant to long term care facilities. All of this will be packaged in a user friendly format for easy access and utilization.

A new format 

Easy access and utilization for our users is important to us. With an increasing number of Infection Control Report (ICR) contributors, we are publishing ICR as a website in a blog format. Welcome to the new Infection Control Report!

 

Influenza Immunization at UNC Health Care: Impact of Implementing a Program where Continued Employee is Conditional on Receipt of Vaccine

by David Weber, M.D., M.P.H.

Each year approximately 10% to 20% of Americans develop viral influenza leading to thousands of deaths.  The risk of severe illness and death is increased in persons who are very young, older, have comorbid conditions (e.g., obesity, diabetes, renal failure, cardiac disease), or are immunocompromised (e.g., HIV-infected, solid organ transplant, cancer).  High coverage rates of influenza vaccine among healthcare personnel have been demonstrated to reduce the risk of acquisition of influenza by patients.  For these reasons, the Centers for Disease Control and Prevention (CDC) and many professional organizations (e.g., SHEA, APIC) have recommended that all healthcare personnel, unless they have a medical contra-indication receive influenza vaccine.  Furthermore, The Joint Commission (TJC) and CMS require that healthcare facilities track influenza vaccine coverage by healthcare personnel.  Many interventions have been demonstrated to improve uptake of the vaccine including the following:  providing vaccine at no cost to healthcare personnel, providing vaccine at convenient times and locations, strong support by senior administration, use of mobile carts, and rewards for taking vaccine.  By using ALL these interventions healthcare facilities can often achieve immunization coverage of 70% to 80%.  However, published papers have demonstrated that to exceed these levels, influenza immunization must be a condition of employment.

UNC Health Care made receipt of influenza immunization a condition of employment (or accreditation for professional staff) for the 2012-2013 influenza season.  We did accept religious objections and medical contra-indications are valid reasons for not receiving vaccine.  Of 9,533 employees at UNC Health Care, 9,529 were compliant with our policy (99.9%) and the other 4 were terminated.  Overall, 9,002 employees (94.4%) were vaccinated, 116 (1.2%) had medical contra-indications, and 370 (3.88%) were granted a religious exemption; 1,048 employees provided documentation of receipt of influenza vaccine by their own medical provider.  Our experience at UNC Health Care demonstrates that receipt of influenza vaccine can successfully be made a condition of employment.  Influenza vaccine protects our employees and our patients and healthcare facilities should comply with CDC and TJC recommendations for use. 

Also of interest, at UNC Health Care we allow our healthcare personnel to choose among inactivated influenza vaccine (IIV) which is given as an intra-muscular injection (IM), attenuated inhaled influenza vaccine, and inactivated intradermal influenza vaccine.  Our personnel made the following choices (numbers are an approximate):  inactivated IM vaccine, 8600, attenuated inhaled vaccine, 460, and inactivated intradermal vaccine, 580. 

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.