Audit in infection control

Examining the impact and response to an outbreak of carbapenemase-producing Enterobacterales in a neonatal unit in the United Kingdom: An outbreak report

Background

Carbapenemase-producing Enterobacterales (CPE) are a group of Gram-negative bacteria causing global concern due to their resistance to carbapenems. In this report, we detail the learning points from a CPE outbreak in a tertiary neonatal unit (NU) in the UK.

Methods

Routine surveillance screening (rectal swabs) of babies on the NU identified a potential cluster of CPE carriage. Samples were sent to a reference laboratory for confirmatory testing. Environmental screening and cot mapping were undertaken to determine movements of babies within the unit. Regular audits of cleaning standards, hand hygiene, and maternal hygiene when expressing breast milk were carried out.

Results

The outbreak lasted 19 weeks. During the outbreak, there were 360 admissions, with 11 babies being colonised with the outbreak strain. Once the outbreak was declared, there were enhanced Infection Prevention and Control (IPC) precautions (including increased environmental and equipment cleaning frequency). CPE screening frequency was increased and cot capacity was reduced. Hand hygiene compliance improved from 92% at the start of the outbreak to 100% by its close. Cleaning standards remained compliant. Maternal hygiene standards varied from 78% to 100%, but no cross-infection links were identified. Environmental screening was negative. No route of cross-infection was identified. Notably, no babies developed invasive CPE infection.

Conclusion

This is the first report of a CPE outbreak in a UK NU. Although no specific mode of cross-transmission was identified and the outbreak's end cannot be attributed to any single intervention, the bundle of interventions proved successful after a 5-month period.

Radiology Department: A Potential Source of Multidrug-Resistant Microorganisms: A Cross-Sectional Study at Tertiary Hospital, Palestine

Introduction

Globally, healthcare facilities face a great challenge in the form of hospital-acquired infections (HAIs). Aside from the morbidity and mortality they cause, these illnesses are also extremely costly. Research on infection transmission in the medical field has been considerable, but not so much in the radiology department.

Aim

This study aims to identify the presence of multidrug-resistant (MDR) microbes on surfaces that are frequently touched in computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), plain X-ray examination rooms, and portable radiography that are susceptible to contamination as well as to investigate the potential dangers of contracting MDR organisms to patients and healthcare providers. Materials and Method. In this study, 160 swab samples were collected from the radiology department during May and June 2022. Samples were obtained from 80 predefined surfaces twice within and outside of CT and MRI examination rooms as well as from US and plain X-ray machines and portable X-ray machines. Samples were taken at 7:00 a.m. using cotton swabs following the regular cleaning procedure. Bacterial colony-forming units (CFUs) per square centimeter were calculated after swabbing a 100 cm2 surface.

Results

Nearly all of the surfaces tested had bacterial CFUs. The highest contamination rate was found on keyboards ranging from (1.2-8) CFU/cm2, the sides of patient tables (1.2-20) CFU/cm2, knee coil (2.4-3) CFU/cm2, and patient leg supports (1.2-8) CFU/cm2. A noticeable increase in the contamination was noticed in June compared to May, and this was consistent with the increase in the number of isolated patients in the hospital, the workload in the radiology department, and the number of patients referred to the hospital. In our study, none of the examined sites showed contamination with MDR Gram-negative bacteria such as extended-spectrum beta-lactamases producing Enterobacterales (ESPL) or Carbapenemase-producing Enterobacterales (CPE). On the other hand, methicillin-resistant Staphylococcus (MRS), vancomycin-resistant Staphylococcus (VRS), and vancomycin-resistant Enterococcus (VRE) were detected.

Conclusion

All of the radiology department equipment and sites could be a source of bacterial infection including MDR, so the obligatory and committed disinfection protocol must be revised and implemented in the morning and between patients.

Effectiveness of Antiepidemic Measures Aimed to Reduce Carbapenemase-Producing Enterobacteriaceae in the Hospital Environment

Purpose

The objective of this study was to evaluate the effectiveness of hospital-based antiepidemic measures aimed at limiting the spread of symptomatic infections and colonization with carbapenem-resistant Enterobacteriaceae (CPE), mainly NDM-producing Klebsiella pneumoniae, with particular emphasis on microbiological screening tests.

Methods

This retrospective study was based on data from 168 hospitals under the supervision of the Provincial Sanitary and Epidemiological Station in Warsaw, Poland, in 2016–2017. Analysis of the effectiveness of antiepidemic procedures focused on the type of implemented antiepidemic procedures, the number of microbiological screening tests per year, the geographic location of the hospitals (inside or outside Warsaw), the timing of the screening tests (on admission to hospital or 48 hours later), and the results of the screening tests.

Results

Rates of proper isolation of patients infected or colonized with an alarm pathogen including NDM-producing K. pneumoniae increased from 38.0% in 2016 to 49.5% in 2017 (p > 0.05). The number of screening tests performed increased by 88% from 68319 in 2016 to 128373 in 2017. The number of epidemic outbreaks of symptomatic infections caused by NDM-producing K. pneumoniae decreased from 11 in 2016 to 7 in 2017 in hospitals in Warsaw, where microbiological screening tests were performed. The number of outbreaks in hospitals outside Warsaw, where the screening tests were not performed or were limited, increased from 8 in 2016 to 24 in 2017.

Conclusion

Screening tests increase the chance of detecting colonization by CPE. The implementation of microbiological screening decreased the risk of epidemic outbreaks of symptomatic infections caused by CPE.

Optimizing orthopedic trauma care delivery during the COVID-19 pandemic. A closed-loop audit of implementing a virtual fracture clinic and fast-track pathway in a Dutch level 2 trauma center

Background

Guidelines concerning outpatient management of patients during the coronavirus pandemic required minimized face-to-face follow-up and increased remote care. In response, we established a virtual fracture clinic (VFC) review for emergency department (ED) patients with musculoskeletal injuries, meaning patients are reviewed ‘virtually’ the next workday by a multidisciplinary team, instead of routine referral for face-to-face fracture clinic review. Patients wait at home and are contacted afterwards to discuss treatment. Based on VFC review, patients with minor injuries are discharged, while for other patients an extensive treatment plan is documented using injury-specific care pathways. Additionally, we established an ED orthopedic trauma fast-track to reduce waiting time. This study aimed to evaluate the extent to which our workflow supported adherence to national coronavirus-related guidelines and effects on ED waiting time.

Methods

A closed-loop audit was performed during two 4-week periods using predefined standards: (1) all eligible ED orthopedic trauma patients are referred for VFC review; (2) reached afterwards; and follow-up is (3) patient initiated, or (4) performed remotely, whenever possible. Total ED waiting time, time to review, time for review, and time after review were assessed during both audit periods and compared with previous measurements.

Results

During both audits, the majority of eligible ED patients were referred for VFC review (1st: n=162 (88.0%); 2nd: n=302 (98.4%)), and reached afterwards (1st: 98.1%; 2nd: 99.0%). Of all referred patients, 17.9% and 13.6% were discharged ‘virtually’ during first and second audits, respectively, while 45.0% and 41.1% of scheduled follow-up appointments were remote. Median total ED waiting time was reduced (1st: −36 minutes (p<0.001); 2nd: −33 minutes (p<0.001)). During the second audit, median ED time to review was reduced by −13 minutes (p<0.001), as well as time for review: −10 minutes (p=0.019).

Discussion

In line with national guidelines, our VFC review allowed time-effective review and triage of the majority of ED orthopedic trauma patients, supporting patient-initiated and remote follow-up, whenever possible. ED waiting time was reduced after implementing the VFC review and orthopedic trauma fast-track.

Level of evidence

IV.

Repeat Auditing of Primary Health-care Facilities Against Standards for Occupational Health and Infection Control: A Study of Compliance and Reliability

Background

The elevated risk of occupational infection such as tuberculosis among health workers in many countries raises the question of whether the quality of occupational health and safety (OHS) and infection prevention and control (IPC) can be improved by auditing. The objectives of this study were to measure (1) audited compliance of primary health-care facilities in South Africa with national standards for OHS and IPC, (2) change in compliance at reaudit three years after baseline, and (3) the inter-rater reliability of the audit.

Methods

The study analyzed audits of 60 primary health-care facilities in the Western Cape Province of South Africa. Baseline external audits in the time period 2011–2012 were compared with follow-up internal audits in 2014–2015. Audits at 25 facilities that had both internal and external audits conducted in 2014/2015 were used to measure reliability.

Results

At baseline, 25% of 60 facilities were “noncompliant” (audit score<50%), 48% “conditionally compliant” (score >50 < 80%), and only 27% “compliant” (score >80%). Overall, there was no significant improvement in compliance three years after baseline. Percentage agreement on specific items between internal and external audits ranged from 28% to 92% and kappa from -0.8 to 0.41 (poor to moderate).

Conclusion

Low baseline compliance with OHS–IPC measures and lack of improvement over three years reflect the difficulties of quality improvement in these domains. Low inter-rater reliability of the audit instrument undermines the audit process. Evidence-based investment of effort is required if repeat auditing is to contribute to occupational risk reduction for health workers.

Long-term effectiveness of infection and antibiotic control programs on the transmission of carbapenem-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex in central Taiwan

Objectives

A carbapenem-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex (CRA complex) infection is one of most the difficult infections to control worldwide. We evaluated the long-term effects of infection control interventions on the incidence densities of healthcare-associated infection (HAI) and CRA complex infection, and the rates of Acinetobacter calcoaceticus-Acinetobacter baumannii complex bacteremia (AB).

Patients and methods

We performed a cross-sectional analysis at the Changhua Christian Hospital from January 2002 to December 2013. Interventions for infection control were implemented from 2002 to 2009 (period 1). From 2010 to 2013 (period 2), infection control programs were improved by in-service education and a hand hygiene campaign to prepare for international and national hospital accreditation. The effectiveness of infection and antibiotic control programs was assessed according to the incidence densities of HAI and CRA complex, rates of CRA complex and of AB, chlorhexidine consumption density, and defined daily dose of antibiotics.

Results

The incidence density of HAI decreased from 4.56‰ to 1.52‰ from periods 1 to 2 (P < 0.001). Likewise, the incidence of AB decreased from 177.79 to 137.76 per person-years per 100,000 admissions (P < 0.001). The incidence density of CRA complex ranged from 3.17–7.38‰. The chlorhexidine consumption density increased from 5.5 to 45.5 L per 1000 patient-days (P < 0.001). The consumption of piperacillin-tazobactam was lower in period 2 than in period 1 (P < 0.001).

Conclusion

Education for infection control programs, hand hygiene campaigns, and antibiotics control programs may decrease the incidence density of AB and HAI, and may help control CRA complex infection.

Successful control of carbapenem-resistant Acinetobacter baumannii in a Korean university hospital: a 6-year perspective

BACKGROUND

This study evaluated the effect of infection control interventions on the incidence of carbapenem-resistant Acinetobacter baumannii (CRAB) in a tertiary hospital over a 6-year period.

METHODS

Multiple interventions, including cohorting, promotion of hand hygiene, active surveillance in the intensive care units, and environmental cleaning, were implemented from 2007 through 2009 (period 1). From 2009 through 2012 (period 2), infection control programs were enhanced by the introduction of an onsite education and hand hygiene campaign in preparation for hospital accreditation. To assess the efficacy of the infection control intervention programs, the nosocomial incidence density of CRAB, consumption of alcohol-based hand gel, and consumption of antimicrobials during the study period were measured.

RESULTS

The incidence density of CRAB increased from 0.35 to 0.46 per 1000 patient-days (PD) during period 1, but decreased to 0.06 per 1000 PD in period 2 (P = .011). The consumption of alcohol-based hand gel increased from 5.6 L to 11.9 L per 1000 PD during the study period (P < .001). There was a significant association between the incidence density of CRAB and carbapenem use (P = .008).

CONCLUSIONS

Education for infection control programs, hand hygiene campaign, and the judicious use of carbapenem may decrease the nosocomial incidence of CRAB.

Governmental surveillance system of healthcare-associated infection in Brazil


Objective: This study aimed to describe the structure of governmental surveillance systems for Healthcare Associated Infection (HAI) in the Brazilian Southeastern and Southern States. Method: A cross-sectional, descriptive and exploratory study, with data collection by means of two-phases: characterization of the healthcare structure and of the HAI surveillance system. Results: The governmental teams for prevention and control of HAI in each State ranged from one to six members, having at least one nurse. All States implemented their own surveillance system. The information systems were classified into chain (n=2), circle (n=4) or wheel (n=1). Conclusion: Were identified differences in the structure and information flow from governmental surveillance systems, possibly limiting a nationwide standardization. The present study points to the need for establishing minimum requirements in public policies, in order to guide the development of HAI surveillance systems.


Infection prevention and control self-audit: just a tick box exercise?

The National Health Service (NHS) in England continues to experience ongoing change in order to complete the transition to the new delivery system outlined in Liberating the NHS (Department of Health, 2010a). Treating and caring for patients in a safe environment and protecting them from acquiring avoidable infections remains a high priority and a central quality improvement component within the outcome Indicator set for 2013/14 (NHS Commissioning Board, 2012a). Infection prevention and control practitioners will be required to use a range of innovative quality improvement strategies to facilitate engagement with clinicians and meet the challenges that lie ahead for the NHS. The purpose of this paper is to report on the implementation of an infection prevention and control self-audit (IPCSA) project within general practice. The aim of the project was to empower practice staff to become actively involved with an infection prevention and control (IPC) audit in order to support the development of an IPC quality improvement culture within general practice teams. The paper outlines the methodology used to implement self-audit. The findings suggest that IPCSA can be used as an effective alternative to an IPC nurse-led infection prevention and control audit.

Evaluating infection control: a review of implementation of an infection prevention and control program in a low-income country setting

BACKGROUND

This study was conducted to review the status of the comprehensive infection prevention and control program (IPCP) established in the Republic of Kiribati in 2005, and to identify opportunities to continue and expand the integration of the IPCP into health service delivery.

METHODS

The review was conducted in 2010 using 2 empirical tools: a pilot IPCP evaluation (IPCPE) tool that evaluated the activities of the program and its implementation, and a previously validated self-administered survey that assessed health care worker (HCW) knowledge, application, and confidence in infection control principles and practice. The survey was given to all 186 clinicians at Tungaru Central Hospital; the response rate was 59.7%.

RESULTS

The Kiribati IPCP demonstrated a minimum level of compliance (75%) with the activity standards set out in the IPCPE tool. The mean scores on the HCW survey were 62% for knowledge, 63% for application, and 79% for confidence. Significant correlations were found among knowledge, application, and confidence.

CONCLUSIONS

This evaluation of the Kiribati IPCP with our IPCPE tool provides valuable insight into the status of a recently adopted comprehensive program and how it has translated into the knowledge, application, and confidence of HCWs in their clinical practice. The HCW survey provides evidence that the IPCP has translated into confidence and ability in the application of infection prevention practices.

The infection control audit: the standardized audit as a tool for change

BACKGROUND

Health care workers' compliance with infection control practices and principles is vital in preventing the spread of disease. One tool to assess infection control practice in clinical areas is the infection control audit; however, many institutions do not approach this in a systematic fashion.

METHODS

Key features of the infection control audit were identified by the infection control team and developed into a standardized format for review of clinical areas. The audit incorporates a review of the physical layout, protocols and policies, knowledge of basic infection control principles, and workplace practice review.

RESULTS

Over the last 13 years, the infection control unit has completed 17 audits involving 1525 employees. Four-hundred-one staff members have filled out questionnaires that assessed their understanding of standard precautions. A total of 257 recommendations have been made, and 95% of these have been implemented. The majority of recommendations address separation of clean and dirty supplies, hand hygiene compliance, hand hygiene signage, proper use of barriers, and environmental cleaning.

CONCLUSION

The infection control audit is an opportunity to implement changes and to introduce remedial measures in collaboration with various departments and services. A standardized approach to the audit allows benchmarking of practices across the institution and enhances standards of care.

Steady improvement of infection control services in six community hospitals in Makkah following annual audits during Hajj for four consecutive years

Background

the objective of this study was to evaluate the impact of annual review of the infection control practice in all Ministry of Health hospitals in the holy city of Makkah, Saudi Arabia, during the Hajj period of four lunar Islamic years, 1423 to 1426 corresponding to 2003 to 2006.

Methods

audit of infection control service was conducted annually over a 10-day period in six community hospitals with bed capacities ranging from 140 to 557 beds. Data were collected on standardized checklists on various infection control service items during surprise visits to the medical, pediatric, surgical, and critical care units, and the kitchens. Percentage scores were calculated for audited items. The results of the audit for hospitals were confidentially sent to them within four weeks after the end of Hajj.

Results

deficiencies observed in the first audit included lack of infection control committees, infection control units, infection control educational activities, and surveillance system and shortage of staff. These deficiencies were resolved in the subsequent audits. The average (range) scores of hospitals in 11 infection control items increased from 43% (20–67%) in the first audit to 78% (61–93%) in the fourth audit.

Conclusion

regular hospital infection control audits lead to significant improvement of infection control practice. There is a need to build a rigorous infection control audit into hospitals' ongoing monitoring and reporting to the Ministry of Health and to provide these hospitals with feed back on such audits to continuously strengthen the safety standards for patients, visitors, and employees.