Healthcare Infection Control Practices Advisory Committee Research Articles

Methicillin-resistant Staphylococcus aureus metrics for patients in Saudi Arabia

The World Health Organization recommends essential measures to "combat drug resistance", including instituting surveillance "everywhere". Standardized metrics are crucial for reliable surveillance. Studies publish metrics with varying definitions for multi-drug resistant organisms (MDRO). The Society for Healthcare Epidemiology of America (SHEA) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) proposed standardized metrics for MDRO for consistent reporting, identifying high-risk groups, and evaluating interventions. We retrieved 73 studies through PubMed using the search terms "methicillin-resistant Staphylococcus aureus", "MRSA", and "Saudi Arabia". We selected 20 studies that reported MRSA incidence or prevalence in patients and/or percentage among Staphylococcus aureus isolates and evaluated these metrics against the closest matching SHEA/HICPAC metrics. We outlined issues applicable to MRSA metrics such as comparison of risk-unadjusted metrics; their pooling for different hospitals; not accounting for post-discharge infections; non-specification of AST-based, and healthcare and community associated infections' related, standardized metrics by SHEA/HICPAC; and appropriate temporal criteria for nosocomial infections. We elaborated salient features of reviewed metrics versus their SHEA/HICPAC complements. Terminology and definitions of reviewed metrics differed from SHEA/HICPAC counterparts. Some did not satisfy the epidemiological or statistical criteria for their reported category; e.g. prevalence indicators were classified as incidence and vice versa. SHEA/HICPAC metrics would be useful for future studies. Our results show an imminent need for an international consensus on fundamental MDRO surveillance metrics; illustrate surveillance scenarios requiring standardized metrics; identify some indicators from Saudi studies supplementing SHEA/HICPAC metrics; and underscore SHEA/HICPAC's advice for avoiding comparison of risk-unadjusted metrics between hospitals.

Challenges of Applying the SHEA/HICPAC Metrics for Multidrug-Resistant Organisms to a Real-World Setting

To test in a real-world setting the recommendations for measuring infection with multidrug-resistant organisms (MDRO) from the Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee (HICPAC). Using data from 3 hospital settings within a healthcare network, we applied the SHEA/HICPAC recommendations to measure methicillin-resistant Staphylococcus aureus (MRSA) infection and colonization. Data were obtained from the hospitals' electronic surveillance system and were supplemented by manual medical record review as necessary. Additionally, we tested (1) different definitions for nosocomial incidence, (2) the effect of excluding patients not at risk from the denominator for hospital-onset incidence, and (3) the appropriate time period to use when including or excluding patients with a prior history of MRSA infection or colonization from nosocomial rates. Negative binomial regression models were used to test for differences between rate definitions. A rating scale was created for each metric, assessing the extent to which manual or electronic data elements were required. There was no statistically significant difference between using 72 hours or 3 calendar days as the cutoff to define hospital-onset incidence. Excluding patients not at risk from the denominator when calculating hospital-onset incidence led to statistically significant increases in rates. When excluding patients with a prior history of MRSA infection or colonization from nosocomial incidence rates, rates were similar regardless of whether we looked at 1, 2, or 3 years' worth of prior data. The SHEA/HICPAC MDRO metrics are useful but can be challenging to implement. We include in our description of the data sources and processes required to calculate these metrics information that may simplify the process for institutions.

Catheter-Acquired Urinary Tract Infection: The Once and Future Guidelines

From the Department of Internal Medicine and Medical Microbiology, University of Manitoba Health Sciences Centre, Winnipeg, Manitoba, Canada Received December 21, 2009; accepted December 27, 2009; electronically published February 15, 2010. Infect Control Hosp Epidemiol 2010; 31:327-329 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3104-0002$15.00. DOI: 10.1086/651092 Catheter-acquired urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. The rate of acquisition of new infection is 3%–7% per day while the indwelling urinary catheter remains in place. More than 80% of hospital-acquired urinary tract infections are catheter associated, and 12%–16% of patients who are admitted to acute care hospitals have an indwelling catheter placed at some time during hospitalization. In addition, approximately 5% of longterm care facility residents have voiding managed with a chronic indwelling catheter. However, morbidity or mortality with catheter use is modest, compared with other deviceassociated infections. Infection with an indwelling urethral catheter is overwhelmingly asymptomatic. Symptomatic infection is uncommon, and the severe manifestation of bacteremia attributable to CAUTI is reported in prospective studies for less than 1% of patients with catheters and less than 5% of patients with CAUTI. Costs directly attributable to CAUTI are also modest and are estimated to average only $589 per infection. Despite these considerations, the intensity of urinary catheter use in healthcare settings means that the cumulative contribution of CAUTI to the burden of hospitalacquired infections is substantial. In addition, there are adverse effects of indwelling urethral catheters beyond infection. Trauma and inflammation from the catheter or complications from patient immobility are other patient-specific adverse effects, and urine drainage bags are a reservoir for drugresistant bacteria in the healthcare environment. In 1981, the Centers for Disease Control and Prevention developed guidelines for the prevention of CAUTI. Now, in 2010, almost 30 years later, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has updated these guidelines. For many of us, the interval from publication of the initial guideline to this first revision spans the greater part of a professional career. Even more extraordinary, the 1981 guideline did not simply fade away as it was eclipsed by time but continued to be a reference for appropriate practice. It is only recently that alternate guidelines addressing CAUTI have been developed, such as the Department of Health of Great Britain guidelines published in 2001 and updated in 2007 and the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America/Association for Professionals in Infection Control Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals published in 2008. Why has there been such an extraordinary lapse of time before this revision? Limited substantive change in practices to prevent CAUTI during the past 3 decades meant there was never any urgent need to update the document, because the initial guidelines were never incorrect. This is, itself, a distressing observation. In an interval of 30 years during which there has been intense interest and continuing progress in addressing hospital-acquired infections, one would have hoped for some meaningful advances in the prevention of CAUTI. A second likely explanation for the delayed revision is that CAUTI has been considered a relatively unimportant hospital-acquired infection. Morbidity with symptomatic urinary infection is uncommon relative to the intensity of urinary catheter use, and attributable mortality is rare, compared with the attributable mortality of other device-related infections, such as central-line bacteremia and ventilator-associated pneumonia. The landmark Study on the Efficacy of Nosocomial Infection Control by Haley et al, published in the 1980s, was important in encouraging this perspective. This study reported that nosocomial urinary infection could be decreased by 31%–41% with an intense infection control program and would achieve the greatest absolute number of infections potentially prevented, compared with programs to prevent surgical wound, lower respiratory, or bloodstream infections. However, the mean extra length of stay was only 2 days for symptomatic urinary infection and 0.4 days for asymptomatic infection, compared with 5.2 days for lower respiratory infection, 7.4 days for bloodstream infection, and 7.7 days for surgical wound infection. With the introduction of surveillance by objective, CAUTI became the most dispensable component. Why are the guidelines updated now? The revision itself

Updating the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC)

This article describes the recent update to the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). These methods are being used to develop future HICPAC guidelines, beginning with the guideline on preventing catheter-associated urinary tract infections released in 2009. The article includes a background on HICPAC, the strengths and limitations of the methods it's used over the last two decades, and the rationale behind these recent updates. In addition, we describe the new infrastructure used to develop guidelines at HICPAC, key changes in methodology, and new elements of HICPAC guidelines, like the implementation and audit section. We also describe current challenges to the development of infection control guidelines. The current update builds on past strengths and current advances in guideline development and implementation, and enables HICPAC to improve the validity and usability of its guidelines while also addressing emerging challenges in guideline development in the area of infection prevention and control.

Preventing healthcare-associatedAspergillusinfections: review of recent CDC/HICPAC recommendations

Aspergillus spp. are ubiquitous environmental fungi that are increasingly recognized as a cause of severe illness and mortality in immunocompromised patients. More than 60 outbreaks of healthcare-associated invasive aspergillosis have been described in the English literature. Information gained from outbreak investigations, especially control measures, form the basis for current guidelines to prevent healthcare-associated aspergillosis. Guidelines from the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) provide evidence-based recommendations for preventing healthcare-associated aspergillosis and should be adopted by healthcare facilities.

Perioperative Management of Multidrug-Resistant Organisms in Health Care Settings

Guidelines for managing multidrug-resistant organisms (MDROs) in health care settings were published by the Healthcare Infection Control Practices Advisory Committee (HICPAC) in October 2006. These guidelines outline appropriate strategies to help prevent MDRO cross transmission. Perioperative nurses should be prepared to implement these strategies in an effort to protect their surgical patients from contracting MDRO infections. The HICPAC recommends elevating contact precautions to "intensified interventions" in facilities with endemic outbreaks of MDROs. Perioperative nurses should participate in these efforts by adhering to infection control practices, championing these practices with other health care personnel, and providing clinical support and leadership.

Mandatory Public Reporting of Hospital Acquired Infections (MPRHAI): Recommendations of the Tennessee Study Group to the Tennessee Legislature

ISSUE: About 2 million Americans acquire healthcare associated infections annually; one third of these infections are considered preventable. Various consumers' groups have highlighted these facts urging legislators to pass legislation mandating public reporting of hospital-acquired infections (HAI). Since 2002, six states have enacted legislation that requires health care organizations to publicly disclose HAI. To date, there are six additional states (including Tennessee) that have required a study of such legislation and many other states with pending legislation. PROJECT: To describe the underlying rationale and recommendations made by Tennessee's study group on MPRHAI. The study group included infection control professionals and hospital epidemiologists from large and small hospitals; urban and rural. It reviewed reporting requirements for the State of Tennessee, impacts and effect of MPRHAI legislation in other states, quality improvement initiatives from multiple organizations, and guidelines from the Healthcare Infection Control Practices Advisory Committee (HICPAC). Emphasis was placed on collection of actionable, verifiable data. RESULTS: The study group found no evidence for or against using MPRHAI to reduce HAI. It recognized that consumers want this information available publicly and that data must be displayed in a way that consumers will be able to comprehend. It recommended that any action taken by the Tennessee legislature be in conjunction with current national reporting initiatives and sufficient resources be allocated to implement a meaningful reporting system. The study group recommended: a) All healthcare institutions be included except: critical access hospitals or hospitals with an average daily census of LESSONS LEARNED: A combination of process and outcome measures and modification of rules was recommended.

Using the Intranet To Document Healthcare Worker (HCW) Declination and Participation in a Mandatory Influenza Vaccination Program

ISSUE: The Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) emphasize HCW vaccination against influenza to prevent disease and transmission to patients. Despite education, incentives and easy access to vaccine our influenza vaccine coverage rate for nearly 20,000 HCWs was 38% in 2004. Because mandatory vaccination was met with resistance due to the perception of coercion, we opted for a strategy of mandatory participation with documentation of declination using the intranet as a tool. PROJECT: To establish an intranet web site where employees were required to document participation, declination or vaccination. The site was accessible on all computers and work stations. Employees logged on using their identification number and selected vaccine received, vaccine contraindicated or vaccine declined. Declining employees automatically received education about vaccination. A Microsoft ® Structured Query Language database was created and linked to a Human Resource database. Administrators were provided feedback on participation rates. The site provided information about where to obtain vaccine, and a place to ask questions linked by e-mail to an Infection Control Practitioner for prompt response. Employees were notified of the program via letter. Reminders were provided through managers and newsletters. Vaccination rates were not provided to managers or administrators. The site was activated October 17, 2005. RESULTS: As of December 1, 2005, 79% of employees (16,138 / 20,361) participated by accessing the intranet: 50% (10,291) indicated vaccine received; 25.9% (5269) declined; 2.8% (578) declined based on contraindications. Self-reported vaccination included 50% of the Division of Medicine and 45% of the Division of Nursing. Declination was 21% and 30% respectively. Departmental data is available for all patient care locations. There were few complaints as employees understood vaccination data was confidential. LESSONS LEARNED: The intranet provided an inexpensive tool for measuring and timely reporting of HCW participation, declination and vaccination rates. Data management was accomplished without significant expense and cumbersome paperwork. The site provided education to large numbers of employees which may have influenced the increase in the vaccination rate. Real time monitoring by location or occupation allows for targeting interventions where rates are low. Detailed departmental data allows for planning future targeted educational programs. The same tool can be used to document other programs such as fit-testing and TB screening.

Ensuring rational public reporting systems for health care–associated infections: Systematic literature review and evaluation recommendations

The Centers for Disease Control and Prevention (CDC) systematically reviewed published studies for the Healthcare Infection Control Practices Advisory Committee (HICPAC) in preparation for guidance to states on mandatory public reporting systems for health care-associated infections (HAI) in hospitals. The HICPAC asked whether public reporting systems are effective in improving health care performance, by measured improvements in clinical processes or patients' health status as the intended outcomes, including but not limited to reduced HAI events; and whether new evidence of effectiveness of private reporting policies to reduce HAI had been published since the 1970s landmark Study on the Efficacy of Nosocomial Infection Control study. Public reporting systems are information provided to the public about the quality of health services. Of 450 published papers reviewed using specific inclusion and exclusion criteria, 10 studies qualified for detailed, protocol-based abstractions. Findings indicate that the evidence for effectiveness for public reporting systems to improve health care performance is inconclusive. No studies have investigated reduction of HAI as an outcome of public reporting. Rigorous evaluation of mandatory public reporting systems for HAI is recommended to ensure that stakeholders' needs are identified and met.

Initiating respiratory hygiene and cough etiquette stations throughout a multihospital university medical center

ISSUE: In September 2003, the state health department, along with our facility, mandated that we develop a response plan for the possible re-emergence of Severe Acute Respiratory Syndrome (SARS). We convened a multidisciplinary SARS task force, and five team members were given responsibility for writing the plan. During that time, we learned that respiratory hygiene and cough etiquette guidelines were being developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC). There was also a threat of a heavy early flu season, and we needed to provide easy access to hygiene supplies in all hospital and clinic waiting areas and lobbies.PROJECT: The SARS planning group came up with an idea for a “sneeze station” since our policy required that facial tissues, hand sanitizers, waste receptacles, masks, and instructional signage be readily available in all hospital and clinic lobbies and waiting rooms. We took our idea to the director of plant operations and the sneeze station concept was approved. A carpenter was assigned to develop a prototype, and after a few minor revisions by the SARS task force the sneeze station was born. Wall-mounted and rolling floor models were designed to accommodate the various space needs in our facility. It was decided that masks would not be placed on the sneeze stations, but would be available at all reception desks due to concerns of inappropriate use. Our faculty and staff were educated on the respiratory hygiene policy and sneeze stations during the February 2004 mandatory safety fair.RESULTS: As of January 2005, we have placed 180 sneeze stations in our hospitals and clinics as well as in other institutions. When new areas open, one of the first concerns is to make sure they get their sneeze stations. The sneeze stations are continuously being used based on audits of supply usage and through monitoring by the environment of care (EOC) tours.LESSONS LEARNED: The sneeze stations are accepted in the medical center as a valuable part of infection control. There are times when supply cannot keep up with demand because we only have one carpenter assigned to manufacture the sneeze stations. Another lesson learned is that placing the station in a cafeteria may result in it being used as a food disposal instead of for its intended purpose. Overall, the sneeze station has met with great success, and this proves that creative ideas can bring about change.

Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee

Since 2002, 4 states have enacted legislation that requires health care organizations to publicly disclose health care-associated infection (HAI) rates. Similar legislative efforts are underway in several other states. Advocates of mandatory public reporting of HAIs believe that making such information publicly available will enable consumers to make more informed choices about their health care and improve overall health care quality by reducing HAIs. Further, they believe that patients have a right to know this information. However, others have expressed concern that the reliability of public reporting systems may be compromised by institutional variability in the definitions used for HAIs, or in the methods and resources used to identify HAIs. Presently, there is insufficient evidence on the merits and limitations of an HAI public reporting system. Therefore, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has not recommended for or against mandatory public reporting of HAI rates. However, HICPAC has developed this guidance document based on established principles for public health and HAI reporting systems. This document is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for HAIs. The document provides a framework for legislators, but does not provide model legislation. HICPAC recommends that persons who design and implement such systems 1) use established public health surveillance methods when designing and implementing mandatory HAI reporting systems; 2) create multidisciplinary advisory panels, including persons with expertise in the prevention and control of HAIs, to monitor the planning and oversight of HAI public reporting systems; 3) choose appropriate process and outcome measures based on facility type and phase in measures to allow time for facilities to adapt and to permit ongoing evaluation of data validity; and 4) provide regular and confidential feedback of performance data to healthcare providers. Specifically, HICPAC recommends that states establishing public reporting systems for HAIs select one or more of the following process or outcome measures as appropriate for hospitals or long-term care facilities in their jurisdictions: 1) central-line insertion practices; 2) surgical antimicrobial prophylaxis; 3) influenza vaccination coverage among patients and healthcare personnel; 4) central line-associated bloodstream infections; and 5) surgical site infections following selected operations. HICPAC will update these recommendations as more research and experience become available.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

AbstractThese guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device–Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.