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What Happens in the Outpatient Clinic Doesn’t Always Stay in the Outpatient Clinic: Lessons from a Regional Outbreak of Adenovirus-associated Epidemic Keratoconjunctivitis (EKC)

Categories: Healthcare-associated infections, Outpatient Care, State HAI Prevention

Andrew Wiese, MPH

Andrew Wiese, MPH

Author – Andrew Wiese, MPH
Applied Epidemiology Fellow
Tennessee Department of Health
CDC, Council of State and Territorial Epidemiologists (CSTE)

This week’s Morbidity and Mortality Weekly Report (MMWR) includes a description of six separate outbreaks of Adenovirus-associated epidemic keratoconjunctivitis (EKC) in four different states. These outbreaks were mainly associated with outpatient eye care.

Last August, as a new CDC/CSTE Applied Epidemiology fellow in the Tennessee Department of Health (TDH), I experienced firsthand an outbreak that was similar to those described in the MMWR. We were contacted by a concerned patient who experienced severe conjunctivitis after receiving care at a local ophthalmology clinic and was aware of similarly affected patients.  I was asked to help lead the investigation.

Communication with the clinic identified gaps related to cohorting of suspected cases, procedures for disinfection of equipment and surfaces, and the policy for the appropriate length of time ill staff should be kept from patient contact.  Our TDH team then guided implementation of appropriate infection control practices to prevent further transmission.  While our investigation identified ninety cases of EKC at the clinic, only a single case from the clinic occurred after the health department’s intervention.

One Hospital, One Heart, Let’s Get Together to Control VRE (Vancomycin-Resistant Enterococci)

Categories: Healthcare-associated infections, Long Term Care (LTC)

Bruce Y. Lee, MD, MBA

Bruce Y. Lee, MD, MBA

 
Authors – Bruce Y. Lee, MD, MBA

Associate Professor of International Health and Director of Operations Research
International Vaccine Access Center
Johns Hopkins Bloomberg School of Public Health

 
Think when another hospital in a region has a vancomycin-resistant enterococci (VRE) bacteria problem that it’s their problem and not your hospital’s problem? Think again. As demonstrated by our recent computer modeling study published in the American Journal of Infection Control, a VRE problem in one hospital can soon spread to hospitals throughout a county. This is because hospitals are connected to each other by patient sharing: a patient colonized with VRE leaving one hospital can readily end up in another hospital, either by direct transfer or after an intervening stay in the community.
 
Therefore, (if it hasn’t already done so), VRE may be coming soon to a hospital near you. And the VRE movie can be a horror show for healthcare workers and patients. The VRE bacteria are resistant to vancomycin, a dear old last line of defense in our antibiotic arsenal. When vancomycin doesn’t work, few alternatives are left to treat life-threatening infections.
 
To study the spread of VRE, our computer modeling “Avengers” team used RHEA (the Regional Healthcare Ecosystem Analyst, a software platform developed by us) to build a computer virtual representation of all the hospitals in Orange County, California, and their patients and surrounding community (instead of SimCity, think SimHospitals-in-Orange-County). This “virtual laboratory” allowed us to perform experiments that you should not do in real life, such as infecting different virtual patients with VRE and seeing how soon VRE appeared or increased in other hospitals or demonstrating how hospitals making no attempt to control VRE could “free-ride” on the efforts of hospitals that do.
 
These experiments demonstrated that, in the spirit of Bob Marley’s song “One Love”, we are in fact “one hospital, “one heart”, so let’s work together to control VRE. The question is, how can we best make this happen?

Time for change? Lessons from a trial of the Dialysis Station Routine Disinfection Checklist

Categories: Dialysis, Healthcare-associated infections

Peggy Bushey RN, CDN

Peggy Bushey RN, CDN

Authors – Peggy Bushey RN, CDN, Renal Services
Linda Fosher, RN, Renal Services
Sally Hess MPH, CIC, Infection Prevention
Fletcher Allen Health Care, Burlington Vermont

The risk of transmitting bloodborne pathogens, including hepatitis C virus, in a hemodialysis unit can be high due to environmental contamination with blood.

Our clinic recently participated in a “test of change” utilizing a new Dialysis Station Routine Disinfection Checklist developed by CDC and their Dialysis Collaborative in hopes of decreasing the potential for cross-contamination and recommending a “best practice.”

The St. Albans clinic is a free standing, 9-station hemodialysis unit staffed by registered nurses and technicians. We are one of six satellites affiliated with Fletcher Allen Health Care, an academic, not-for-profit medical center in the state of Vermont.

We reviewed the proposed Dialysis Station Routine Disinfection Checklist noting that the major difference from our current practice was discharging the patient from the treatment station before performing terminal station disinfection. Staff agreed to a one week trial of the new checklist, if only to prove that this “waiting for the patient to leave the station” was not truly feasible.

Initially, the change in workflow was challenging. Staff felt time was wasted waiting for the patient to leave the station before starting to disinfect it. Patient turnover was extended by 10-15 minutes with an overall increase of approximately 20-30 minutes for the day. If patients required prolonged post-treatment care, they were moved out of the station and into a holding area.

Proper Environmental Disinfection: A Basic Patient Safety Expectation

Categories: Dialysis, Healthcare-associated infections

Priti R. Patel, MD, MPH

Priti R. Patel, MD, MPH

Author – Priti Patel, MD, MPH
CDC, Division of Healthcare Quality Promotion

Imagine walking into an operating room and seeing staff disinfect the room and open up sterile equipment for the next surgery while a patient is still on the table completing their procedure. Most of us would find this strange and unacceptable. Yet it happens every day in dialysis centers across the country, where it has become the norm to clean dialysis stations and set up machines for the next patient while a patient is still sitting in the chair completing their treatment. The staff who clean up the area are doing so while they are also helping a patient finish dialysis treatment, a time when patients can bleed for some time before they are ready to go home.

It’s not hard to see how this kind of multitasking for efficiency can lead to cross contamination (i.e., contamination of one patient’s medical supplies with blood or organisms from another patient). Such practices have been identified by CDC as dangerous and potentially contribute to outbreaks. Anecdotally, we have heard from dialysis center staff that the pressure they feel to get patients in and out of the stations quickly can interfere with more than just their ability to properly clean the stations. In some instances, proper hand hygiene and even medication preparation practices can suffer when they are under such intense time constraints.

New Guideline to Reduce Unexpected Disease Transmission Through Organ Transplantation

Categories: Healthcare-associated infections, Organ and Tissue Safety

Matthew J. Kuehnert, MD

Matthew J. Kuehnert, MD

Author – Matthew J. Kuehnert, MD
Director, Office of Blood, Organ, and Other Tissue Safety
CDC Division of Healthcare Quality Promotion

This week, the U.S. Department of Health and Human Services (HHS) released a new guideline to improve patient safety by reducing disease transmission through organ transplantation.  This guideline updates the 1994 U.S. Public Health Service (PHS) guideline for preventing transmission of human immunodeficiency virus (HIV) through organ transplantation, and adds guidance for reducing unexpected transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) through organ transplants. 

Disease transmission from infected donors has been reported in heart, lung, liver, kidney and pancreas recipients.  From 2008 to 2011, the Centers for Disease Control and Prevention (CDC) participated in more than 200 investigations of suspected, unexpected disease transmission through transplants.  Of these, there were 15 instances in which HIV, HBV or HCV infection was confirmed to have been transmitted from the organ donor to the recipient.

The 2013 PHS Guideline for Reducing Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Transmission through Organ Transplantation, published in Public Health Reports, recommends the use of more sensitive tests so that patients can be protected from infections transmitted from a transplanted organ, and be informed of risks to the greatest extent possible.

The major changes from the previous 1994 PHS guideline are:

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