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April 2013

Infection Prevention

IP Update

CDC: Action needed now
to halt spread of deadly bacteria

A family of bacteria has become increasingly resistant to last-resort antibiotics during the past decade, and more hospitalized patients are getting lethal infections that, in some cases, are impossible to cure. The findings, published in the Centers for Disease Control and Prevention’s Vital Signs report, are a call to action for the entire healthcare community to work urgently — individually, regionally and nationally — to protect patients. During just the first half of 2012, almost 200 hospitals and long-term acute care facilities treated at least one patient infected with these bacteria.

The bacteria, Carbapenem-Resistant Enterobacteriaceae (CRE), kill up to half of patients who get bloodstream infections from them. In addition to spreading among patients, often on the hands of healthcare personnel, CRE bacteria can transfer their resistance to other bacteria within their family. This type of spread can create additional life-threatening infections for patients in hospitals and potentially for otherwise healthy people. Currently, almost all CRE infections occur in people receiving significant medical care in hospitals, long-term acute care facilities, or nursing homes.

Enterobacteriaceae are a family of more than 70 bacteria including Klebsiella pneumoniae and E. coli that normally live in the digestive system. Over time, some of these bacteria have become resistant to a group of antibiotics known as carbapenems, often referred to as last-resort antibiotics. During the last decade, CDC has tracked one type of CRE from a single healthcare facility to healthcare facilities in at least 42 states. In some medical facilities, these bacteria already pose a routine challenge to health care professionals.

The Vital Signs report describes that although CRE bacteria are not yet common nationally, the percentage of Enterobacteriaceae that are CRE increased by fourfold in the past decade. One type of CRE, a resistant form of Klebsiella pneumoniae, has shown a sevenfold increase in the last decade. In the U.S., northeastern states report the most cases of CRE.

According to the report, during the first half of 2012, four percent of hospitals treated a patient with a CRE infection. About 18 percent of long-term acute care facilities treated a patient with a CRE infection during that time.

In 2012, CDC released a concise, practical CRE prevention toolkit with in-depth recommendations for hospitals, long-term acute care facilities, nursing homes and health departments. Key recommendations include: enforcing use of infection control precautions (standard and contact precautions); grouping patients with CRE together; dedicating staff, rooms and equipment to the care of patients with CRE, whenever possible; having facilities alert each other when patients with CRE transfer back and forth; asking patients whether they have recently received care somewhere else (including another country); and using antibiotics wisely. Visit CDC for the CRE Toolkit at

This Month's Advertisers

Germ warfare goes viral

Infection Prevention, Environmental Services pros share success stories

by Susan Cantrell, ELS

Fighting the good fight means to stay the course, to persevere, to be faithful to the truth. The truth is that healthcare workers and environmental service workers are fighting the good fight against hospital-acquired infections (HAIs) every day. It is not easy work. It can be messy and smelly and thankless. It can be monumentally frustrating, because often there are no quick fixes while patients’ lives hang in the balance—but—they persevere until they figure out what works. Lives will be saved.

Some examples of those who have fought the good fight follow. These infection-prevention success stories represent those who are willing to go the extra mile, those who are willing to stick their neck out, those who are willing to think out of the box. Take heart. The good fight is being fought with more and more successes.

Using hospital surfaces to battle infections

Copper Development Association
New York, NY

A multiyear study was conducted in the medical intensive care units (MICUs) at three hospitals: Memorial Sloan Kettering Cancer Center in New York City, the Medical University of South Carolina, and Ralph H. Johnson VA Medical Center, both located in Charleston, South Carolina. The purpose was to demonstrate the effect of antimicrobial copper alloy touch services on three pathogens and relate it to reduced HAIs.

Antimicrobial copper touch surfaces in an ICU room at
Ralph H. Johnson VA Medical Center, Charleston, SC.

How they did it: Harold T. Michels, PhD, PE, Senior Vice President, Technology and Technical Services, Copper Development Association Inc., described the problem and their approach to improvements. "A multiyear study was conducted to determine the impact of inherently antimicrobial copper alloy touch surfaces on three microbes found in healthcare facilities: methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant enterococci; and Acinetobacter baumannii, assessing principally whether a lower microbial bioburden would reduce the number of HAIs."

"Microbial burden values on hospital surfaces were collected for 21 months. Patient infection data were collected from July 12, 2010, to June 14, 2011," said Michels. "Results from the project firmly established that the built environment represents a substantial risk.1 The baseline microbial burden on frequently touched surfaces in close proximity to MICU patients routinely exceeded a value believed to represent a risk for the acquisition of infectious agents, 2.5 colony-forming units/cm2."

Results: The study’s results were astounding. "After an intervention, where inherently antimicrobial copper alloys replaced existing plastic, metal, wood, and painted materials on 6 high-touch surfaces, sampling showed a median reduction in burden of >99.9%," said Michels. "This observation is significant in that antimicrobial copper surfaces were able to maintain bacterial burdens below levels set for terminal cleaning during the routine course of patient care. In addition to this marked reduction in microbial burden, a significant reduction in HAIs was observed in rooms with copper-clad surfaces, representing a relative-risk reduction to the rate of HAIs of greater than 50% (N=564, 95% confidence interval, P=0.00003).2 This signifies the first time a continuously active material placed in the built environment facilitated a simultaneous reduction to both microbial burden and the rate with which HAIs are contracted. The bulk of this research has been published."1-4

This work was supported by the U.S. Army Medical Research and Materiel Command under Contract No. W81XWH-07-C-0053. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the U.S. Army Medical Research Acquisition Activity.

Persistence in hand hygiene

Baptist Memorial Hospital
North Mississippi, Oxford, MS

Baptist Memorial Hospital, North Mississippi, a 217-bed regional hospital, needed "to determine if using persistent products would reduce HAI rates and healthcare costs," said Betty A. von Kohn, RN, BSN, CNOR, CIC. "Current healthcare guidelines require frequent sanitizing, but it is not persistent or long-acting. This allows transmission of germs between normal cleaning, sanitizing, and disinfecting. The objective of this study was to determine if using a persistent antimicrobial hand-sanitizing lotion and surface disinfectant would bridge any gaps and reduce HAIs and healthcare costs."

How they did it: The study, which took place in 2011, is a before and after comparison of nosocomial infection markers (NIMs) rate, as reported by MedMined (a CareFusion company, Birmingham, AL) surveillance technology. Three months’ (April to June) NIMs rate before Germ Pro [use] was compared to 3 months
(August to October) during Germ Pro use," said von Kohn. "July was not used for the comparison, because project approval and in-service training were done in July."

Germ Pro
Hand Sanitizing Lotion

Staff were instructed to continue observing CDC hand-hygiene guidelines. Then they turned the program up a notch. "Healthcare workers were instructed to apply Germ Pro Hand Sanitizing Lotion at start of their workday and to reapply every 4 hours. Placement of Germ Pro Lotion at the time clocks makes using the lotion quick and easy," noted von Kohn. "Staff really liked the lotion. [It] was reported to heal cracked hands and to be nonsticky. Employee Health reported a reduction in hand irritation."

"Environmental-service employees were instructed to apply Germ Pro Surface Disinfectant to high-touch points after terminal discharge cleaning in patient rooms and monthly in common areas. Germ Pro did not replace any products or sanitizing practices. They were used in addition to all current guidelines."

Results: "The study determined product effectiveness and cost-benefit analysis," said von Kohn. "A 43% reduction of NIMS validated the theory that using a persistent antimicrobial sanitizing lotion and surface disinfectant can fill the gaps in surface disinfecting and hand hygiene," said von Kohn. "Patient safety is greatly improved, while realizing significant cost savings."

The following numbers illustrate Baptist Memorial’s success: MRSA rate reduction, 53.8%; quantity of NIMS reduced, 62; cost per NIM, $4,055; 3-month cost savings, $251,410. Projected annual savings is $1,005,640, and estimated annual cost is $20,000. Here’s the kicker: "One week’s savings pays for both persistent products for the entire year," noted von Kohn.

"The data validated the importance of the role of Germ Pro’s hand sanitizing lotion and surface disinfectant in infection prevention and the role high-touch surfaces play in transmission. The trial has been a positive measure for our facility, as we promote a safer environment for staff, patients, and visitors," said von Kohn.

Increasing hand-hygiene compliance

Greenville Hospital System University Medical Center
Greenville, SC

Greenville Hospital System (GHS) University Medical Center is a 5-campus, 1,268-bed health system ranked among the nation’s top 50 hospitals in U.S. News & World Report’s America’s Best Hospitals, 2012-2013. Heather McLarney, Vice President Marketing, DebMed, Charlotte, NC, explained the hospital’s goal: "The GHS Infection Prevention Team, with the support of the organization’s leadership, initiated a highly focused effort to improve hand-hygiene compliance systemwide. The study began in December 2009. It was published in April 2011."

DebMed GMS hand-hygiene–compliance reports

How they did it: As is the case with many successful infection-prevention efforts, this one began with teamwork. "Realizing the importance of staff involvement to the success of the program, the first effort was to hold a contest among employees to create a campaign theme," explained McLarney. "The winning slogan was ‘Germ Warfare: Join the Battle.’ The team created employee communications and tools related to hand hygiene using this motto."

The team enlisted yet more help. "The team also recognized that they needed a physician advocate on their side," explained McLarney, "and approached Tom Diller, MD, Vice President of Quality and Patient Safety, who enthusiastically agreed to support their efforts. Kevin Gilroy, MD, a hospitalist with a passion for hand hygiene, was appointed the physician leader for the hand-hygiene team."

"The team also participated in a study with Elaine Larson, PhD, Columbia University School of Nursing. The HOW2 Benchmark Study established the expected numbers of hand-hygiene opportunities in various types of units in different hospital settings, based on the WHO’s Five Moments for Hand Hygiene standard. This breakthrough study was published in the American Journal of Infection Control in April 2011.5 This study was used to create the algorithms in the DebMed GMS [Group Monitoring System], being used at GHS to monitor compliance rates electronically. It allows GHS to create a culture of safety based on collaboration and working as a team, rather than singling out individuals."

McLarney summarized the three main efforts leading to their success. "The keys to the GHS team’s success were getting frontline staff involved, using a scientific approach to data analysis that was credible, and engaging physicians to champion the initiative. "

Results: Reduction in infections, costs, and hand-hygiene compliance was significant. Central-line—associated bloodstream infections (CLABSIs) were reduced by 60%. It was estimated to have saved more than $3 million this past year. More than 50% reduction in ventilator-associated pneumonia rates also saved nearly $3 million this past year. They created an interactive hand-hygiene program, based on data collection and identifying barriers to compliance, which resulted in improved hand-hygiene compliance from 50% to over 90%, per direct observation findings.

Reducing CLABSIs and increasing hand-hygiene compliance

Children’s Hospital of Atlanta
Atlanta, GA

Wava Truscott, Director Medical Sciences and Clinical Education, Kimberly-Clark Health Care, Roswell, GA, explained the goal was to involve everyone at Children’s Hospital of Atlanta, from front-line staff to executive committees to home health agencies to patients’ families, in an effort to reduce infections among pediatric patients significantly. "The campaign started at the 529-bed healthcare organization in 2006, with the goals of reducing systemwide and unit-level CLABSIs and increasing hand-hygiene compliance," stated Truscott.

How they did it: "The vascular access, performance improvement, and infection-prevention teams were first enlisted to develop a campaign to increase awareness, educate, and reduce harm to their patients. A key strategy was to enable clinicians and nonclinicians to recognize that they play an instrumental role in the prevention of infections."

Children’s Hospital of Atlanta received Kimberly-Clark's 2010 HAI Watchdog Award for "Best in Class" for hospitals with >300 patient beds.

"The Bloodstream Infection Task Force was created," said Truscott, "with key stakeholders across the continuum of care. They adopted evidence-based CLABSI prevention bundles and practices supported by national quality organizations such as Child Health Corporation of America and the Institute of Healthcare Improvement. The infection-prevention and quality team also initiated change by helping to create tools for real-time CLABSI data monitoring and analysis, first piloting and then rolling out a ‘BSI huddle,’ a strategy to improve communication among the various staff members. A vital underpinning of this initiative was ongoing education of clinicians and non-clinicians about their roles in preventing CLABSIs."

"Early on, for example, the team engaged the hospital’s medical staff governing body and the medical executive committee to support physician practice changes such as hand-hygiene and sterile-barrier guidelines during line insertion. Area home health agencies are periodically invited to an educational session on central-venous–line care. A ‘Days Since Last Infection’ sign is displayed in each unit as a daily visual reminder to staff. To reinforce the importance of proper hand hygiene, a cornerstone of any CLABSI reduction initiative, the hospital’s communication department created a ‘Foam Up’ education campaign that targeted physicians, staff, and, most importantly, patient families."

"Children’s Hospital also worked closely with vendors like Kimberly-Clark," said Truscott. Kimberly-Clark is well known for their educational programs for both patient and provider. Their tools on HAIs are available at www.preventinfections.com and www.haiwatch.com.

Results: "Since the launch of this initiative in 2006," said Truscott, "Children’s has reduced its BSI rates by 76%, resulting in more than 816 avoided BSIs, with a cost avoidance of over $37 million. As of September 2012, 2 of the critical-care units at Children’s have celebrated more than 900 and more than 1,100 days each without a CLABSI. Hand-hygiene rates increased from 35%, now consistently remaining above the 95% target and currently at 98.3%, evidence that hand hygiene has become engrained in the culture of safety."

"Children’s has been recognized for its work in reducing CLABSIs as a recipient of the 2010 HAI Watchdog Award for ‘Best in Class’ for hospitals that have more than 300 patient beds," said Truscott. Kimberly-Clark created the HAI Watchdog Awards (www.haiwatchdog.com) specifically to recognize clinicians making a difference in reducing and preventing the spread of HAIs.

Reducing BSIs related to peripheral IVs

Methodist Hospitals–Northlake Campus
Gary, IN

"Methodist Hospitals–Northlake Campus, a 507-bed community hospital, sought to reduce BSIs in its central and peripherally inserted central catheter (PICC) lines and, notably, also in its peripheral intravenous (PIV) lines," explained Michelle DeVries, MPH, CIC, Senior Infection Control Officer. "Hospitals usually focus BSI reduction efforts on central catheters; yet, PIVs, which also carry BSI risk, are the most common lines. Guidelines now permit longer dwell times, which make the risk greater."

How they did it: "An audit revealed a potential cause of Methodist’s BSIs: improper manual disinfection of IV connectors. Nurses were complying with the mandated practice, but few if any were performing it correctly," said DeVries, "risking IV-line contamination."


SwabCap, Excelsior Medical

"With the support of the infection-control and nursing-administration departments, bedside nursing staff were consulted about the issue and suggested that two different device solutions be tried," explained DeVries. "The first was an evidence-based disinfection cap (SwabCap by Excelsior Medical, Neptune, NJ). The device dispenses isopropyl alcohol when twisted onto the connector hub’s threads and protects the hub from contamination between line accesses. Its design addresses multiple problems with the technique for manually disinfecting hubs. The second device was a disinfecting cleaner with a friction scrub design."

"The Materials Management Department consented to a trial of both devices in the health system’s three intensive care units (ICUs), with nurses choosing the winner," said DeVries. "After the trial, they selected the disinfection cap."

"Over the next 3 months, each of the ICUs reported zero BSIs. This data, plus positive response by staff, led to the hospital adopting the cap for use housewide, with materials management support."

Results: "The infection rate for both PIVs and central lines has dropped substantially since the disinfection cap was implemented, with a statistically significant reduction in overall and central-line rates."

During the 13-month pre-intervention period, PIVs plus central lines experienced a BSI rate of 0.1 per 100 patient-days. In contrast, during the 13-month post-intervention period, the BSI rate dropped to 0.04 per 100 patient-days, a 60% reduction (P<0.000001).

For central lines only, during the 13-month pre-intervention period, the BSI rate was 0.09 per 100 patient-days. During the 13-month post-intervention period, the BSI rate dropped to 0.03 per 100 patient-days, a 67% reduction (P<0.000001).

For PIVs only, during the 13-month pre-intervention period, the BSI rate was 0.09 per 100 patient-days. During the 13-month post-intervention period, the BSI rate dropped to 0.04 per 100 patient-days, a 56% reduction (P=0.11).

"The PIV-only BSI rate reduction is associated entirely with cap use," noted DeVries, "because the cap was the only new intervention for PIVs. During the post-intervention period, the PICC team became more involved in line monitoring and dressing changes, which conceivably contributed to the BSI drop in those lines."

Assuring environmental cleanliness

Hygiena USA
Camarillo, CA

"Hygiena is a microbiology and life science company that serves industrial food processors, healthcare institutions, sanitation suppliers, life-science researchers, and the general public," said Lauren Roady, Marketing Manager.

"Our rapid ATP cleaning verification system is used throughout hospitals to measure cleaning effectiveness and improve overall cleanliness. With offices in the US, UK, China, India, and over 100 distributors worldwide, Hygiena products span the globe," said Roady. "Our SystemSURE Plus ATP Cleaning Verification System, used with UltraSnap ATP tests, was implemented at North Tees (470 beds) and Hartlepool (220 beds) hospitals in the UK in 2008."

How they did it: "ATP cleaning verification was implemented in an effort to improve overall facility cleanliness and universal reduction in HAIs. Clostridium difficile infection rates were tracked as an indicator of HAI rates and overall facility cleanliness," explained Roady.


SystemSURE Plus ATP Cleaning Verification System, with UltraSnap ATP, from Hygiena USA

"North Tees and Hartlepool Hospitals implemented ATP monitoring using the Hygiena SystemSURE Plus luminometer and UltraSnap ATP swabs." Testing is routinely used throughout both hospitals for monitoring of cleanliness of patient rooms after terminal cleaning; for training of cleaning staff; for protocol and process training of environmental services staff; to demonstrate effective hand-washing techniques; for performance management; and ATP monitoring results are used as proof of cleaning-staff performance.

Roady emphasized the need for teamwork. "Cleaning improvements and infection reductions are a cooperative effort between facilities, nursing, and infection-control staff members.
To oversee monitoring in the facilities, a project champion was assigned to each facility. This monitoring officer is independent from nursing and environment­al-services staff and reports to department managers if corrective action is required, ie, poor cleaning is discovered."

"On a monthly basis, reports are produced and circulated in a cross-functional team meeting of nursing, facilities, and infection-control staff. This meeting opens up discussion on all cleaning and maintenance related issues, as well as suggestions for improvement."

Results: "From April 2007 to March 2008, the facilities shared a total of 210 post-48 hour C difficile cases, or 9.934 infections per 10,000 occupied bed-days," said Roady. "From April 2009 to March 2010, the facilities shared a total of 136 post-48 hour C diff cases, or 6.054 infections per 10,000 occupied bed-days. This is a 35% reduction in C diff cases in just 2 years."

"Not only has the facility sustained reduced infection rates since the implementation of ATP monitoring, but cleanliness levels have also improved. Cleaning scores are rated as ‘pass,’ ‘caution,’ or ‘fail’ with Hygiena’s ATP Cleaning Verification system. Since 2008, the hospitals have seen a 20% increase in pass cleaning scores, indicating improvements in cleaning practices and personnel performance. Their successes have influenced the adoption of Hygiena ATP monitoring systems in a national health system in Scotland."

Preventing pressure ulcers 

Tempe (AZ) St. Luke’s Hospital
St. Luke’s Medical Center
Phoenix, AZ

Two facilities participated in this program to reduce incidence of pressure ulcers: Tempe St. Luke’s Hospital, an 87-bed full-service hospital, and St. Luke’s Medical Center, a 226-bed, state-of-the-art hospital in Phoenix, Arizona.

How they did it: Kathy Berry, FNP, MSN, BSN, CWON, St. Luke’s Medical Center, Phoenix, and St. Luke’s Tempe, described their mission: "The two hospitals in this study had prevalence rates of 38.2% (St. Luke’s Medical Center) and 14.8% (Tempe St. Luke’s Hospital), whereas the National Database of Nursing Quality Indicators benchmark standard is 9.6%. We started this campaign to reduce the prevalence of pressure ulcers in April 2012. We are continuing it today and into the future. It is now part of our everyday patient care."
Berry explained their approach: "The first step was forming a multidisciplinary team consisting of the administration chief nursing officer (CNO), materials-management director and manager, housekeeping director and manager, CNO acute-care and all managers, education director, infectious-disease director, rehab director, acute-care wound, ostomy, and continence nurse." The second step was developing a skin formulary. The third step was setting up a baseline pressure-ulcer prevalence.

Medline’s Pressure Ulcer Prevention Program incorporates education,
training, products, and program management.

"The 2 directors in charge of this program set a goal of reaching the national benchmark or being below the national benchmark in 4 months’ time," said Berry. "Data were collected at both hospitals by 2 nurses with expertise in wound care. All patients in both hospitals, on 1 day, were examined and pressure ulcers counted."

Other steps included seeking support from Medline’s Pressure Ulcer Prevention Program (PUPP) and working with hospital administration to get support and resources. "Following consultation with Medline and hospital administration, the following key steps were identified," said Berry: reassess risk for all patients daily; inspect skin of at-risk patients daily; manage moisture; optimize nutrition and hydration; and minimize pressure.

"Education and product changes were made. Medline Remedy advanced skin-care products [were used] on all floors, and hospitals began use of Ultrasorb dry flow pads." Berry described some of the educational changes: mandatory requirement of all nursing staff to complete three pressure-ulcer prevention modules on Medline University, Medline’s free online education resource (www.medlineuniversity.com); measurement and documentation of wounds, wound management, and prevention of pressure ulcers; new nurse orientation that includes a 1-hour lecture on pressure-ulcer prevention, given by a wound nurse; a skin-and-wound quick reference guide.

Next, they evaluated the effects of the product and educational changes. "Post-PUPP implementation prevalence data were collected again," said Berry. "These data were collected by the same two nurses as the pre-PUPP data. Again, all patients in both hospitals, on 1 day, were examined and pressure ulcers counted."

Results: "We have seen a sustained significant reduction in the prevalence rates of pressure ulcers at both hospitals for almost a year now. For both hospitals combined, the prevalence went from 30.15% to 0.85% after we implemented our initiative. For St. Luke’s Medical Center, the prevalence of pressure ulcers dropped to 0% from 38.2% after implementing PUPP. For Tempe St. Luke’s Hospital, the prevalence dropped from 14.89% to 2.38% after implementing the PUPP program."


1. Schmidt MG, Attaway HH, Sharpe PA, John J Jr, Sepkowitz KA, Morgan A, et al. Sustained reduction of microbial burden on common hospital surfaces through introduction of copper. J Clin Microbiol 2012;50(7):2217-2223.

2. Salgado CD, Sepkowitz KA, John JF, Cantey JR, Attaway HH, Freeman KD, et al. Copper surfaces reduced the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. In Press.

3. Attaway HH 3rd, Fairey S, Steed LL, Salgado CD, Michels HT, Schmidt MG. Intrinsic bacterial burden associated with intensive care unit hospital beds: Effects of disinfection on population recovery and mitigation of potential infection risk. Am J Infect Control 2012;40(10):907-912.

4. Schmidt MG, Attaway HH III, Fairey SE, Steed LL, Michels HT, Salgado CD, et al. Copper continuously limits the concentration of bacteria resident on bed rails within the intensive care unit. Infect Control Hosp Epidemiol. In press.

5. Steed C, Kelly JW, Blackhurst D, Boeker S, Diller T, Alper P, Larson E. Hospital hand hygiene opportunities: where and when (HOW2)? The HOW2 Benchmark Study. Am J Infect Control 2011;39;19-26.