Deborough MacBeth

Clinical diagnostic criteria for isolating patients admitted to hospital with suspected pandemic influenza.

Australian hospitals have now experienced the fi rst wave of pandemic H1N1 infl uenza during a southern hemisphere winter. Patients admitted to Australian hospitals with suspected pandemic infl uenza during this period were identifi ed by use of approved national clinical diagnostic criteria. However, the imprecise nature of clinical diagnosis limited the ability of hospitals to isolate infectious patients eff ectively before the laboratory confi rmation of infection (which typically takes a minimum of 48 h). Concern about our reliance on these criteria to isolate potentially infectious patients led us to analyse our early experience with pandemic infl uenza at the two teaching hospitals in the Gold Coast region of Queensland. We collected nasopharyngeal and throat specimens and reviewed clinical and laboratory data on all 346 patients admitted to the hospitals with acute respiratory disease during the period from May 24 to Aug 16, 2009. Pandemic H1N1 infl uenza virus RNA was detected in specimens collected from 106 of 346 patients (31%). On the basis of our experience, we compared the performance of Australian clinical diagnostic criteria with those of WHO, the US Centers for Disease Control and Prevention (CDC), and the UK Health Protection Agency (HPA; table). We make the following observations: (1) Criteria that rely on documented fever (eg, those of WHO and CDC) sacrifi ce sensitivity for specifi city. In our recent experience, 41 of 106 admitted patients (39%) with laboratory-confi rmed pandemic infl uenza did not have any tempera ture recorded above 37·8°C at any stage during their admission. Such criteria are simply not sensitive enough to support good hospital infection control practice. (2) Criteria that include a “history” of fever and respiratory symptoms rather than a documented fever (eg, those of the HPA and the Australian Government Department of Health and Ageing) are adequately sensitive to the diagnosis of pandemic infl uenza. However, the resulting lack of specifi city overwhelmed the ability of our hospitals to isolate suspected cases and resulted in cohorting of infected cases with wrongly suspected cases. (3) Age seems to be a useful criterion by which to discriminate pandemic infl uenza (H1N1) from other causes of acute respiratory disease necessitating hospital admission. Only four of 106 patients admitted with the infection were older than 65 years in our population. 80 (33%) of 240 patients admitted with acute respiratory disease not due to pandemic infl uenza were older than 65 years. Given the limitations of existing criteria, we have adopted a modifi ed approach with better sensitivity and specifi city for the purpose of isolating patients admitted to hospital during the pandemic: age less than 65 years and history suggestive of fever and cough or sore throat.

Roles, responsibilities and scope of practice: describing the ‘state of play’ for infection control professionals in Australia and New Zealand

Background In the past decade the policy and practice context for infection control in Australia and New Zealand has changed, with infection control professionals (ICPs) now involved in the implementation of a large number of national strategies. Little is known about the current ICP workforce and what they do in their day-to-day positions. The aim of this study was to describe the ICP workforce in Australia and New Zealand with a focus on roles, responsibilities, and scope of practice. Methods A cross-sectional design using snowball recruitment was employed. ICPs completed an anonymous web-based survey with questions on demographics; qualifications held; level of experience; workplace characteristics; and roles and responsibilities. Chi-squared tests were used to determine if any factors were associated with how often activities were undertaken. Results A total of 300 ICPs from all Australian states and territories and New Zealand participated. Most ICPs were female (94%); 53% were aged over 50, and 93% were employed in registered nursing roles. Scope of practice was diverse: all ICPs indicated they undertook a large number and variety of activities as part of their roles. Some activities were undertaken on a less frequent basis by sole practitioners and ICPs in small teams. Conclusion This survey provides useful information on the current education, experience levels and scope of practice of ICPs in Australia and New Zealand. Work is now required to establish the best mechanisms to support and potentially streamline scope of practice, so that infection-control practice is optimised.

An assessment of high touch object cleaning thoroughness using a fluorescent marker in two Australian hospitals

Abstract Objective We needed to better understand the usefulness of different methods of monitoring and achieving sustained improvement in cleaning. Common elements of successful international approaches include a covert nature, the use of a method to visually identify and highlight deficiencies in the cleaning of high touch objects (HTOs) and the provision of feedback and education before re-evaluation. The specific purpose of this study was to evaluate fluorescent marking, education and feedback for assessing and improving HTO cleaning in a typical Australian inpatient hospital setting. Methods A three-phase, prospective study was conducted in two acute care hospitals over 17 weeks. For each phase, in a set of 37 specific single-inpatient rooms, seven predefined HTOs were marked with a liquid isopropyl alcohol and optical brightener formulation targeting material solution containing a fluorescent marker (FM), known as DAZO ® , designed specifically for the purpose of evaluating surface cleaning. In each hospital we targeted rooms located in the four wards with the greatest de novo multidrug resistant organism burden. Forty-eight hours after applying the FM we used a black-light to visualise the marks presence or removal. In phase 1 only, HTOs were swabbed before marking. Also in the first phase only and immediately following the initial assessment, eachHTOwas cleaned, remarked and re-assessed at 48 h. Between phases 1 and 2, investigators provided results to environmental services (EVS) leadership and staff. Education was provided to EVS staff after phase 1 only. Results A total of 986 marks were evaluated. The cleaning scores for individual HTOs in phases 1–3 ranged from 9.4 to 77.8%, 10.8 to 93% and 13.5 to 67.7% respectively. In phase 3, three HTOs scored lower than in phase 1. The mean overall cleaning scores for phases 1–3 were 34%, 53% and 41% respectively. Conclusions The FM was useful to assess HTO cleaning thoroughness. It facilitated relevant feedback and education and motivated staff to strive for continual improvements in environmental cleaning. Without on-going education, preliminary improvements were unsustained. However, investigators better understood flaws in cleaning and policy/procedure conflicts.

Seasonal variation in health care-associated bloodstream infection: Increase in the incidence of gram-negative bacteremia in nonhospitalized patients during summer

OBJECTIVE Recent research has suggested that episodes of gram-negative (GN) bloodstream infection (BSI) are more common in the population during summer months. Our objective was to determine if the same phenomenon could be observed in patients with health care-associated (HCA) BSI, and if so, whether a summer peak was less apparent in patients accommodated in a climate-controlled hospital environment. METHODS Data from episodes of HCA BSI spanning an 11-year period were analyzed. To test for seasonal variation in HCA BSI among hospitalized and nonhospitalized patients, and between GN and gram-positive organisms, the χ(2) goodness-of-fit test was used. RESULTS There were 440 episodes of HCA GN BSI of which 259 (59%) occurred in inpatients and 181 (41%) occurred in noninpatients. A significant increase in the frequency of HCA GN BSI was observed in nonhospitalized patients during the summer months (P = .03) but not in climate-controlled hospitalized patients. The most common source of infection in these patents was an intravascular device (38%). CONCLUSIONS We found an increased incidence of GN HCA BSI during summer that was not apparent in our inpatient cohort. The cause is unknown. It might be prudent to advise patients at risk of BSI (eg, those receiving intravascular infusions) to minimize exposure to high environmental temperature and to educate on possible behavioral factors that may increase risk.

Auditing hand hygiene rates for quality and improvement

Since the work of Ignaz Philipp Semmelweis, hand hygiene has been recognised as an effective means of preventing healthcare-associated infection. More recently, the World Health Organisation developed guidelines and strategies for improving hand hygiene compliance which have subsequently been adopted and implemented in healthcare facilities around the world. In Australia the imperative to ensure appropriate hand hygiene as a component of safe healthcare provision has been supported and promoted at state and national levels by various bodies. However, in spite of improvements in compliance rates and reported decreases in multi-resistant organisms, criticism has arisen around the commitment of scarce healthcare resources to hand hygiene auditing. This study demonstrates that hand hygiene audits can contribute to quality healthcare delivery and improvement.

Pathway to credentials

Abstract The issue of credentialling infection control practitioners (ICPs) has sparked considerable debate and, at times, concern among the Australian Infection Control Association (AICA) membership. This paper seeks to discuss the relevant issues and inform readers on factors influencing the development of a credentialling process for Australian ICPs. In addition, it outlines the credentialling process, ratified by the AICA executive, that will be implemented for Australian ICPs. [AIC Aust Infect Control 1999; 4(4):21-23.]

Infection control standards and credentialing.

Infection control professionals (ICPs) play an integral part of developing, implementing, and evaluating infection control programs. In Australia, there is no minimum or standardized education to practice as an ICP. The Australasian College of Infection Prevention and Control, the professional body for ICPs in Australasia, sought to address the issue by developing a credentialing process.1, 2 and 3 This decision was made in recognition that self-regulation is one of the hallmarks of professionalism.4 The process of becoming credentialed as an ICP in Australia involves the submission of evidence against a range of criteria with a subsequent peer-review process...

Impact of electronic healthcare-associated infection surveillance software on infection prevention resources: a systematic review of the literature

BACKGROUND Surveillance of healthcare-associated infections is fundamental for infection prevention. The methods and practices for surveillance have evolved as technology becomes more advanced. The availability of electronic surveillance software (ESS) has increased, and yet adoption of ESS is slow. It is argued that ESS delivers savings through automation, particularly in terms of human resourcing and infection prevention (IP) staff time. AIM To describe the findings of a systematic review on the impact of ESS on IP resources. METHODS A systematic search was conducted of electronic databases Medline and the Cumulative Index to Nursing and Allied Health Literature published between January 1st, 2006 and December 31st, 2016 with analysis using the Newcastle-Ottawa Scale. FINDINGS In all, 2832 articles were reviewed, of which 16 studies met the inclusion criteria. IP resources were identified as time undertaken on surveillance. A reduction in IP staff time to undertake surveillance was demonstrated in 13 studies. The reduction proportion ranged from 12.5% to 98.4% (mean: 73.9%). The remaining three did not allow for any estimation of the effect in terms of IP staff time. None of the studies demonstrated an increase in IP staff time. CONCLUSION The results of this review demonstrate that adopting ESS yields considerable dividends in IP staff time relating to data collection and case ascertainment while maintaining high levels of sensitivity and specificity. This has the potential to enable reinvestment into other components of IP to maximize efficient use of scarce IP resources.

Exploring the context for effective clinical governance in infection control

HighlightsEffective clinical governance supports improvements in infection controlWe examined the clinical governance context for Australian hospital infection controlInfection preventionists are engaged with evidence based practiceCultural challenges include lack of leadership or active resistanceInfrastructure challenges include lack of specialist expertise, funding and technology Background: Effective clinical governance is necessary to support improvements in infection control. Historically, the focus has been on ensuring that infection control practice and policy is based on evidence, and that there is use of surveillance and auditing for self‐regulation and performance feedback. There has been less exploration of how contextual and organizational factors mediate an infection preventionists (IPs) ability to engage with evidence‐based practice and enact good clinical governance. Methods: A cross sectional Web‐based survey of IPs in Australia and New Zealand was undertaken. Questions focused on engagement in evidence‐based practice and perceptions about the context, culture, and leadership within the infection control team and organization. Responses were mapped against dimensions of Scally and Donaldsons clinical governance framework. Results: Three hundred surveys were returned. IPs appear well equipped at an individual level to undertake evidence‐based practice. The most serious set of perceived challenges to good clinical governance related to a lack of leadership or active resistance to infection control within the organization. Additional challenges included lack of information technology solutions and poor access to specialist expertise and financial resources. Conclusions: Focusing on strengthening contextual factors at the organizational level that otherwise undermine capacity to implement evidence‐based practice is key to sustaining current infection control successes and promoting further practice improvements.

Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures

Background: We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia. Methods: Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures. Results: The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism‐based typing, demonstrating that all linked isolates clustered together. Conclusion: Arresting the national point‐source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution.