Sue Barnes

APIC position paper: Safe injection, infusion, and medication vial practices in health care

Outbreaks involving the transmission of bloodborne pathogens or other microbial pathogens to patients in various types of health care settings due to unsafe injection, infusion, and medication vial practices are unacceptable. Each of the outbreaks could have been prevented by the use of proper aseptic technique in conjunction with basic infection prevention practices for handling parenteral medications, administration of injections, and procurement and sampling of blood. This document provides practice guidance for health care facilities on essential safe injection, infusion, and vial practices that should be consistently implemented in such settings.

Leveraging Electronic Medical Records for Surveillance of Surgical Site Infection in a Total Joint Replacement Population

OBJECTIVE To evaluate whether a hybrid electronic screening algorithm using a total joint replacement (TJR) registry, electronic surgical site infection (SSI) screening, and electronic health record (EHR) review of SSI is sensitive and specific for SSI detection and reduces chart review volume for SSI surveillance. DESIGN Validation study. SETTING A large health maintenance organization (HMO) with 8.6 million members. METHODS Using codes for infection, wound complications, cellullitis, procedures related to infections, and surgeon-reported complications from the International Classification of Diseases, Ninth Revision, Clinical Modification, we screened each TJR procedure performed in our HMO between January 2006 and December 2008 for possible infections. Flagged charts were reviewed by clinical-content experts to confirm SSIs. SSIs identified by the electronic screening algorithm were compared with SSIs identified by the traditional indirect surveillance methodology currently employed in our HMO. Positive predictive values (PPVs), negative predictive values (NPVs), and specificity and sensitivity values were calculated. Absolute reduction of chart review volume was evaluated. RESULTS The algorithm identified 4,001 possible SSIs (9.5%) for the 42,173 procedures performed for our TJR patient population. A total of 440 case patients (1.04%) had SSIs (PPV, 11.0%; NPV, 100.0%). The sensitivity and specificity of the overall algorithm were 97.8% and 91.5%, respectively. CONCLUSION An electronic screening algorithm combined with an electronic health record review of flagged cases can be used as a valid source for TJR SSI surveillance. The algorithm successfully reduced the volume of chart review for surveillance by 90.5%.

Surgical wound irrigation: a call for evidence-based standardization of practice.

Surgical wound irrigation has long been debated as a potentially critical intraoperative measure taken to prevent the development of surgical site infection (SSI). Unlike many other SSI prevention efforts, there are no official practice guidelines or recommendations from any major medical group for the practice of surgical irrigation. As a result, practitioner implementation of the 3 major irrigation variables (delivery method, volume, and solution additives) can differ significantly. A focus group of key thought leaders in infection prevention and epidemiology convened recently to address the implications of different surgical irrigation practices. They identified an urgent need for well-designed clinical trials investigating surgical irrigation practices, improved collaboration between surgical personnel and infection preventionists, and examination of existing evidence to standardize irrigation practices. The group agreed that current published data are sufficient to support the elimination of antibiotic solutions for surgical irrigation; the avoidance of surfactants for surgical irrigation; and the use of sterile normal saline, sterile water, and 1 medical device containing a sterile 0.05% chlorhexidine gluconate solution followed by sterile saline. Given the current lack of sufficient evidence identifying ideal delivery method and volume choices, expert opinion must be relied on to guide best practice.

To bathe or not to bathe with chlorhexidine gluconate: is it time to take a stand for preadmission bathing and cleansing?

any health care facilities have incorporated an antiseptic skin cleansing protocol, often referred to as preoperative bathing and cleansing, to reduce the endogenous microbial burden on the skin of patients undergoing elective surgery, with the aim of reducing the risk of surgical site infections (SSIs). According to a recent study by Injean et al, 91% of all facilities that perform coronary artery bypass surgery in California have a standardized preoperative bathing and cleansing protocol for patients. Historically, this practice has been endorsed by national and international organizations, such as the Hospital Infection Control Practice Advisory Committee and the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology (APIC), AORN, the Institute for Healthcare Improvement (IHI), and the National Institute for Health and Care Excellence (NICE), which recommend bathing and/or cleansing with an antiseptic agent before surgery as a component of a broader strategy to reduce SSIs. The 2008 Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA)/Surgical Infection Society (SIS) strategies to prevent SSIs in acute care hospitals declined to recommend a specific application policy regarding selection of an antiseptic agent for preoperative bathing but acknowledged that the (maximal) antiseptic benefits of chlorhexidine gluconate (CHG) are dependent on achieving adequate skin surface concentrations.

Preventing infections in hemodialysis: An executive summary of the APIC Elimination Guide

This article is an executive summary of the APIC Hemodialysis Infection Elimination Guide. Infection preventionists are encouraged to obtain the original, full-length APIC Elimination Guide for more thorough coverage of hemodialysis infection prevention.

A primer on on-demand polymerase chain reaction technology

Efforts to reduce health care-associated infections (HAIs) have grown in both scale and sophistication over the past few decades; however, the increasing threat of antimicrobial resistance and the impact of new legislation regarding HAIs on health care economics make the fight against them all the more urgent. On-demand polymerase chain reaction (PCR) technology has proven to be a highly effective weapon in this fight, offering the ability to accurately and efficiently identify disease-causing pathogens such that targeted and directed therapy can be initiated at the point of care. As a result, on-demand PCR technology has far-reaching influences on HAI rates, health care outcomes, hospital length of stay, isolation days, patient satisfaction, antibiotic stewardship, and health care economics. The basics of on-demand PCR technology and its potential to impact health care have not been widely incorporated into health care education and enrichment programs for many of those involved in infection control and prevention, however. This article serves as a primer on on-demand PCR technology and its ramifications.

Environment of care: Is it time to reassess microbial contamination of the operating room air as a risk factor for surgical site infection in total joint arthroplasty?

&NA; In the modern operating room (OR), traditional surgical mask, frequent air exchanges, and architectural barriers are viewed as effective in reducing airborne microbial populations. Intraoperative sampling of airborne particulates is rarely performed in the OR because of technical difficulties associated with sampling methodologies and a common belief that airborne contamination is infrequently associated with surgical site infections (SSIs). Recent studies suggest that viable airborne particulates are readily disseminated throughout the OR, placing patients at risk for postoperative SSI. In 2017, virtually all surgical disciplines are engaged in the implantation of selective biomedical devices, and these implants have been documented to be at high risk for intraoperative contamination. Approximately 1.2 million arthroplasties are performed annually in the United States, and that number is expected to increase to 3.8 million by the year 2030. The incidence of periprosthetic joint infection is perceived to be low (<2.5%); however, the personal and fiscal morbidity is significant. Although the pharmaceutic and computer industries enforce stringent air quality standards on their manufacturing processes, there is currently no U.S. standard for acceptable air quality within the OR environment. This review documents the contribution of air contamination to the etiology of periprosthetic joint infection, and evidence for selective innovative strategies to reduce the risk of intraoperative microbial aerosols.

Update on the infection preventionist role.

References 1. Ulmer BC. The hazards of surgical smoke. AORN J. 2008; 87(4):721-734. 2. Buzea C, Pacheco II, Robbie K. Nanomaterials and nanoparticles: sources and toxicity. Biointerphases. 2007; 2(4):MR17-MR71. 3. Iwai K, Mizuno S, Miyasaka Y, Mori T. Correlation between suspended particles in the environmental air and causes of disease among inhabitants: cross-sectional studies using the vital statistics and air pollution data in Japan. Environ Res. 2005;99(1):106-117.

Surgical Site Infection Prevention in 2018 and Beyond

The majority of states in this country now have laws or regulations requiring public reporting of HAIs.2 For almost a decade, the care necessitated to treat many of these infections has not been reimbursed by the Centers for Medicare & Medicaid Services. A different approach has been adopted by private insurers with payforperformance or valuebased purchasing programs. Both types of programs are designed to incentivize safer care, either with financial rewards for meeting certain performance measures or with penalties for poor outcomes, such as HAIs.3 At the same time, a variety of national collaborative infection prevention (IP) initiatives have been undertaken. Unfortunately, many of the proposed practice improvements in the IP initiatives are often ineffective in producing improved outcomes because they are not executed well or sustainable (eg, staff member hand hygiene compliance).4 In addition, the payforperformance and valuebased purchasing programs are not consistently effective. Authors from the Harvard and Stanford University Business Schools have reported that the penalties have had a negative effect by increasing the incidence of hospital upcoding, possibly unintentionally (ie, a provider bills a health insurance payer using a Current Procedural Terminology [CPT] code for a more expensive service than was performed) to collect greater reimbursement.5

An Incision Closure Bundle for Colorectal Surgery

Surgical site infections (SSIs) are among the most common and expensive of all health care–associated infections, and as many as 50% are considered preventable. Surgical care bundles, which involve a small set of reliably performed evidencebased practices, may effectively reduce SSI rates. However, closure of the surgical incision is one aspect of surgical care that is not well described in current SSI prevention bundles; this presents an opportunity for perioperative professionals to improve care by identifying and implementing evidencebased incision closure practices for highrisk procedures (eg, colorectal surgery). We propose and review the evidence supporting a colorectal incision closure bundle composed of a glove and sterile instrument set change, irrigation with 0.05% chlorhexidine solution, use of triclosancoated sutures, removal of surgical drapes after applying postoperative dressings, use of topical skin adhesive or an antiseptic dressing, and distribution of comprehensive postoperative patient instructions.