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Background Hand hygiene (HH) is a critical infection prevention practice to prevent transmission of microorganisms in healthcare settings. Direct overt HH observation programs provide opportunities for direct feedback, but face concerns over potential Hawthorne effect. We sought to compare our overt HH program to covert observations and perform quality assessments. Methods During May-July 2019, covert HH observations were conducted on inpatient units of healthcare personnel (HCP) in direct contact with patients and patient surroundings. An observer was trained to perform observations using the World Health Organization's Five Moments for HH. Electronic data collection included time, unit, HCP role, moments of HH and compliance. Quality metrics included duration of alcohol-based hand rub (ABHR), hand areas missed and compliance with nail policy. Observations included varying times and days covering all shifts and roles. Data was excluded if the observer was unable to fully visualize HH or if staff became aware of observations. Simultaneously, the institutional HH overt observations continued. Results During the study period, 189 covert observations were obtained, compared to 1826 overt observations on study units. We found no significant difference (p=0.217) between the rate of compliance of overt HH observations (99%, n=1804) and covert HH observations (95%, n=179). The majority of staff were nurses (77%). The median ABHR was 6 seconds (range: 2-15 seconds), with 10% of HCP completing the recommended 15 second hand rub. Most commonly missed areas (n=48) included the fingertips (65%, n=31) and between the fingers (65%, n=31). Staff were compliant with our nail policy (98%). Conclusions We describe the validation of a direct, overt HH program. The Hawthorne Effect did not make a statistically significant difference in compliance rates and HCP maintained high compliance (>95%) whether or not they knew they were observed. Quality metrics including appropriate duration of AHBR and coverage of hands were identified as opportunities for improvement.

Background No single strategy is more effective than proper hand hygiene (HH) in reducing the spread of nosocomial infections. Unfortunately, health care worker compliance with HH is imperfect. We sought to improve HH compliance using an electronic hand hygiene monitoring system (EHHMS) in 2 units to collect unbiased data and provide feedback. Methods In this prospective, quasi-experimental study, the Hyginex EHHMS was installed in 2 units at Tufts Medical Center. Ninety-one bracelets were assigned, and electronic data were collected over 8 months. Human observations continued. We compared HH compliance as measured by human observation before, during, and after EHHMS implementation. Pre- and post-implementation surveys were distributed to staff. Results The number of electronically captured HH compliance observations was small due to infrequent bracelet use after month 2 of the intervention. HH compliance, as determined by human observation, increased by an average of 1.3 percentage points per month (P = .0005). Survey responses revealed negative attitudes about the EHHMS before and after its implementation. Conclusions Despite poor EHHMS participation and negative attitudes toward its implementation, HH compliance, as measured by human observation, significantly improved. Hospitals considering implementing an EHHMS should look to refine the intervention to encourage health care worker participation.

BACKGROUND Despite multiple rapid laboratory tests available for Clostridium difficile infection (CDI), delays in specimen collection may contribute to delays in diagnosis and treatment. Additionally, specimen collection delays may contribute to falsely increased National Health and Safety Network (NHSN) laboratory-identified (Lab ID) hospital onset (HO) CDI rates. Time from order to specimen collection and the impact of collection delays on HO CDI rates is unknown. METHODS Two community hospitals (450 and 472 licensed beds) conducted a retrospective review of electronic data from March-October 2018, including date of order for C. difficile toxin assay and date of specimen collection. Time to collection was compared for hospital of admission, level of care (intensive care unit [ICU] versus other) and shift of order (day versus night) using Mann-Whitney U (SPSS) and Chi-square analysis (Epi Info). The impact of delay on HO CDI cases was assessed. RESULTS 1516 stool specimens were collected. On average, there were 7.7?hours between order and collection (maximum delay = 7.9 days). Hospital A, ICU level of care, and night shift were correlated with significantly shorter time to specimen collection (p = 0.01, 0.02. 0.02, respectively). 330 specimens (22%) were collected on a subsequent calendar day, although this was only significantly impacted by level of care (p = 0.04). Of the 31 cases determined to be HO-CDI per NHSN Lab ID definition, 4 (13%) would have been CO had they been collected on the day ordered. Conclusions In this sample, delay in specimen collection for C. difficile testing was common, with many tests delayed to the next day. This may have a considerable impact on HO CDI rates, impacting reimbursement and hospital reputation. Future research is needed to remedy these delays. Until that time, use of order date and time should be considered for inclusion into NHSN Lab ID event definitions.

BACKGROUND Post cesarean section (CS) surgical site infections (SSI) surveillance may be challenging due to short postoperative hospital stays and time and resource intensive post discharge surveillance methods. At our obstetrical/gynecological facility, which is housed within a large pediatric hospital, surveillance was limited to inpatient readmissions and patients who presented to an urgent care center. Our purpose was to expand CS SSI surveillance to include outpatient clinics in our system by creating and implementing the use of a custom surveillance tool in October 2018. METHODS Reports of patients who underwent CS within the past 30?days were generated from the electronic data warehouse. Of these, patients who presented to our outpatient clinics and were prescribed antibiotics were considered. After chart review, two infectious diseases physicians further refined the list of antibiotics based on local prescribing patterns for wound infections. Patients queried through this tool received an additional full medical chart review by an infection preventionist to determine the possibility of SSI following CS. RESULTS After two months of implementation, 4 of 8 (50%) of CS SSI were identified through the use of this surveillance method. Compared to the previous year, enhanced surveillance resulted in a 1.7 fold increase in the CS SSI rate. CONCLUSIONS CS SSI surveillance using antibiotic prescription data in the outpatient setting is an efficient method to enhance traditional SSI surveillance. In our facility, implementation of this tool has improved the identification of CS SSI. Accurate case identification will aid in identifying trends and guide targeted interventions.

Background Decreasing the transmission of resistant organisms in hospitals is a key goal of infection prevention plans. Studies have consistently shown inadequate health care worker (HCW) compliance with isolation precautions. Evaluating adherence through direct observation of HCW behavior is considered the "gold standard" but is labor-intensive, requiring the collection and analysis of a large volume of observations. Methods Two methods of data collection to assess HCW compliance were evaluated: a manual method using a paper form (PF), with subsequent data entry into a database, and an electronic method using a Web-based form (WBF) with real-time data recording. Observations were conducted at 4 hospitals (a total of 2,065 beds) to assess the availability of gloves, gowns, and masks; isolation sign postings; and HCW isolation practices. Results A total of 13,878 isolation rooms were observed in 2009. The median number of rooms observed per day was 61 for PF and 60 for WBF, and the respective mean observation times per room were 149 seconds and 60 seconds. Thus, use of the WBF provided a time savings of 89 seconds per room. Conclusion Simple electronic forms can significantly decrease the required resources for monitoring HCW adherence to hospital policies. Use of the WBF decreased the observation time by 60%, allowing for increases in the frequency and intensity of surveillance activities.

Recently, the convergence of several themes in health care has stimulated interest in exploiting data collected during clinical encounters to monitor and improve the quality of health care. Infection control departments can be supported by assembling previously collected electronic data into a data warehouse to monitor infections, report communicable diseases, and detect clusters of organisms. I present the rationale for constructing a data warehouse and describe the steps and challenges of developing a data warehouse to support infection control activities.

Efforts are underway at the Centers for Disease Control and Prevention to foster greater use of electronic data stored in health care application databases for surveillance of health care-associated infections and antimicrobial use and resistance. These efforts, referred to as the National Healthcare Safety Network (NHSN) eSurveillance Initiative, focus on standards-based solutions for conveying health care data and validation processes to confirm that the data received at the Centers for Disease Control and Prevention accurately reflect the data transmitted by health care facilities. Standard vehicles for data transmission, specifically Health Level Seven standards for electronic messages and structured documents, and standard vocabularies for representing microorganisms and other information needed for surveillance, are central features of the eSurveillance Initiative. Progress to date in this initiative is reviewed, and future project plans are outlined. Enhanced interoperability between health care and public health information systems is achievable for surveillance purposes, but major challenges must be overcome to realize the full benefits sought by the eSurveillance Initiative.

Background Algorithms leveraging electronic data may reduce manual review burden for surgical site infection (SSI) surveillance with little to no reduction in sensitivity. We developed an algorithm to identify colon and open reduction of fracture (FX) SSIs to reduce manual chart review. Methods A retrospective cohort of colon and FX procedures and associated SSIs was constructed. Potential SSIs were identified by positive microbiologic cultures or administrative data for diagnosis or treatment of wound infection. Sensitivity and specificity of the algorithm were assessed. The number of charts needing review to identify 1 SSI, and the potential time-savings from the algorithm, were calculated. Results Four hundred seventy-three colon (SSI rate = 7%) and 1081 FX (SSI rate = 3%) procedures were identified. The algorithm was 91% and 97% sensitive and 76% and 93% specific for colon and FX procedures, respectively. Overall, chart review would have been reduced by 24.3 hours per 100 procedures, decreasing the number of charts to review to identify 1 SSI from 23.9 for manual review to 3.9 with the algorithm. Conclusions The algorithm identified SSIs with excellent sensitivity and specificity, resulting in substantial reductions in manual chart review. This algorithm could be tailored and applied to other hospitals.

As legislative mandates for disclosure of data on health care-associated infections (HAIs) to the public escalate, with both economic and reputational implications for hospitals, the development of a valid national surveillance system has become imperative. Recent studies have identified interinstitutional variability of surveillance techniques. These inconsistencies affect the validity of publicly reported HAI data, which has as a primary goal the advancement of patient safety through the reduction of HAIs. The continued funding of state validation studies, the expansion of qualitative research to further assess interrater bias, the endorsement of educational materials to assist infection preventionists with application of National Healthcare Safety Network criteria, and the development of automated surveillance methods are all necessary to ensure a national HAI surveillance system that can be used for public reporting.

alongwith the hospital’s Surgical Site Infection Committee initiated an investigation and gathered data on patients, physicians, operating room suite, Implant Company, lot numbers and organisms. Based on the results of the investigation of all orthopedic patients, the hospital initiated pre-surgical MRSA testing for all total joint patients in August of 2008. Between May and July 2009, six total hip infections occurred. One surgeon was associated with four cases and one surgeon each for the remaining two cases. All six procedures were performed in one operating room and various environmental contaminating organisms were identified. During the second half of 2009, the quality improvement team addressed operating room physical plant issues and an outside environmental group evaluated the orthopedic suite. The team performed airflow and exchange assessments of the suspect operating room. Based on the results, positive airflow monitors were installed in all operating rooms. In January 2010, the team identified drains, faucets and aerators as potential sources of contamination; these were removed and cleaned and a preventive maintenance schedule was instituted. Additionally, the Facilities Department removed overhead anesthesia columns in the operating rooms found to have high levels of environmental contaminants A Clinical Outcomes and Coding group was developed with representatives from Administration, Nursing, Hospital Information Management, Quality Systems and Infection Prevention. This group was charged with reviewing all healthcare associated infections. In 2011, the Surgical Site Infection Committee developed a shared electronic data base that was accessible to Surgical Services, Quality Systems and Infection Prevention. The electronic document storage system was designed to improve communication and have access to the information among the various interested parties. RESULTS: Our 2008 total knee replacement surgical infection rate was 5.6%. After implementing our multifaceted intervention, the rate dropped to 0.0% for 2009 through July 2012. Our 2009, total hip replacement surgical infection rate was 6.8%. In 2010 it was reduced to 3.1%. In 2011 through August 2012, the infection rate was 0.0%. LESSON LEARNED: A comprehensive multi-faceted approach to orthopedic surgical site infection prevention reduced our infection rate to 0.0% during the study period.

percutaneous exposure to infected blood. According to the CDC, an estimated 385,000 percutaneous injuries occur in HCW annually. Transmission of hepatitis B (HBV), hepatitis C (HCV), or human immunodeficiency virus (HIV) after mucous membrane or nonintact skin exposure to blood has also been reported. PROJECT: Risk of BBP transmission following occupational exposures depends on the HCW’s immune status, source patient factors, and the type of injury and quantity of blood transferred to the HCW. Prevention of transmission requires prompt reporting, expert postexposure assessment, and rapid dispensing of post-exposure prophylaxis medications (PEP). A body substance exposure (BSE) hotline was implemented by our healthcare organization in 1997, staffed by trained nurse specialists with infectious disease physician oversight and standing HIV PEP orders. The hotline is answered 24-7, and procedures are in place at all entities for source patient lab testing, HIV PEP, and employee testing. RESULTS: Six hotline nurse specialists serve the hotline at least 8 weeks per year, taking call for a week at a time. The hotline services 11 inpatient facilities, 3 long-term care facilities, 3 occupational health clinics, 2 physician medical groups, 1 orthopedic surgery center, 1 behavioral health agency, 1 home care agency, external healthcare agencies, and first responders. A total of 4,682 hotline calls have been managed (Figure 1) from 2000 to 2013, and HCW self-reported BSE are collected in an electronic data repository. The annual increase in the number of calls represents an increase in hotline customers. LESSON LEARNED: The BSE hotline provides a regional service to support exposed employees with after-hours expertise avoiding employee visits to the ER. Standardized training, assessment tools, standing orders, protocols, and expert physician guidance provides consistent exposure management for exposed HCW by nurse specialists. The hotline services over 28,000 employees and calls are responded towithin 10 minutes. Specialists provide HIV PEP within two hours of warranted exposures for BBP exposure prevention.

prosthesis type, spinal level, diabetes status, height, and weight were less frequently available. LESSON LEARNED: In our experience, facilities utilizing CSV/CDA electronic import for NHSN submission must still manually abstract data elements that are not available within the SDS. Several data elements not documented within the SDS are available within other hospital data systems or inherent to the ICD-9 procedure code(s) assigned to the surgical case. These data sources are sufficient for manual abstraction, but information/ codes from other systems are rarely accompanied by case-specific identifiers needed for electronic correlation with SDS intra-op details. Some facilities have incorporated custom fields into the SDS for completion by OR staff. Custom fields are still problematic as staff may not complete values as intended by the NHSN. Additional cost and competing priorities among OR staff cause many facilities to discount custom fields as a viable option. As procedure reporting is expanded at the state and federal level, the burden of data collection on clinicians may grow to unmanageable levels if steps are not taken by facilities and vendors to facilitate electronic data extracts/submissions. More needs to be done to standardize and support interoperability so that information can easily be extracted and linked across multiple source systems.

ISSUE: Traditional surveillance for nosocomial infections is labor-intensive and time-consuming. In today's healthcare setting, infection control professionals (ICPs) must be continuously searching for time-efficient alternative ways to collect reliable data. We sought to determine whether electronic review of our clinical-financial database could identify post–cesarean section (C-section) endometritis with sufficient accuracy to provide sound data to the obstetrics (OB) service. PROJECT: Our Labor and Delivery Department was asked to provide a monthly list of C-section patients, ASA scores, wound classifications, and durations of surgery. A Performance Improvement Specialist used DRGs to identify C-section patients and then ICD9 codes to identify cases of endometritis. Validity of the electronic data was confirmed by chart for the first 2 months. RESULTS: During the early phases, we found that chorioamnionitis was also captured. This was eliminated by changing the ICD9 screening codes. Other infections being captured under this code which were discounted were urinary tract infections and were due to coding errors. Electronic versus traditional surveillance initially showed only a 79% match. After changing our method of collecting the ICD9 codes, the match was 88%. The OB service now receives data they can benchmark against National Nosocomial Infection Surveillance (NNIS) rates. Providing them with this information has allowed them to evaluate their service and identify tools to improve the quality of patient care in our facility. LESSONS LEARNED: With a little effort up front, surveillance time can be greatly reduced without compromising the quality of the data received. Computer-assisted surveillance can be a valuable tool for today's ICP, but the success of this method is dependent on the accuracy of chart documentation and the experience of the coders.

Project: A Quality Improvement Team was chartered to implement best practices and evidence-based guidelines. WHO guidelines for ‘‘5 Moments of Hand Hygiene’’ were adopted. The hand hygiene observation tool was revised. An interactive electronic data entry tool and database were developed and placed on the intranet for the health system. A designated group of champions were trained by Infection Preventionists to perform hand hygiene observations, educate the entire health system staff regarding hand hygiene, and enter data on direct observations into the intranet-based electronic database. After training they received an Infection Prevention Champion certificate. Metrics include 1) measureable improvement in number of audits per area, 2) improvement in hand hygiene adherence.

INTRODUCTION: This medical center is a 234-bed acute care facility located in Pennsylvania, where hospitals are required by the Pennsylvania Health Care Cost Containment Council (PHC4) to report all nosocomial infections. The medical center has an automated surrogate marker for nosocomial infection that has been accepted by PHC4 as meeting the mandated reporting requirement. The marker electronically analyzes patient clinical data and automatically identifies 1) patients and 2) the site (with the corresponding site code required by PHC4 for reporting). The medical center has been recognized by PHC4 as providing both comprehensive and objective public reporting. METHODS: In October 2003, the medical center instituted a new addition to surveillance, data-mining technology to perform hospital-wide, early warning surveillance based on electronic microbiology and patient movement information. This system additionally provided a surrogate marker for infection known as an “NIM” (Nosocomial Infection Marker™). The NIM had been validated elsewhere (sensitivity 89%; specificity 98%) and had previously been shown to correlate closely (R2 of.98) with increased variable cost and length of stay. Using the medical center's own data, it was determined that patients with a NIM on average add $2,533 (DRG-adjusted) in variable cost and had an increased length of stay of 3.34 days. In March 2004, the medical center formally petitioned PHC4 to accept the NIM as a valid means for public reporting of nosocomial infections. RESULTS: The medical center now uses an electronic data interface to automatically produce information for PHC4. This tool identifies all nosocomial infections across all hospital locations, which is the ultimate goal of PHC4 reporting. PHC4 now considers the medical center to be a model for public reporting of nosocomial infections and has requested state funds to support widespread use of the NIM for public reporting by other hospitals. CONCLUSIONS: Public reporting requirements threaten to tax the overstrained resources of infection control. The automated NIM reporting system solves this problem by using technology to count nosocomial infections, freeing practitioners to spend more time on targeted improvement opportunities. The NIM is comprehensive, allowing automated, hospital-wide surveillance. The NIM is also objective, which means that if all hospitals used it as a basis for reporting a more fair comparison would result.