Reducing the Risk of Healthcare Associated Infections from Legionella and Other Waterborne Pathogens Using a Water Management for Construction (WMC) Infection Control Risk Assessment (ICRA) Tool

Construction activities in healthcare settings potentially expose building occupants to waterborne pathogens including Legionella and have been associated with morbidity and mortality. A Water Management for Construction—Infection Control Risk Assessment (WMC-ICRA) tool was developed addressing gaps in building water management programs. This enables healthcare organizations to meet the requirements of ANSI/ASHRAE Standard 188 referenced in numerous guidelines and regulations. A WMC-ICRA was modeled after the ICRA required for prevention and control of airborne pathogens to reduce the risk of healthcare associated infections. The tool allows users to evaluate risk from waterborne pathogen exposure by analyzing construction activities by project category and building occupant risk group. The users then select an appropriate level of risk mitigation measures. Technical aspects (e.g., water age/stagnation, flushing, filtration, disinfection, validation testing), are presented to assist with implementation. An exemplar WMC-ICRA tool is presented as ready for implementation by infection prevention and allied professionals, addressing current gaps in water management, morbidity/mortality risk, and regulatory compliance. To reduce exposure to waterborne pathogens in healthcare settings and improve regulatory compliance, organizations should examine the WMC-ICRA tool, customize it for organization-specific needs, while formulating an organizational policy to implement during all construction activities.

Reimagining Construction and Renovation of Health Care Facilities During Emergence from a Pandemic

The built environment has been integral to response to the global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In particular, engineering controls to mitigate risk of exposure to SARS-CoV-2 and other newly emergent respiratory pathogens in the future will be important. Anticipating emergence from this pandemic, or at least adaptation given increasing administration of effective vaccines, and the safety of patients, personnel, and others in health care facilities remain the core goals. This article summarizes known risks and highlights prevention strategies for daily care as well as response to emergent infectious diseases and this parapandemic phase.

COVID-19 Outbreak and Hospital Air Quality: A Systematic Review of Evidence on Air Filtration and Recirculation

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

The impact of a multimodel approach to designing a new orthopedic department

OBJECTIVE

To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department.

DESIGN

Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention.

SETTING

A 1,000-bed, tertiary-care, university hospital.

PATIENTS

Adult patients admitted to the orthopedics department between January 2015 and December 2018.

METHODS

During the preintervention period (2015-2016), 1 general orthopedic department was in operation. In the postintervention period (2017-2018), 2 separate departments were created: one designated for elective "clean" surgeries and another that included a "complicated wound" unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed.

RESULTS

The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6-9) to the postintervention period (median, 4 days; IQR, 2-7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001).

CONCLUSIONS

Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

Renovation in hospitals: Training construction crews to work in health care facilities

BACKGROUND

Health care facilities require frequent renovations to maintain or enhance their service, and to meet the dynamic demands of their patients. Construction activities in active health care facilities are a significant contributor to various challenges that range from infection to death. It is therefore essential to minimize the adverse impacts of construction activities on health care units as well as their adjacent sites.

METHODS

A questionnaire was developed to study current training modules to prepare construction crews to work in health care environments. The survey was disseminated among professionals of the top 15 health care contractors. A total of 129 individuals participated, and their responses were analyzed using descriptive and categorical statistics.

RESULTS

This study investigates current training practices regarding (1) the level of training, (2) the frequency of training, and (3) the impact that the sensitivity of the project has on the training. To effectively prepare construction crews, special training must be provided to them.

CONCLUSIONS

There are uncertainties about the sufficiency and impact of the existing training. Existing trainings are tailored for upper management positions, and the amount/frequency of training for construction crews are substantially low. Findings of this study contribute to characterizing the activities and conditions pertaining to training of construction crews.

The relevance of sink proximity to toilets on the detection of Klebsiella pneumoniae carbapenemase inside sink drains

We report a higher prevalence of bla_KPC in patient room sink drains located next to toilets (87.0%) when compared with sink drains located farther away from toilets (21.7%) using direct polymerase chain reaction assay. However, culture methods were only able to recover bla_KPC-positive isolates from 16% of polymerase chain reaction-positive drains.

Prevention by Design: Construction and Renovation of Health Care Facilities for Patient Safety and Infection Prevention

The built environment supports the safe care of patients in health care facilities. Infection preventionists and health care epidemiologists have expertise in prevention and control of health care-associated infections (HAIs) and assist with designing and constructing facilities to prevent HAIs. However, design elements are often missing from initial concepts. In addition, there is a large body of evidence that implicates construction and renovation as being associated with clusters of HAIs, many of which are life threatening for select patient populations. This article summarizes known risks and prevention strategies within a framework for patient safety.

Key performance measures to control maintenance-associated HAIs

PURPOSE

The purpose of this paper is to improve overall healthcare maintenance (HM) service performance in NHS infection control (IC). Hence, the authors identify critical success factors (CSFs) and key performance measures in maintenance-associated infections. These infections occur because of the poor performance of HM service in IC.

DESIGN/METHODOLOGY/APPROACH

In the first Delphi exercise, complete CSFs and performance measures were presented to the Delphi participants for refinement and modification. Delphi round 1 data were analysed manually and used to refine the rounds 2 and 3 Delphi instruments. In subsequent Delphi rounds, the results were analysed through descriptive statistics.

FINDINGS

In total, eight CSFs and 53 key performance measures were identified for reducing maintenance-associated infections in hospitals. For example, establishing clear communication between the infection control team (ICT) and HM unit is important for preventing maintenance-associated HAIs. Dust prevention is also identified by the healthcare experts as an important measure to prevent maintenance-associated HAIs in high-risk patient areas.

ORIGINALITY/VALUE

The findings provide CSFs and key performance measures for measuring performance in HM in IC. Reducing the rate of maintenance-associated infections will have important socio-economic and health ramifications for hospitals. It will reduce cost and free up additional resources for alternative projects. It will also raise confidence among healthcare users about the quality of services provided by hospitals.

Infection control in design and construction work

OBJECTIVE

To clarify how infection control requirements are represented, communicated, and understood in work interactions through the medical facility construction project life cycle. To assist project participants with effective infection control management by highlighting the nature of such requirements and presenting recommendations to aid practice.

BACKGROUND

A 4-year study regarding client requirement representation and use on National Health Service construction projects in the United Kingdom provided empirical evidence of infection control requirement communication and understanding through design and construction work interactions.

METHODS

An analysis of construction project resources (e.g., infection control regulations and room data sheets) was combined with semi-structured interviews with hospital client employees and design and construction professionals to provide valuable insights into the management of infection control issues.

RESULTS

Infection control requirements are representationally indistinct but also omnipresent through all phases of the construction project life cycle: Failure to recognize their nature, relevance, and significance can result in delays, stoppages, and redesign work. Construction project resources (e.g., regulatory guidance and room data sheets) can mask or obscure the meaning of infection control issues.

CONCLUSIONS

A preemptive identification of issues combined with knowledge sharing activities among project stakeholders can enable infection control requirements to be properly understood and addressed. Such initiatives should also reference existing infection control regulatory guidance and advice.

Rapid Monitoring by Quantitative Polymerase Chain Reaction for Pathogenic Aspergillus During Carpet Removal From a Hospital

Monitoring for pathogenic Aspergillus species using a rapid, highly sensitive, quantitative polymerase chain reaction technique during carpet removal in a burn unit provided data that allowed patients to be safely returned to the refloored area sooner than if only conventional culture monitoring had been used.

Cluster ofBacillusSpecies Bacteremia Cases in Neonates during a Hospital Construction Project

We report an outbreak ofBacillusbacteremia among premature infants during a construction project. Our investigation revealed potential environmental sources. After replacement of air filters, cleaning of the unit, emphasis on hand hygiene, and relocation of the loading dock for linen and supply delivery, no further cases were detected.

Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit?

We review the context of the environment of care in the intensive care unit setting in relation to patient safety and quality, specifically addressing healthcare-associated infection issues and solutions involving interdisciplinary teams. Issues addressed include current and future architectural design and layout trends, construction trends affecting intensive care units, and prevention of construction-associated healthcare-associated infections related to airborne and waterborne risks and design solutions. Specific elements include single-occupancy, acuity-scalable intensive care unit rooms; environmental aspects of hand hygiene, such as water risks, sink design/location, human waste management, surface selection (floor covering, countertops, furniture, and equipment) and cleaning, antimicrobial-treated or similar materials, ultraviolet germicidal irradiation, specialized rooms (airborne infection isolation and protective environments), and water system design and strategies for safe use of potable water and mitigation of water intrusion. Effective design and operational use of the intensive care unit environment of care must engage critical care personnel from initial planning and design through occupancy of the new/renovated intensive care unit as part of the infection control risk assessment team. The interdisciplinary infection control risk assessment team can address key environment of care design features to enhance the safety of intensive care unit patients, personnel, and visitors. This perspective will ensure the environment of care supports human factors and behavioral aspects of the interaction between the environment of care and its occupants.

Aerosolization of methicillin-resistant Staphylococcus aureus during an epidemic in a burn intensive care unit

Despite prompt identification of cases, rigorous isolation techniques, negative environmental samples, and largely negative personnel cultures, an epidemic of methicillin-resistant Staphylococcus aureus (MRSA) continued in our Burn Intensive Care Unit (BICU). We sought to determine whether there was any aerosolization of that organism in the unit and if there were air quality characteristics that might have enabled its transmission to patients. We measured air exchange and flow rates into rooms and using a Burkhard air sampler measured MRSA generated inside and just outside the rooms before, during, and after dressing changes in burned patients and in controls. We compared MRSA colonization and disease rates in the BICU before and after renovation. Airflow in rooms was variable with positive pressure rooms found adjacent to negative pressure rooms. In the rooms of patients with burns and MRSA infections, MRSA was found by the air sampling machine at four equidistant parts of the rooms and just outside the door during dressing changes and in one instance before a dressing change. Control patients had negative cultures. After renovation that allowed door closure during dressing changes, increased space per patient and improved indoor air quality, there was a sustained fall in MRSA cases. Dressing changes in MRSA infected burned patients generate infectious aerosols. Knowledge and consideration of that fact greatly influenced renovation of our BICU. Along with other infection control measures, this has led to a decreased number of patients with MRSA colonization and disease.

OR Expansion-A Journey into the Unknown

WATCHING A CONSTRUCTION PROJECT mature from concept to culmination is a journey of both professional and personal growth. EFFECTIVE PLANNING and communication are essential for a project to be successful. SUCCESSES AND FAILURES provide learning experiences.

Designing Hospital for better Infection Control: an Experience

The physical design of hospital is an essential component of a hospital's infection control strategy, incorporating infection control issues to minimise the risk of infection transmission. Hospital design therefore, needs to consider the separation of dirty and clean areas, adequate ventilation, lighting and storage facilities and design of patient accommodation areas, including adequate number of wash hand basins and single bed facilities. A 250 bed general hospital was planned keeping in view structural and design elements necessary for success of a good infection control programme. Various National and International Standards like BSI recommendations, JCAHO, IC Standards, DHSS, ASHRAE, AIA and OSHA were studied and compared with our planning parameters. Planning of ward unit, ICU, Operation theatre and Isolation wards were especially reviewed in the light of recent knowledge available in the field of hospital acquired infection and modifications were carried out. Need for effective identification of potential infections, risks in the design of a hospital were stressed. Engineering controls required to reduce the concentration of infectious droplet nuclei in the air and prevention of transmission of disease were highlighted.

Invasive pulmonary aspergillosis soon after therapy with infliximab, a tumor necrosis factor-alpha-neutralizing antibody: a possible healthcare-associated case?

BACKGROUND

Infliximab is a chimeric monoclonal antibody against tumor necrosis factor (TNF)-alpha, used for the treatment of Crohn's disease and rheumatoid arthritis. Recently, an increased risk of infection due to Mycobacterium tuberculosis and rare cases of invasive fungal disease have been reported following infliximab therapy.

CASE REPORT

A 73-year-old woman with chronic rheumatoid arthritis who had been treated with methotrexate, leflunomide, and prednisone was given the first of three doses of infliximab in June 2001. In July 2001, she presented with cough, and in August, she had a right upper lobe infiltrate that was treated with levofloxacin without improvement. In October, the patient had right upper and middle lobe infiltrates on a chest X-ray and computed tomography scan. At bronchoscopy, an endobronchial mass was biopsied, which demonstrated Aspergills fumigatus. Our patient had frequently accompanied her daughter on visits to another medical center following a stem cell transplant, where her daughter was instructed to wear a mask during all visits because of extensive building construction. We postulate that our patient may have acquired pulmonary aspergillosis during this period. Literature reviews on granulomatous diseases following infliximab therapy and hospital-acquired aspergillosis are presented.

CONCLUSION

The temporal relationship between the administration of infliximab and A. fumigatus infection in this patient suggests a causal relationship and possible healthcare-associated acquisition. These data underscore the importance of both patient and family education on prevention strategies when potent immune-modulating medications such as infliximab have been prescribed.

Infection control considerations in critical care unit design and construction: a systematic risk assessment

When contemplating major renovation or new construction of a critical care unit (CCU), the use of systematic infection control risk assessment (ICRA) provides guidance to limit infectious perils for patients and to reduce occupational hazards for employees in this environment. The nursing representative and other members of the multidisciplinary planning and design team must routinely address infection control factors throughout the project and assist administration in understanding the rationale for the floor plan, equipment, and furnishings required to support sound infection control practices. Collaborative team skills, articulate communication techniques, and frequent rounds are integral throughout the construction.

Essentials of paediatric infection control

Young children readily transmit and acquire nosocomial infections. Children are also vulnerable to endogenous infections as a result of the breakdown of their normal defences by disease, invasive procedures or therapy. The increasing acuity of illness in hospitalized children and therapeutic advances have resulted in a patient population that is increasingly at higher risk for nosocomial infections. Antibiotic resistance has emerged as a problem in some paediatric hospitals, usually in intensive care and oncology units. Infection rates are the highest in neonatal and paediatric intensive care units (where bloodstream infections are the most frequent), and are usually associated with intravascular devices. On general paediatric wards, respiratory and gastrointestinal infections predominate, reflecting the occurrence in the community. The surveillance of nosocomial infections identifies priorities for infection control activities and permits evaluation of interventions.The prevention of transmission between patients and to personnel requires that certain measures be taken with all patients, and that additional precautions be taken with some infections, based on the route of transmission. The prevention of transmission from personnel involves ensuring that personnel are appropriately immunized and counselled about working with infections. The prevention of nosocomial infection also involves control of visitors, appropriate management of invasive procedures and devices, sterilization and disinfection of equipment, provision of a clean environment and adequate staffing. Severely immunocompromised children require extra protection, including ventilation systems that reduce the risk of exposure to filamentous fungi. Infection control in paediatrics is an evolving field that must adapt to changes in the paediatric patient population and in health care technology.