Sarcopenic obesity

Sarcopenic obesity is a medical condition which is defined as the presence of both sarcopenia (loss of muscle) and obesity.

Sarcopenia refers to the presence of low muscle mass and either low muscular strength or low physical performance.

When this is accompanied by a high fat mass the condition is known as sarcopenic obesity.[1]

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Case 7: Paediatric Issues in Infection Control (practice/redo)

You were informed by one of the patient service managers that one of her staff (a 26 year-old female) has just been diagnosed by her family practitioner as having chicken pox. She works on the general paediatric ward and her last day of work was three days ago, the same day the rash developed. The nurse had worked with three patients in adjacent rooms for five days prior to her last day of work, although she had been giving break relief to other nurses throughout that period. The unit has twelve patients on the one wing. The children range from age 2 to 13.

Case Seven Questions:

1.What precautions should be taken, if any, to protect patients on the ward? Would you recommend prophylactic therapy for any of the patients? Justify your response.

Precautions for patients:

  • Varicella zoster can be transmitted through air or contact from persons (Lautenbach, p. 301) Therefore all patients with symptoms should be placed on airborne and contact precautions.
  • Patients who have contracted varicella zoster should remain on precautions until lesions have dried and crusted to prevent hospital exposures (Lautenbach, p. 301).
  • Non-immune exposed patients should be placed on airborne precautions for the period from day 10 through day 21 after their exposure or through day 28 if the patient is immunocompromised or has received Varicella zoster immunoglobulin
  • Varicella zoster is rarely spread through air from individuals with localized herpes zoster so patients, visitors and healthcare workers with this disease entity do not need to be restricted so long as their lesions are covered (Lautenbach, p. 301)

Prophylactic therapy:

  • Patients and staff who are non-immune should receive the varicella zoster vaccine as it results in milder outbreak and is cost effective for the hospital given costs associated with secondary cases (Lautenbach, p301)
  • All patients on the unit are a high risk for complications therefore if they can safely receive varicella vaccine, and it is within 3 to 5 days after exposure, give the vaccine (BCCDC, 2004)
  •  For immunocompormized patients give Varicella zoster immune globulin (VZIG) given within 96 hours of exposure (BCCDC, 2004)

2. What, if any, infection control measures should be considered for the hospital workers.

  • non-immune workers could be incubating the infection and could spread it to others
  • all healthcare workers who might have been exposed should not work in patient care capacity during the incubation period (Lautenbach, p. 301)
  • staff members who develop varicella zoster must not work until all lesions have crusted over(Lautenbach, p. 301)
  • non-immunized exposed staff should be considered potentially infectious 8 to 21 days following exposure (28 days if VZIG was given (BCCDC, 2004)

  • Staff who are pregnant or have immunocompromizing conditions such as corticosteroid treatments should receive VZIG  (BCCDC, 2004).
  • immunization status of current staff should be known or sought (BCCDC, 2004)

  • Lab results for Serology for VZV IgG should be determined for non-immune staff before immunization (i.e.unknown or no history of chickenpox) (BCCDC, 2004).

  • staff who are immunized are considered to be immune (4 weeks after the second dose) and no special precautions need to be taken if they are exposure

  • If susceptible staff is not eligible for immunization, or if serology results can not be promptly obtained, refer to a physician for clinical management, which may include prophylaxis with antiviral and VZIG if the HCW is at high risk for complications of varicella disease.

  • susceptible non-immunized HCW/students from work from days 8 through days 21 post-exposure. Extend the exclusion to 28 days, if VZIG is given.

3. What are the tests available to confirm a diagnosis of chicken pox? Is laboratory confirmation always necessary – why or why not?

Laboratory confirmation from Isolation of varicella virus from an appropriate clinical specimen or significant rise in serum varicella IgG antibody level by any standard serologic assay (BCCDC, 2004).

Laboratory confirmation not always necessary in cases where clinical illness arises in an epidemiologically linked person where the link individual has lab confirmed chicken pox.

4. How effective is Varicella zoster vaccination in children? In adults? What are the potential complications?

  • In immunocompetent children 12 months to 12 years of age, a single univalent varicella vaccine dose results in a seroconversion rate of 98% at 4 to 6 weeks after vaccination, with antibodies persisting in 98% at 5 years and 96% at 7 years after vaccination.
  • A second dose of a univalent varicella vaccine in children produces an improved immunologic response that is correlated with improved protection (Government of Canada, 2016).
  • In immunocompetent adults and adolescents 13 years of age and older, 2 vaccine doses administered 4 to 8 weeks apart result in seroconversion rates of 99% at 4 to 6 weeks after the second dose, with persistence of antibodies 5 years later in 97% of vaccine recipients(Government of Canada, 2016).

Potential Complications:

  • injection site pain
  • swelling and redness in 10% to 20% of recipients
  • A low-grade fever has been documented in 10% to 15% of vaccine recipients.
  • A varicella-like rash occurs at the injection site or is generalized in 3% to 5% of vaccine recipients after the first dose.
  • The rash usually appears within 5 to 26 days after immunization.
  • As varicella-like rashes that occur within the first 2 weeks after immunization may be caused by wild-type virus (varicella virus circulating in the community), health care providers should obtain specimens from the vaccine recipient to determine whether or not the rash is due to a natural varicella infection or to the vaccine-derived strain (Government of Canada, 2016).

5. This nurse, as the case turns out, is pregnant and delivers the day following her visit to her family practitioner. The baby is admitted to the neonatal intensive care unit. What measures should be taken?

References:

  1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.
  2.  BCCDC. 2004. Communicable disease control Varicella zoster.  http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/Epid_GF_VaricellaZoster_July04.pdf
  3. Government of Canada. 2016. Canadian Immunization guide. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-24-varicella-chickenpox-vaccine.html#p4c23a4

Case 6: Infection control in institutional contruction and design (practice/redo)

You have identified a burn patient (60% burns) in the ICU with serial blood and tissue cultures positive for Aspergillus fumigatus. Upon reviewing the patient in ICU and inspecting the area, you notice a bulging ceiling tile in the corridor adjacent to his room. You are told that the tile has been like this for one week now. Maintenance is called and the ceiling tile is removed, at which point you notice greenish discoloration of the inner surface of the tile and evidence of water leakage from the pipe above. The air intake into the patient’s room runs above the discoloured ceiling tile.
Case Six Questions:
1. What special precautions should have been taken for this burn patient upon his admission to the unit?

The patient has burns to 60% of his body and is therefore at very high risk of infections.

Precautions for the patient upon admission to the unit:

  • physical isolation in a private room
  • gloves and gowns during patient contact
  • full body wound assessment
  • appropriate empirical antimicrobial therapy
  • laboratory surveillance cultures
  • routine microbial burn wound cultures (Coban, 2012)
  • patient should have been moved or air intake sealed off when discoloured ceiling tile noted near the air intake to his room

“During, maintenance, renovation and contruction, bacterial or fungal microorganisms in the dust and dirt can contaminate air handling or water systems wich can transmit these organisms to susceptible persons” (Lautenbach, p. 394).
2. If you had been asked to perform an infection control risk assessment prior to tile removal and plumbing remediation, what risk would you assign and why?

Type construction activity: Type C (working on ducts, removing ceiling tiles) (LAUTENBACH, P. 446).

Patient risk group: high risk, immunocompromized, burn patient (Lautenbach, p. 447).

Class of precautions: III/IV due to highest risk and type C (Lautnbach, p. 447).
3. What precautions should the maintenance workers take when they remove and dispose of the affected materials? Is this considered biohazardous material?

Precautions to be taken:

Seeing as we designated the risk class III/IV above, class 4 precations should be used for the most encomapssing precations for all involved.

Class IV precautions to be taken during the contruction project according to Lautenback, p. 448 are as follows:

  • Isolate HVAC systems in the work area to prevent air duct contamination
  • Implement barrier cube method or barrier sealing off of work area out of sheetrock, plywood, or plastic (Lautenback, p. 448)
  • maintain negative air pressure within work site
  • use HEPA equipped air filitration units (lautenback, p. 448)
  • seal off holes, pipes, conduits, punctures
  • construct anteroom: 1. all personel to be HEPA vaccummed before leaving the work site or 2. workers change out of paper coveralls each time they exit the work site (Lautenback, p. 448)
  • all personel to wear shoe covers  that are changed prior to exiting the work site
  • contain contruction waste: transport in tightly covered containers with added cover over transport receptacle or cart (Lautenbach, p. 448).

Disposal of material: Aspergillus is not a biohazard because it is readily found in the hospital environment (dust, dirt, construction debris). Aspergillus is not harmful to healthy people therefore can be disposed of without biohazard precautions(Lautenbach, 441).

4. How should air flow be designed in intensive care areas such as burn units and ICUs?

  • patient rooms should have 6 air changes per hour (Lautenbach, p. 451).
  • 2/6 of the air exchanges per hour must be outdoor exchanges
  • rooms where high risk procedures are performed such as bronchoscopies, should have negative pressure with respect to adjacent areas (Lautenbach, p.451)
  • these high risk ventiliation procedure rooms should have flexible ventilation where pressure can be changed from neutral to negative (Lautenbach, p. 451).
  • If a room with special ventiliation is renovated, air exchanges and air pressure should be measured following the renovation
  • exterior air intakes should be place minimum 8m upwind of exhaust outlets
  • the bottom of such air intakes should be minimum 2m above ground or 1m above roof level
  • air intakes should be located away from cooling towers, trash compactors, loading docks, heliports, biological safety exhaust hoods, sterilizers, aerators, and incinerators (Lautenbach, p. 451).

5. Guidelines exist for new construction and renovations in hospitals. Give examples of these and explain how they differ from construction regulations.

References:

1. Coban, Y. K. (2012). Infection control in severely burned patients. World Journal of Critical Care Medicine, 1(4), 94–101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3953869/

2. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

Case 5: blood borne infections (practice/redo)

While replacing a central venous line on a 29 year-old intravenous drug user, the resident receives a sharps injury from the syringe used for the local anaesthetic. The injury, which bleeds freely, is on his left index finger. The resident notes that there was visible blood in the syringe.
Case Five Questions:

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1. What are the immediate preventive measures the resident should take and to what organisms has the resident potentially been exposed?

The resident has potentially been exposed to:  Hep A,B,C, HIV (Lautenbach, p. 322).

Immediate preventative measures:

  • Save the syringe to send to the lab for testing.
  • The resident should continue to allow the wound to bleed freely
  • not promote bleeding by squeezing the wound as it may damage the tissues and increase uptake of any pathogen(s) (BCCDC, 2016).
  • Wash the area well with soap and water (BCCDC, 2016)
  • Notify the hospital’s occupational medical service (Lautenbach, p.322) and file incident report.

4 Key measures:

1. Assessment of the risk of exposure

2. Laboratory testing on the exposed person and the source person

3. Administration of PEP treatment when appropriate to prevent the development of infection

4. Counseling the exposed person to address anxiety, ensure follow-up testing and modify behavior to prevent transmission to contacts (BCCDC, 2016).

The resident should undergo a risk assessment at the hospital ER or occupational health department which includes the following:

  • HBV vaccine history or HBV immune status
  • Personal risks for HCV and/or HIV
  • Obtain verbal informed consent for testing for HBsAg, Anti-HBs, Anti-HBc Total, Anti- HCV and HIV.
  • Also obtain consent for disclosure of their results to their Worksite occupational health department and WorkSafeBC
  • Follow-up the resident’s family physician.
  • Inform HIV testing will be done either Nominally – in which the test is conducted and reported using the client’s full name, address and contact information; or Non-nominally – in which the test is conducted using initials as per agency standards
  • Positive HIV results will be reported to the Medical Health Officer using the nominal or non-nominal identifiers. Non-nominal HIV reporting is identified through checking a tick box on the laboratory requisition form.
  • Test results for HBV and HCV, if positive, will be reported to the person’s testing physician and public health for follow-up.

2. What post-injury preventive measures should be undertaken and under whose direction? What long-term follow-up should the resident receive?

Post injury prevention for each top blood borne disease listed belowe under the hospital’s occupational medical service (Lautenbach, p.322)

HBV measures:

  • If the resident  has not been immunized against HBV they should be given 0.06ml/kg of hepatitis B immune globulin IM. The first dose should be administered within 24hrs post-exposure.
  • The first dose of HBV vaccine should be adminstered at the same time (Lautenbach, p. 323).
  • An additional vaccine dose should be given 1 month later
  • An additional vaccine dose should be given 6 months later
  • a baseline level of HB antibody should be deterined pre-treatment, if the result is positive for HBV no further treatment is required.
  • if the resident was previously vaccinated, a baseline anti-HB should be determined (Lautenbach, p. 323).

HCV measures:

  • tested to determine their level of aminotransferases (alanine and asparate) (Lautenbach, p. 324)
  • determine HCV antibody level with sensitivity and antibody test at baseline within 15 weeks of exposure
  • monitor for symptoms as acute hepatitis
  • immune serum globulin should not be administered for occupational exposures
  • monitor with HCV RNA polymerase chain reaction tests
  • use immunomodulators to treat (Lautenbach, p. 324)

HIV measures

  • follow antiretroviral regime for post-exposure prophylaxis
  • Serology test at time of exposure
  • follow up testing at 6 weeks, 3 months and 6 months post-exposure (Lautenbach, p.327)
  • 1 year follow up testing post-exposure, varies on institution

3. Discuss the difference between active and passive sharps injury prevention devices. Give examples of each. Give examples of work practice modifications that reduce the risk of exposure to blood-borne pathogens.

Active sharps injury prevention devices:   Active devices require one- or two-handed activation by the healthcare professional after use (Stankovic, 2011). eg needle protection sheiths that need to be pushed over the needle post-use

Passive sharps injury prevention devices: do not require additional steps to initiate the safety mechanism since it activates automatically during device use (Stankovic, 2011). eg. insulin or subcut butterfly sheiths that automatically sheith the lance.

examples of practice modifications that reduce risk of exposure:

  • using needless systems for subcut medication administration
  • standard precautions so that health care workers hands have a barrier between them and open wounds/areas
  • use of face shields to prevent spash/spray exposure.
  • staff educational programs(CDC, 2008, p. 12)
  • avoidance of recapping and safe needle disposal systems (CDC, 2008, p. 12)
  • Using alternate routes for medication delivery and vaccination when available and safe for patient care(CDC, 2008, p. 13)
  • specimen collection systems that consolidate and eliminate unnecessary punctures(CDC, 2008, p. 12)

4. After reading the article on human factors engineering in the link below, please give your own unique examples of how this approach could be used to prevent injuries and enhance task performance. (Human factors engineering article from WHO: http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf )

Human factors help improve safety in areas such as

  • safe prescribing practices
  • team communication
  • information handover in between healthcare team members (WHO, date unknown)

 

  • “Human factors recognize that the workplace needs to be designed and organized to minimize the likelihood of errors occurring and the impact of errors when they do occur. While we cannot eliminate human fallibility, we can act to moderate and limit the risks.” (WHO, unknown)
  • eg IV umps that require certain rate to function and beep to inform user if air is in the line
  • “The fact that we can misperceive situations despite the best of intentions is one of the main reasons that our decisions and actions can be flawed, resulting in making “silly” mistakes—regardless of experience level, intelligence, motivation or vigilance.” (WHO, unknown)

  • eg routines like OR swab and instrument counts before and after surgery prevent a swab or instrument being left in the patient.

5. Describe the “bundles” or Class A (Strong evidence) recommendations to prevent central line associated infections. (Central line-associated bloodstream infections. http://www.apic.org/Resources/Topic-specific-infection-prevention/Central-line-associated-bloodstream-infections)

 

References:

1. Lautenbach

2. BCCDC. (2016). Blood and Body Fluid Exposure Management. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpManage.pdf

3. Stankovic, Ana. (2011). Porotection against needlestick injuries: active or passive safety. https://www.mlo-online.com/protection-against-needlestick-injuries-active-or-passive-safety.php

4. CDC. (2008). Workbook for designing, implementing and evaluating a sharps injury prevention program. https://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf

5.WHO.  Human factors engineering. http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf

Case 9: Community and ambulatory care issues in infection control

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The staff of your ambulatory care unit in a community-based hospital have asked you to meet with them regarding some specific issues they have as influenza season approaches.

Their concerns are as follows:
a) lack of separation between potentially infectious patients and non-infectious patients,
b) lack of facilities for adequate handwashing
c) concerns regarding side-effects of influenza vaccination and
d) whether vaccination of staff is compulsory and what will happen if staff choose not to be vaccinated.

You visit the area and note that there is a common waiting room, that rooms are usually used for multiple clinics during the week, and that there is indeed a lack of sinks. Further questioning reveals that approximately 30% of the staff are vaccinated for influenza yearly.

Case Nine Questions:
1. How would you mitigate against the risk of respiratory infections in the ambulatory care setting?

Promote good hand hygiene: Place hand sanitizer stations at the front door, admin/admissions desk and outside every clinic room (lautenbach, p. 397).

Educate:

  • Implement respiratory hygiene and cough etiquette: Post “cough etiquette” signs in the waiting room and washrooms along with hand sanitizer dispensers and tissues within easy reach(CDC, 2016).
  • Screening and triage of symptomatic patients: Ask any sick patient to phone ahead so that they may be re-scheduled and seen at the start or end of appointment days to prevent their sitting in the shared waiting room for extended periods (CDC, 2016). Note: if the patient’s appointment can be postponed until they are no longer sick, do so to avoid sick patients coming into the hospital at all. (CDC, 2016)
  • Instruct patients (and those accompany them) to inform staff upon arrival if they have symptoms of any respiratory infection (cough, runny nose, fever) and to take appropriate preventive actions (wear a facemask), (CDC, 2016).
  • Instruct sick patients (and educate staff triage patients) to report to the front desk upon arrival so that they may be shown into the next available clinic room rather than sitting out in the shared waiting room for long periods where they might infect others.
  • For clinic team leads “strong organizational leadership and an infrastructure for clear and timely communication and education, and for program implementation, have been common elements in successful programs.”(CDC, 2016)

Vaccinate:

  • Promote the flu vaccine and offer vaccination clinics to staff and vulnerable patients prior to the onset of flu season (Lautenbach, 397).
  • Also consider offering vaccination to vulnerable patients against preventable infectious diseases beyond the flu considering the shared environment in which different clinics are run(Lautenbach, p. 397).
  • The infection preventionist’s goal should be to vaccinate everyone who shares the community-based hosptial “unless contraindicated, vaccinate all people aged 6 months and older, including HCP, patients and residents of long-term care facilities” (CDC, 2016).

Use techniques to increase the flu vaccine rate amongst staff (we know currently on 30% are vaccinated).

Strategies such as:

  • providing incentives
  • providing vaccine at no cost to staff or vulnerable patients
  • improving access (e.g., offering vaccination at work and during work hours)
  • require staff and patients to sign a form to acknowledge that they have been educated about the benefits and risks of vaccination to be kept on file
  • mandating influenza vaccination for all healthcare professionals without contraindication is also an option (this seems to be debated every year!) (CDC, 2016).

Sanitization and cleaning:

  • Ensure proper adherence to environmental infection control procedures
  • ensure proper protocols are followed for sterilization and disinfection of all equipment
  • ensure high-touch surfaces in the environment are cleaned frequently throughout the clinic days
  • ensure proper cleaning procedures are followed for cleaning and disinfection of waiting room and clinic rooms as they are at higher risk to transfer infections being used for multiple clinics during a week (Lautenbach, p. 397).

Surveillance: perform surveillance for healthcare-associated infections at this community based hospital

  • Investigate any influenza outbreaks.
  • Ensure a mechanism of investigation and reporting of sentiel healthcare associated infection events is in place (Lautenbach, p. 398).
  • Sick staff: appropriate management of ill health care workers (use influenza screening tool for sick calls) (CDC, 2016).
  • Risk management: adherence to infection control precautions for all patient-care activities and aerosol-generating procedures (CDC, 2016)

Infection control precautions for staff to mitigate against the risk of respiratory infections:

  • wear gloves when in contact with any potentialy infectious material
  • gown for care activities with risk of contact with blood, body fluids, secretions (including respiratory), or excretions (CDC, 2016)
  • Remove gown and perform hand hygiene before leaving the patient’s environment.
  • Upon arrival, and until departure from the community-based hospital place patients on droplet precautions with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer (CDC, 2016).
  • Staff are to follow influenza patient care policy of putting on a mask prior to entering a room containing an influenza infected patient. (CDC, 2016).

Implement engineering controls:

  • Renovate the community-based hospital if possible to a design with control measures to reduce or eliminate exposure to infection
  • Install elements that shield staff and other patients from infected individuals
  • Examples of engineering controls include installing physical barriers such as partitions in triage areas and curtains that are drawn between patients (CDC, 2016).

Limit visitors:

“Visitors who have been in contact with the patient before and during hospitalization are a possible source of influenza for other patients, visitors, and staff”(CDC, 2016).

  • Restrict visitors to those necessary for the patient’s emotional well-being and care
  • Screening visitors for symptoms of acute respiratory illness over the phone before they accompany a patient to the community-based hospital
  • provide instruction (if possible before arrival) or at the front door using posters and signage on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) if needed.
  • Visitors should not be present during aerosol-generating procedures.
  • Visitors should be instructed to limit their movement within the facility (CDC, 2016).

2. Do you have any suggestions on how to involve the patients and family in infection control in this unit and in the community?

According to the public health agency of Canada, there are key elements to effiectively engaging the public. The 5 steps are:

  • Planning
  • Developing products
  • Implementing
  • Reporting
  • Evaluating (HC and PHAC, 2016)

Examples of engagement are:

  • Provide handwashing and cough etiquette material and posters for patients and families to read, share, put up in their community such as at their schools, local libraries, their workplaces and even in their homes.
  • Patients and families can help one another as well as other families and patients they come in contact with in this unit by following good flu prevention strategies.
  • They can get the seasonal vaccine, remind others to do so as well along with reminders to wash hands or cover their cough.
  • Families and patients both can help prevent the spread of the seasonal flu by staying home when sick.
  • Broadcast public education and information on social media, TV and radio (PH and PHAC, 2016).
  • Place flu prevention technique posters on buses, in public washrooms and publc waiting areas around town.

3. What is the current recommendation or directive from your province regarding vaccination of healthcare workers? Explain the rationale for the directive and why you agree or not.

The BCCDC influenza prevention policy states:

“BC’s Influenza Prevention Policy requires all healthcare workers to either be vaccinated against influenza or wear a mask in patient care areas throughout the influenza season. The policy also applies to visitors, volunteers and students who attend a patient care area” (BCCDC, 2017).

The rationale for the directive:

If less than the target of 80% of healthcare workers are immunized herd immunity falls below levels effective at preventing an influenza outbreak in a healthcare setting which places vulnerable patients at risk.

Healthcare workers are exposed to the most vulnerable individuals in a population – those at greatest risk for contracting the flu and suffering potentially life-threatening complications as a result of the flu. “Severe illness can result in hospitalization or death. Certain populations, such as young children and seniors, may be at higher risk for serious influenza complications such as viral pneumonia, secondary bacterial pneumonia and worsening of underlying medical conditions.” (PHAC, 2017).

If healthcare workers become sick with the flu they may spread it to vulnerable patients whom are unable to fight it off due to their underlying conditions.

Some patients may be immunocompromised as a result of their underlying conditions or as a result of treatment. These patients cannot build sufficient immunity against the flu even if a vaccine is given as therefore rely on (herd immunity) those around them being healthy (BCCDC, 2017).

Rationale according to the ministry of health:

  • “Influenza – or the flu – can be a serious contagious disease, which is spread by droplet transmission through close contact with an infected person. Infected individuals are highly contagious and can transmit the virus for 24 hours before they show any symptoms.”
  • Influenza causes by far the most deaths among vaccine- preventable diseases, outpacing all others combined.
  • Hospitalized patients and seniors in residential care are more vulnerable to influenza than healthy adults.
  • The vaccine is also less effective for frail seniors or other hospitalized patients, making it even more important that their caregivers are vaccinated.
  • Infected health care providers can pass the virus on to their patients before they even know they are sick. The most effective way to prevent the flu is by getting vaccinated” (Ministry of health, 2014).

4. What other respiratory illness might cause outbreaks in the community and the hospital setting? What rapid diagnostic methods are used to identify viral respiratory pathogens?

Respiratory illnesses that cause community outbreaks:

  • Severe acute respiratory syndrom (SARS)
  • Measles
  • Tuberculosis (TB) (Lautenbach, p. 357)

Other illnesses spread in outpatient settings:

  • Bordetella pertussis (Lautenbach, p. 361)
  • Varicella- zoster virus
  • parvovirus B19

Rapid diagnostic methods for viral respiratory pathogens:

New methods:

  • rapid respiratory virus culture methods
  • pooled antibody reagents
  • rapid antigen direct tests (RADTs)
  • improved specimen collection devices
  • nucleic acid amplification tests (NAATs).
  • “The introduction of these new systems has created new challenges for laboratory directors, who must decide which of the many tests to offer and what specimen types to accept for diagnostic testing”(Gnocchino and McAdam , 2011).

Old/Traditional methods:

  • RADTs
  • direct fluorescent antibody testing (DFA)
  • virus culture
  • traditional methods are often inferior in assay sensitivity, specificity, time to virus identification, and breadth of pathogen detection compared to NAATs. (Gnocchino and McAdam, 2011)

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(Above table from USCDC, 2016)

5. You decide they might benefit from a more structured infection control approach. What key elements are important to consider in an outpatient infection control program?

  • Patients maybe carrying unrecognized pathogens in and out of the outpatient envirmonment (Lautenbach, p. 357).
  • the appropriate level of infection prevention to prevent ambulatory care-associated pathogen transmission is presently unknown (Lautenbach, p. 357).
  • The CDC has not yet recommended specific infection prevention and control surveillance systems for ambulatory care (Lautenbach, 357).
  • Infection prevention and control programs, planning and resources are lften lacking beyond inpatient hospital settings.

Key elements of infection prevention and control for outpatient settings are:

Pathogen Transmission occurs in 2 ways:

  1. congregation of patients in waiting rooms/areas or common rooms/areas
  2. invasive procedure-associated

Pathogens can be spread via healthcare workers in these amublatory care settings when staff fail to follow proper:

  • aseptic technique
  • hand washing technique
  • environmental sanitation standards(Lautenbach, p. 357)

In structuring infection control in outpatient settins Infection Preventionists must determine:

  • which infections to conduct surveillance on
  • whom to report the data to
  • who will be responsible for implementing the changes (Lautenbach, p. 357).

Methods to reduce respiratory illness spread in outpatient settings:

  • post visual alerts at the entrance to instruct patients to report respiratory symptoms
  • cover nose and mouth when coughing or sneezing
  • use tissues to contain respiratory secretions and dispose of them in nearest garbage
  • perform hand hygiene after contact with respiratory secretions, contaminated objects or materials
  • provide conveniently located handwashing agents
  • offer masks to coughing persons
  • trage coughing persons out of the common areas asap (Lautenbach, 359).

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

2.  Center for disease control and prevention, CDC (2016). Prevention Strategies for Seasonal Influenza in Healthcare Settings Guidelines and Recommendations. https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

3. BCCDC. (2017). Influenza Prevention Policyhttp://www.bccdc.ca/health-professionals/clinical-resources/immunization/influenza-prevention-policy

4. Public Health Agency of Canada. (2017). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2016-2017. http://www.phac-aspc.gc.ca/naci-ccni/flu-2016-grippe-eng.php#i2

5. Ginocchio, C. C., & McAdam, A. J. (2011). Current Best Practices for Respiratory Virus Testing. Journal of Clinical Microbiology, 49(9 Suppl), S44–S48. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185851/

6. Health Canada and the Public Health Agency of Canada. (2016). Guidelines on Public Engagement. Obtained from: http://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/guidelines-public-engagement-publique-lignes-directrice/alt/pub-eng.pdf

7. USCDC. (2016). Rapid Diagnostic Testing for Influenza: Information for Health Care Professionals. https://www.cdc.gov/flu/professionals/diagnosis/rapidclin.htm#Table1

8. ministry of Health. (2014). Influenza Vaccine – Frequently Asked Questions Influenza Control Program. http://www.immunizebc.ca/sites/default/files/graphics/influenzavaccinefaqphsa.pdf

Case 4: Antimicrobial resistance and infection control

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    The 600-bed tertiary adult care hospital where you work has had 46 patients with Methicillin Resistant Staphylococcus aureus (MRSA) in the past two months. Cases have occurred on the General Surgical Floor and this is a significant increase from the previous two months. You have implemented appropriate procedures and the situation appears to be under control. However, now you are asked to deal with issues regarding transfer of patients within your own institution, to long-term care facilities and to other acute care facilities. In particular, the long-term care institutions are reluctant to accept patients because of concerns regarding increased work-load and spread of “infection” to other residents.
    Case Four Questions:
    1. What are the specific mechanisms of resistance in MRSA, vancomycin resistant enterococcus (VRE) and carbapenem resistance in Gram Negative Bacilli?

Mechanism of resistance in MRSA
Resistance to methacillin in S. aureus is due to an alternate penicillin binding protein being produced called PBP2a (Lautenbach, P.198). This alternative penicillin binding protein has a low affinity for beta-lactam antibiotics. As a result the bacteria continues to be able to generate stable peptidogycan structures (that forms it’s cell wall) in the presence of formerly inhibitory concentrations of beta-lactam antibiotics (Lautenbach, P.198).

The gene that encodes for this resistance is located on the staphlococcus chromosome cassette mec, SCCmec. Transfer of the SCCmec gene from strain to strain has been rare and worldwide spread has been greatly due to clonal expansion of a few strains.
There are community acquired strains – SCCmec type IV
Multidrug resistant strains – CA-MRSA USA 300

Mechanism of resistance of Vancomycin resistant enterococcus (VRE)

Resistance to vancomycin in Enterococccus strains is for the most part due to acquiring either vanA or vanB genes (Lautenbach, P.199). These genes hold the DNA blueprint for the creation of the enzyme used to produce the precursors of peptidoglycan which then have reduced binding affinity for glycopeptides resulting in a weakened bacterial cell structure (Lautenbach, P.199). Resistance genes are carried on easily transferrable plasmids shared between strains.

Mechanism in Carbapenem resistance in Gram Negative Bacilli is the ”
carbapenemase genes, located on transferable plasmids” (picnet CPO toolkit, p.4)
These mechanisms of resistance cause outer-membrane protein deficiencies, result in carbapemase production and impact the efflux pumps (Lautenbach, P.211).

As to specific mechanisms of this resistance, in P. aeruginosa, imipenem resistance results when the OprD outer membrane protein that was accessible to carbapenems is lost. With P. aeruginosa, some efflux mechanisms reduce susceptibility to meropenem and doripenem (Lautenbach, P.212).

Carbapenem resistance in K. pneumonia is due to production of KPC, broad spectrum beta-lactamases which confer resistance to beta-lactams, beta-lactam-beta-lactamase inhibitor combinations and carbapenems. The enzyme that encodes this resistance is located on an easily transmissible plasmid (Lautenbach, P.213).
2. What procedures would you have implemented immediately to control this outbreak?

  • All infected patients would be placed on contact isolation (glove and gown) until until lab results return with no detectable MRSA colonization (PICNET, 2013, p. 17).
  • ensure staff and patients are compliant with hand hygiene (Lautenbach, p. 200)
  • ensure proper disinfection protocols are being followed for equipment and environment
  • staff education about MRSA
  • Implement an MRSA monitoring program (Lautenbach, p. 200)
  • continue to monitor MRSA case reporting and infection rates
  • conduct active surveillance testing for MRSA colonization among patients on the general surgery floor
  • provide decolonization therapy to MRSA colonized patients in conjunction with active surveillance testing program (Lautenbach, p. 200)

3. How will you address the long-term care institutions concerns and what evidence do you have to support your suggestions/recommendations?

For patients being transferred from hospital to a long term care facility, the sending unit will provide ARO status in their transfer report to the receiving facility. The facility can then take steps to ensure proper infection control measures are in place if needed and that further treatment can be continued if needed. “Admission should not be denied or delayed by a RCF on the basis of colonization or infection with an ARO. If a resident is known to be colonized with an ARO, it should be included in their health history and documentation, as this information may guide antibiotic or other treatment choices and is required should they require admission to acute care” (picnet ARO toolkit, p. 13).

Screening should be done following this outbreak and prior to transfer for high risk patients or those who had close contact with an ARO patient and were potentially exposed to MRSA on the general surgery floor (picnet ARO toolkit, p. 14).

The receiving care facility would perform a transmission risk assessment
“Patients at increased risk of disseminating MRSA include:
individuals with colonized tracheostomy and uncontrolled respiratory secretions

individuals with respiratory infections

individuals with wound or stoma drainage that is not contained by a dressing or appliance

individuals with desquamating skin conditions (e.g. psoriasis, burn patients)

individuals who are cognitively impaired (unable to comply with instructions)

individuals who have poor hygiene and are non-compliant with instructions. ” (picnet ARO toolkit, p. 15).

The facility would use the transmission risk assessment to determine what precautions are necessary as they await the return of MRSA swab results.

For admission to long term care of MRSA colonized patients contact precautions should be implemented and this will help prevent transmission to other patients in the facility(picnet ARO toolkit, p. 16).

The following precautions should be followed:

“gloves upon entering the room or patients bed space for any contact with patient or their environment

gowns when providing care to patient or if skin or clothing may come in to contact with their environment

if possible, dedicate any equipment (e.g. blood pressure cuff, stethoscope) to that patient; otherwise, clean and disinfect with a hospital-grade disinfectant prior to using with another patient.

Gloves and gowns must be removed and hands cleaned upon leaving the room or patient’s bed space.

Routine practices recommend the use of a mask when caring for individuals who have a febrile

respiratory illness. As well, a small number of studies support the use of a fluid-resistant mask when

caring for a patient who has respiratory symptoms or a tracheostomy, and has MRSA identified in their sputum ” (picnet ARO toolkit, p. 17).
4. Your facility has decided that a hand hygiene program could be effective in decreasing MSRA. Briefly list and discuss key elements of a hand hygiene program.

Key elements of a hand hygiene program:

  1. System change: make it possible, easy and convenient – sinks and products such as alcohol based hand rub in reach
  2. Hand hygiene education: Knowledge of hand hygiene guidelines, transmissible diseases spread by lack of hand hygiene etc
  3. Promote/faciliate hand washing and skin care for healthcare worker’s hands
  4. Routine observation and feedback: Audits of hand hygiene practices and performance feedback
  5. Reminders in the workplace: posters at sinks, outside clinic rooms etc
  6. Improve institutional safety climate: involvement from individual and institutional levels, ensure adequate staffing, institutional rewards, empower patients to ask/remind staff and involve them to perform good hand hygiene themselves
  7. Combine several of the above factors(WHO, 2009, p96).

5. Currently there is controversy regarding whether infection prevention should primarily employ a “vertical” versus a “horizontal” approach to ARO management or a combination of both. Please state what your position is and why.

We are currently using a combination of both vertical and horizontal approaches to ARO management after noting the examples of both in the table in the Goldmann et al article

Vertical approaches reduce risk of infections due to specific pathogens:

  • Active surveillance testing to identify asymptomatic carriers
  • Contact precautions for patients colonized or infected with specific organisms
  • Decolonization of patients colonized or infected with specific organisms

Horizontal approaches reduce risk of a broad range of infections and are not pathogen specific:

  • Standard precautions (eg, hand hygiene)
  • Universal use of gloves or gloves and gowns
  • Universal decolonization (eg, chlorhexidine gluconate bathing)
  • Antimicrobial stewardship
  • Environmental cleaning and disinfection” (Goldmann et al, p798).

“applying other evidence-based, horizontal strategies such as universal decolonization in settings where benefits are likely to outweigh risks and costs; and …using AST and other vertical approaches selectively when epidemiologically important pathogens are newly emerging and rare to a given institution or region or to control out- breaks of specific pathogens.”(Goldmann et al, p798).

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

2. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva; 2009. http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf

3. Goldmann, Donald A., Perl, Trish M., Septimus, Edward., Weinstein, Robert A., and Yokoe, Deborah S. (2014). Infection Control and Hospital Epidemiology. http://www.jstor.org/stable/pdf/10.1086/676535.pdf

Case 3: Nosocomial infections and Surveillance/Outbreak Investigations

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Upon reviewing the monthly statistics for C.difficile in your facility you note that there are seven cases of C.difficile associated disease (CDAD) on the gastrointestinal surgery floor in the past three weeks. You decide to investigate further and find that these are, indeed, laboratory confirmed cases and that all of them have been acquired in-hospital The number of cases is above the usual baseline for this ward.
Case Three Questions:
1. Describe the steps you would take to immediately investigate and control this outbreak.

“Epidemic associated infections often are clustered temporary or geographically suggesting that infections are from a common source (e.g. contaminated equipment or devices), …secondary to person-person transmission” (Lautenbach p. 143). With this in mind my immediate steps to control the outbreak would be to:

steps to control the outbreak
Step1. ensure all patients with confirmed cases of C.Difficile are on contact isolation precautions and those with suspected C. Difficile are tested (c.diff tool kit PDF) .

Step 2. I would implement a gastrointestinal illness algorithm “to immediately identify and implement Contact Precautions for patients with acute onset diarrhea” (c.diff tool kit PDF) and ensure stool samples are tested for this patient group and that contact precautions remain in place for the duration of diarrhea, then 48-72hrs after stools normalize(c.diff tool kit, p.8).

Step 3. Implement “A transmission risk assessment of each patient” (c.diff tool kit, p.8) to determine if further precautions required.
Step 4. Implement an infection control sheet for documentation in the chart that indicates when precautions are initiated and when they are discontinued along with a stool chart.

Step 4. Provide ongoing staff, patient and visitor education re: hand hygiene and infection prevention precautions

Patients with C.diff should be in a single room when possible, in shared room with other c.diff patients (each under contact precautions with their own personal commodes or if that is not possible, ensure the contact precautions in place for the patient’s bed space and immediate surroundings. ( c.diff tool kit PDF).

Special note: Deciding whether or not to close the gastrointestinal surgery floor would be based on “the severity of the illness, the size of the outbreak and the rate at which new cases are occurring” (Lautenbach p. 149). Deciding whether to limit new admissions to the floor would occur in consult “with the MHO, or designate for the management of outbreaks by IPC and the facility administrator is required under the public health act” (c.diff tool kit PDF)

I would then contact the lab to save all specimen “isolates that might be part of the outbreak” for C. diff strain comparison and outbreak source tracing (Lautenbach p. 145).

Steps to investigate the outbreak
The immediate steps I would take to investigate the outbreak would be to

Step1. test all patients on the unit and test rooms that had contained a C.diff treated patient after discharge and before new admission to ensure that current sterilization/cleaning measures are adequate so that the room and surfaces within it are not C.diff reservoirs.

Step2. Continue trace infection source or reservoir. Consider the OR if needed and lab test the OR and surgical equipment to ensure the equipment or OR itself is not the disease vector for transmitting the C. difficile. “Contamination of environmental surfaces along with lapses in infection control precautions…have been implicated repeatedly in outbreaks of…C.difficile” (Lautenbach p. 145).

Step3. Implement cleaning schedule and review cleaning practices such as the use of sporicidal cleaning agents. Ensure surfaces frequently touched by patients are cleaned twice daily (c.diff PDF, p8)

Step 4. Implement a discharge/transfer cleaning audit too.

In the event that the outbreak is traced back to a single patient, following up with public health may help prevent the spread in community. In the event the outbreak is traced back to equipment (surgical equipment not being able to be effectively sterilized), following up with the manufacturer may help prevent similar outbreaks in other institutions using the same devices.

Special note: Conducting an epidemiologic study would be a step (being mindful of resources) if there is “need to convince clinical staff that the proposed source or mechanism (of disease spread) suggested by chart reviews and observations is correct” and lab testing was unable to trace outbreak back to source.
2. Provide a case definition for this outbreak and provide the rationale for your answer.

A case definition states which individuals have symptoms or findings and specifies the time period: the time the symptoms began, were recognized and specifies the location associated with the onset of symptoms (lautenbach, p146). In this case the case definitions includes the seven patients on the gastrointestinal surgery floor who have laboratory confirmed cases of C. difficle over the last three week period. Our case definition is based on the laboratory confirmed data however this case definition may widen or narrow depending on the results of the investigation and the discovery of the final source of infection (infection reservoir). “How broad or narrow to make the case definition often depends on the frequency with which the organism or condition is encountered”(Lautenbach, p.146). At present our case definition has not expanded outside the GI surgery floor’s 7 confirmed cases

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3. Staff are concerned about their risk for acquiring C.difficile. What is your response?

Staff should place C. diff infected patients on contact precautions to prevent transmission. Staff should glove and gown upon entering infected patients’ rooms or patient area. (PICNet, 2012).

Staff should follow good hand hygiene practices before and after patient contact. Soap and water is more effective than alcohol base handrub against C. Diff (Picnet, 2012, p. 6).

Staff should maintain patients on contact preautions for 48-72 hours after stools normalize (Picnet, 2012, p. 7)

Few staff will have risk factors for acquiring C. Diff. Risk factors for C. Diff are:

  • age over 65 years
  • prior hospitalizations
  • increased length of stay in an intensive care unit, ICU
  • nonsurgical admission to the hospital
  • exposure to broad spectrum antimicrobials
  • longer duration of antimicrobial use
  • exposure to multiple antimicrobials
  • exposure to acid supressive therapy
  • cancer chemotherapy
  • renal insufficiency
  • hemodialysis
  • nasogastric tube in-situ

4. Staff are also concerned that alcohol handrub may not be adequate. What is your reply?

Alcohol based hand rubs do not kill C. diff spores so hand washing with soap and water is necessary. (Lautenbach, p.224).
5. You decide to implement a system for monitoring the quality of cleaning. What types of monitoring might you consider and why? What are some of the newer adjunctive technologies to cleaning and disinfection of surfaces and equipment.

  • Develop a schedule to regularly review and evaluate all cleaning practices by an individual external to the unit. (PicNET, 2012, p.7 ).
  • Use sporicidal agents to address environmental contamination in areas associated with increased rates of CDI such as Sodium hypochlorite 1000 ppm – 5000 ppm and Hydrogen peroxide enhanced action formulation (PicNET, 2012, p.7)
  • UV light
  • Physical cleaning of surfaces is required in order to reduce the bioburden.
  • ensure pre-cleaning to reduce bioburden occurs before sporocidal cleaning
  • Insigate twice daily cleaning of frequently touched surfaces in the patient’s bed space and bathroom (Picnet, 2012, p8)
  • put in place a discharge/transfer cleaning audit tool for room cleaning when the patient is removed from Contact Precautions as well as upon transfer/discharge.

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

2.  Provincial Infection Control Network of British Columbia: PICNet BC Clostridium difficile infection toolkit and clinical management algorithm at https://www.picnet.ca/wp-content/uploads/Toolkit-for-Management-of-CDI-in-Acute-Care-Settings-2013.pdf.