Denise M. Bleak MSN, PHN, CIC Infection Prevention Specialist

Henry Mayo Newhall Memorial Hospital

“Seek and Destroy” strategy: Plan to neutralize transmission factors for Acinetobacter

2. Remember the risk factors for Acinetobacter and other organisms in uninfected patients

3. In groups: Discuss how to prevent recurrence of the infection in susceptible patients, and prevent further outbreaks,

Plan a outbreak control strategy using SWAT and war room strategy.

Distinguish between routine control measures for transmission of infection, and outbreak control measures.

Review methods of surveillance to use when determining that an outbreak exists in the healthcare facility or setting.

Discuss physician responses to the interventions used by patient care staff to control the outbreak: specifically Pharmacy, Nursing, and peers.

OutbreakPatient mortalityRoot cause analysis

• What is it• What happened• Transmission of the organisms and accelerating

factors• Action and mitigating factors

Reporting the Outbreak

“There is no greater calamity than lightly engaging in war. Lightly to engage in war is to risk the loss of our treasure.”

Sun Tzu, The Tao of War (Art of War), China

Here we issue a proposal for change

in tolerance levels in behavior in “noise”

Further explanation…

Infection preventionists issue a proposal for change

in tolerance levels …………….Zero in behavior ………………..Compliance in “noise”, for sensitivity to indicators

NEXT Review a few famous war battles and participants or leaders of war

F. Nightingale in a hospital some miles from the battlefield, lowered the rate of death and increased survival after injuries.

M. Seacole treated the soldiers on the field, prevented cholera, and also started a hospital unit near the battlefield.

Neither could work together.

http://www.spartacus.schoolnet.co.uk/WARcrimean.htm

Alexander’s horse, Bucephalus, whom he had ridden into battle in Greece and Persia, died in battle in India.

Alexander conquered much of the known world in the years 300-323, until his death.

He rode to Babylon, despite warnings not to travel (ravens fighting, men being sacrificed, even imbibing in poisoned drink).

Then he died.

President Lincoln reframed Civil War conflict from a battle between the Industrial Northern States and the Southern Agrarian States

to the conflict between right and wrong, and the moral imperative.

Lincoln died …….. defending the Union,

defeating slavery.

Rename the conflict to a battle listing the highest objective possible

“We win, they lose”.

“Of the four wars in my lifetime, none came about because the US was too strong”.

By “all-out fight”, Reagan did not mean military action.http://www.ashbrook.org/publicat/onprin/v10n6/garrity.html

Quarantine and vaccination to prevent smallpox: proven strategy

Modern Superheroes’ save the world!

May over-idealize the situation

Comic: Inside the Outbreaks: the Epidemic Intelligence Service

Don’t wait for the Emergency to be declared…Incident Command may do this for you.

It is not always an “incident” and may not fit into ICS: Emergency Preparedness is robust.

Modern management: lateral and horizontally integrated chains of command: ICS is not this model.

Seminal article AJIC, 2010:

“Barriers to implementing infection prevention and control guidelines during crises”

This is about experiences of health care professionals from dealing with SARS, C difficile, Avian flu and rubella

http://www.ajicjournal.org/article/S0196-6553(10)00454-2/abstract

4 generic barriers identified: lacking

� Imperative, or precise wording;� Easily identifiable instructions particular to

each profession; � Concrete performance targets;� Timely and adequate guidance on personal

protective equipment and other safety measures.

Wireless technology to control outbreaks

Los Angeles County Syndromic Surveillance System involves Infection preventionists, Public Health epidemiologists, Emergency departments, Admitting Departments, local Pharmacies, Physician offices and rapid care centers.

Quick group response

Neutralize threat

Protect surroundings

Clear command

Armed and protected

Media and influence on belief systems about the outcome of an infectious outbreak

Web page for Armor games :

“1 minute after the outbreak, 100 infected. 10 minutes after the outbreak: 100,000 infected”.

The Hot Zone: Ebola and SWAT responses

UCSF widely copied (13 pages)

Healthcare Quarterly (12) 1, 2009: 30-32:

ICES Report: Five Policy recommendations from Toronto's SARS outbreak to improve the safety and efficacy of restrictions on hospital admissions to manage infectious disease outbreaks.

Establish or verify the diagnosis and case(s).

Develop a case definition

Confirm the existence of an outbreak

Case finding

Compare current and baseline incidence

Notify Infection Control Chairman, Administration HMNMH, DHS

Implement control measures (isolate, culture, line list) based upon the magnitude of the problem

Characterize the outbreak according to person, place and time

Formulate a tentative hypothesis as to the likely cause

Test the hypothesis by utilizing an epidemiological approach• Case control study• Comparisons of organisms from similar cases

Demonstrate significant differences between cases and contracting population

Institute additional Infection Control measures.

Evaluate effectiveness of control measuresReport periodically and when concluded

1. What is Acinetobacter?

2. How does Acinetobacter resemble, and differ from, other bacterial colonizers in the inpatient unit?

“Because colonization is the rule and infection is the exception, colonized patients have no associated physical findings.

Patients with Acinetobacter infection have signs and symptoms related to the organ system involved, ie, wound infection, episodic outbreaks of nosocomial pneumonia, CAPD-associated peritonitis, nosocomial meningitis, or catheter-associated bacteruria.”

http://emedicine.medscape.com/article/236891-overview

1. What is Acinetobacter?

Gram negative Enterobacteraciae species

Several varieties: can be M D R O

Acinetobacter (not “Assetobacter” or “Acnebactro” or even “Ascenobacter”)

What does it need to flourish?

Food sourceWater sourceGrowth medium- also lives on surfacesBreaks in transmission control

APIC Guide to Multi-resistant Acinetobacter baumanii

With grateful appreciation to the Quality Compass program,The Health Advisory Board, 2008.

How does Acinetobacter resemble other bacterial colonizers in the inpatient ICU?

• Gram negative colonizing bacteria include Enterobacteraciae, and also Pseudomonads, etc.

• Remember the KES group acquires MDR traits: Klebsiella Enterobacter Serratia

Recall the immediate threat of “CRE” aka Carbepenem Resistant Enterobacteraciae.

How does Acinetobacter differ from other bacterial colonizers in the inpatient ICU?

• Intermittently seen, can live in situ or on surface• Seen in persons going back and forth to other

residential care and the hospital• Culturing of environment may or may not locate

any reservoir of Acinetobacter• Rapid spread within a few hours to same or other

sites in susceptible persons

Chain of Transmission:

Reservoir of Acinetobacter in ICU

Infectious Agent

Susceptible Host

Route of Transmission

Transmission-based

Evidence-based (how is the organism getting out of/being expressed by the index case)

Body Substance Isolation: could be involved here i.e.. Droplet precautions for novel infectious entities in tandem with this pathogen.

Contents:� Patient Safety/TJC mandates on outbreaks,

influx and Infection Prevention and Control

� Graphs and relevant data� Drugs and changes in therapeutics� Few, then progress to no cases� Is it truly gone? Look back (could be

hiding…)

Part of this success was our attention to Patient Safety.

Routine prevention of infections is centered around reliable, repeated

• routine surveillance, • control and • reporting systems.

Also mandated to plan for an influx of unexpected infection.

HAI’s are preventable20-30% can be preventedStructured, proactive and resilient

surveillance Identify outbreaks: robust identification

of new bacterial…pathogens

2010 Joint Commission Infection Prevention & Control Handbook for Hospitals

Graph of the outbreak

Simply Stated:

There are too many patients with the organism within a short period of time-

therefore, some cause or pressure is forcing the organism to multiply and infect several patients in a narrow area.

“Why is it a problem now?”

The reasons for infections are known,

such as lack of hand washing, failure to clean equipment and the ineffectiveness of isolation systems to confine the organism.

Also, there may be pressure for an organism to have increased bacterial resistance to selective antibiotics.

It places us on high alert when an

outbreak occurs. This puts into effect some

measures that would be considered

extraordinary, such as notification to the

Health Department and Administration.

2009

Don’t let Acinetobacter

become established

BATTLE CRY

One multisystem failure mortality, others recovered.

Number of cases in 6 weeks: 9, compressed into onset dates of three to four weeks.

Is it truly gone, or just hiding?What does APIC Guide say about this???

Ask anyone who was in the war room

The atmosphere was electric.

This energy was maintained in the Environment of Care during the outbreak.

How battle works & the study of actions in a war are useful.

Generals, lieutenants and soldiers are all used in varying ways.

Command hierarchy: chain of command.• (Method in which orders are passed and carried

out.)• Other military concepts are Rank, Accountability,

Feedback and Decision making.

4 generic barriers identified: (recall?)

� lack of imperative or precise wording;� lack of easily identifiable instructions

particular to each profession; � lack of concrete performance targets;� lack of timely and adequate guidance on

personal protective equipment and other safety measures.

“Scatter shot”: covering a wide range in a random way. Indiscriminate.

“Whimsy”: an odd and fanciful idea. A whim.

Democracy: a common set of agreed upon rules for a meeting to make the members comfortable and make the meeting run well.

Dictatorship: overbearing absolute authority of one individual, the leader.

How did “RANK”, “Accountability”, “Feedback” and Decision making apply to the following?

• Variance in cleaning by EVS• Hand hygiene by physicians• Status of screening cultures on all patients• Visitor control and restrictions• Information about isolation in entire unit• Wipes used on patients during outbreak

“Experience and evidence have taught us that the core components of infection prevention and control are

consistent application of proper hand-hygiene measures,

maintenance of a clean environment, use of barriers where appropriate, and prompt identification of patients at high risk of

colonization with a transmissible microorganism.”

Johnston BL and Bryce E. Hospital infection control strategies for vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus and Clostridium difficile. Can Med J.180(6): 627-631. March 17, 2009.

Wireless technology to control outbreaksQuarantine and vaccination to prevent

smallpox John Snow and the Control of Cholera: the

Broad Street pump Inside the Outbreaks: the Epidemic

Intelligence ServiceWest Nile Virus: 1937 (one woman) to 2010,

world wideAnthrax vs. science, intentional

contamination. 2001 to present.

Fiction

Andromeda Strain, Michael CrichtonOutbreak and Contagion, Robin CookThe Stand, Steven KingPandemic, Daniel Kalla

Non-Fiction

Scurvy and saving lives of sailorsCholera in London and elsewhere1918 Spanish influenza outbreakHerpes simplexHIV/AIDSPolioCurrent battles raging to prevent patient

injury and death in hospitals in US

1 General2 Lieutenants4 Soldiers

Two sets of questions

Fifteen Minutes (sharing for five minutes)

On Day 1, a new Resistant organism is seen, in a given patient care unit, in one individual who has never had this infection.

Infection is presentNever colonized with organismOrganism is resistant and one that we

commonly place into isolation

Teams are assigned. General, read the following to the troops.

Now three additional patients near the first patient have also grown out isolates from body sites of the Resistant organism. It is Day Three from the first culture. All patients are alive and remain on the same unit.

Generals: finish the first Question. Sum up.

1. What is your battlefield plan?

Did you seek and destroy? How?

2. Was your battle group involved in neutralizing transmission factors?

What was different as compared to the everyday work?

New GeneralNew Soldiers (not the same people who

took orders. Switch the lieutenants and soldiers please.

QUIETLY

Now five patients, all from the same unit over 7 days, all have the Resistant organism in multiple sites.

1. With whom should the General be meeting?

Everyone suggest who is involved in the meeting.

2. When should the first meeting with stakeholders in the facility take place?

3. Did “everyone” get to contribute to idea-forming about how to stop this organism?

Are the groups clear that the outbreak continued even though the first group worked on it?

Is it logical to expect that an organism will respond immediately to actions taken to neutralize it or destroy it?

Generals, report:

Who met?

What was the main topic?

Who else was brought in to assist with the outbreak?

Is Emergency management involved?At what point did you reveal the outbreak to

the community, facility or physicians? Is the PIO involved? Is the Administrator involved?

Review content here to determine if you followed the OUTBREAK POLICY

UCSF widely copied (13 pages)

Healthcare Quarterly (12) 1, 2009: 30-32:

ICES Report:

Five Policy recommendations from Toronto's SARS outbreak to improve the safety and efficacy of restrictions on hospital admissions, to manage infectious disease outbreaks.

1 restrict non-urgent admissions for a reasonable time

2 public information campaigns to inform patients to seek care when necessary should be part of the campaign

3 develop urgent admission criteria for the most common surgical conditions

4 recognize limited impact of creating restrictions on surge capacity

5 implement strategies that protect access to highly regionalized tertiary care programs

1. Restrict non-urgent admissions2. Inform patients to seek care3. Develop urgent admission criteria4. Limit surge capacity5. Access protection to tertiary care

R I D L A

Popular- consider Return on Investment

• Effective?• Controlled?• Evidence-based?• Expensive?• Entertaining?

No vaccine against this organisms:

that is counter to usual military measures for all trainees during basic training

Two good recent articles:1. Nosocomial transmission of Acinetobacter

baumanii in Iraq at military presentation. IDSA07-0060_WhitmanTimothy_1.pdf(page 1 of 16)

http://www.military.com/features/0,15240,162552,00.html….about Acinetobacterinfections in military hospitals

Military demonstrating tactics to fight infections

By November 2008 cases were diminishing.

ICU was out of group isolation.

By December 2008 there were no new cases of Acinetobacter

To date:

There has been no established colonization nor prolonged incidence of this organism in the ICU or on any nursing unit.

Clostridium difficile increase

Associated decrease following control measures

Reference List attached to handout.

The joy of living

is

Living.

-Reich