Background: Patients with suspected pulmonary TB tuberculosis (PTB) often require scarce airborne isolation rooms; minimizing use depends on clinician understanding of sputum and bronchoscopic test characteristics. Limited knowledge can lead to over-testing and unnecessary isolation days, straining hospital resources. Objective: Evaluate the impact of a PTB screening algorithm on reducing unnecessary testing and excess isolation days in patients with low to moderate pre-test probability. Methods: The study occurred 2022–2024 at a 1,286-bed tertiary care hospital in Toronto, Ontario (~880 TB cases annually). Inclusion criteria included inpatients placed on airborne isolation for suspected PTB with orders for either ≥3 expectorated sputa, ≥1 induced sputum, bronchoscopy, or combinations thereof. Patients with suspected Mycobacterium avium complex were excluded. A positive case is TB PCR or culture positive. Harm is defined as PTB exposure due to premature discontinuation of isolation. The algorithm recommended clinicians to collect a single induced sputum for low/moderate-risk patients with additional testing reserved for high-risk cases. Results: A total of 1,152 samples were collected from 747 patients; 513 expectorated sputa (44%), 194 induced sputa (16.8%), 445 bronchoscopies (38.6%). The median isolation duration was 6 days and the turnaround time for results ranged from 3–11 days. The positivity rate was 0.2% for performing expectorated sputum first (1/513), 2.5% for performing induced sputum (3/118) first, and 1.8% for BAL performed first (3/169). When comparing repeated induced sputum testing, all the samples were positive from the first specimen (Figure 2). Conclusion: These findings illustrate the real-world implications of using a single induced sputum to rule out PTB in low/moderate pre-testing probability patients, potentially leading to the reduction in airborne isolation days. No added harm via patient exposures was detected with the use of this algorithm.

Background: Blood Culture Contamination (BCC) is a significant safety and quality indicator for intensive care units (ICU) at the Veteran Affairs North Texas Healthcare System. In February 2023, the combined ICU BCC rate was 4.7%. The American Society for Microbiology and the Clinical Laboratory Standards Institute recommends a BCC rate not exceed 3%. Methods: In March 2023, a multidisciplinary workgroup was created to reduce the combined ICU BCC rate to a target goal of evidence-based standardized process was implemented using a blood culture kit and guide, hand hygiene, site prep, and aseptic technique. Nurses were also educated to avoid drawing from existing lines. In phase two, a second verifier was added to observe blood culture draws, and documentation fields were modified to record the verifier’s name and location. Training reinforced hand hygiene, use of clean gloves, site prep, and cleaning bottle tops with alcohol. In addition, the Microbiology supervisor disseminated monthly BCC reports to key stakeholders. BCC Champions used reports to monitor compliance with processes, and if deficits were detected, feedback was provided to nurses for immediate corrective action. Results: In the 6-month pre-intervention period (12/1/22 – 3/31/23), 16 BCC events occurred from 570 blood cultures, 2.7% BCC rate. In the 6-month intervention period (4/1/23 – 9/30/23), 16 BCC events occurred from 548 blood cultures collected, 3.1% BCC rate (Phase 1: 2.2% BCC rate, Phase 2, 3.5% BCC rate). The BCC rate reduced by 60% from a peak of 4.7% in the pre-intervention period (2/23) to 1.9% (9/23). In May 2024, a new blood culture kit was piloted and adopted for use in the ICU. Quarterly workgroup meetings were implemented to monitor the quality initiative. In the 12-months post-intervention (10/23 – 9/24), the ICU BCC rate was 1.9%. Conclusion: We reduced the ICU BCC rate to Reducing BCC may lower healthcare costs and reduce unnecessary antibiotic use.

Background: Candida auris (C. auris) and carbapenemase-producing organisms (CPOs) are rapidly emergent healthcare-associated infections (HAIs) with high mortality. Early identification and isolation of colonized patients are crucial in preventing spread. Currently in Oregon, both organism types are uncommonly encountered such that local public health guidance advises travel-related screening as an important component of regional prevention. In 2024, VA Portland Health Care System (VAPORHCS) implemented a C. auris/CPO travel screening program as a quality improvement project. Methods: Using the Plan-Do-Study-Act (PDSA) framework, starting 4/1/2024 patients admitted to acute care were asked, “Have you had an overnight stay in a hospital, nursing home, or other healthcare facility outside of Oregon or Washington in the last year?” If patients responded affirmatively, the admitting nurse educated the patient and collected swabs after verbal consent: axilla/groin swabs for C. auris and peri-rectal swabs for CPOs. Patients were placed on empiric contact precautions in a single-bed room while awaiting results. Infection prevention prospectively monitored the implementation, and retrospectively medical records were reviewed. Results: The PDSA framework informed the implementation and helped organize the approach to addressing barriers such as missed screenings, communication breakdowns, complex disinfection protocols, the need for staff re-education, and delayed C. auris results (see Figure).

Of 3199 acute care admissions between 4/1/24–11/30/24, 72 patients (2.3%) reported a qualifying travel-related risk factor. 64 patients reported overnight healthcare elsewhere in the United States and Territories (including 5 in Puerto Rico) whilst 8 patients had international exposure (Mexico n=6, Philippines n=2). Of the 72 patients with qualifying travel, 9 patients were not tested (patient refused n=2, staff deemed inappropriate n=3, readmission n=1, unknown/technical issues n=3). An additional 32 patients (1%) initially reported qualifying travel but on chart review, travel was not confirmed. Of those, 16 had testing performed, all of which were negative. The average C. auris test turnaround time was 7.7 days with a range from 3-18 days. One patient (2.4%) tested positive for CPO. Conclusion: The C. auris/CPO screening program was effectively implemented and identified one positive CPO case, preventing the need for an urgent outbreak investigation. The PDSA framework helped the organization methodically plan the implementation and address barriers. The long turn-around-time for C. auris testing resulted in undesirable duration of empiric contact precautions. Continued evaluation of program metrics and public health recommendations are critical to sustainment and refinement over time.

Background: There is a high prevalence of catheter associated urinary tract infections (CAUTIs) on a hospital cardiology unit, with a rate of 2.48 CAUTIs per 1,000 catheter days over the past two years compared to the national average of 0.96 CAUTIs for similar units. CAUTIs lead to increased lengths of stay, mortality, and hospital expenditures. Per NHSN, the presence of an indwelling urinary catheter (IUC) increases the risk for developing a CAUTI by 3-7% each day an IUC is in place. Method: A process improvement approach was utilized to study the problem of increased CAUTIs and implement a PDSA intervention.

A process map was created to identify opportunities for error that could increase risk for CAUTIs (Figure 1). Contributing factors were explored through developing a driver diagram (Figure 2).

Data was collected to study root causes of CAUTI development and identify opportunities for improvement. 7 nurses were observed placing IUCs in mannequins to assess insertion practices. 19 maintenance audits of IUCs among patients were conducted. Electronic medical record (EMR) data was compiled to assess hospital location of catheter insertion, catheter utilization ratio, indication for insertion, and duration of catheterization. Based on data, team decided to focus PDSA intervention on reducing IUC duration, a process measure for the desired outcome of reducing CAUTIs. Results: EMR baseline data during the period 11/6/2024- 12/29/2024 revealed an average IUC duration of 7.92 days. A SMART(IE) goal was established to reduce the average duration of IUCs on this unit by 15% from 7.92 days to 6.73 days within 4 weeks.

An intervention was developed to incorporate discussion of IUC indication, duration, and eligibility for removal for patients with IUCs during daily multidisciplinary rounds. Unit charge nurses received training on CAUTI prevention, facilitating rounds discussions, and data collection. Intervention is being implemented over the period 12/30/2024- 1/25/2025.

During the pre-intervention period 11/6/2024- 12/29/2024, 70 IUCs were reviewed. In preliminary analysis of the post-intervention period of 12/30/24- 1/15/25, 15 IUCs were reviewed. Preliminary analysis shows the average duration of IUCs per patient decreased by 31%, to an average of 5.47 days (Figure 3). There were 4 IUCs that were removed after discussions at multidisciplinary rounds. Conclusion: Process improvement tools can be utilized to study contributors to CAUTIs and develop unit-level solutions. Preliminary data demonstrates that incorporating review of IUCs during multidisciplinary rounds may reduce average duration of IUC use.

Background: OPAT has emerged as an effective modality for continued treatment of serious infections outside the hospital, requiring complex care coordination and close monitoring for patient safety. Despite increasing availability of OPAT services nationwide, monitoring and benchmarking of treatment-related adverse events, patient outcomes, and program quality remain labor intensive and inconsistent across programs. Method: A previously reported OPAT-specific bundle of modifications to an Epic® Systems Corporation electronic health record (EHR) at a large academic OPAT program was leveraged to develop a model for longitudinal electronic monitoring and reporting of OPAT adverse event and safety outcomes data. An EHR-based SQL report evaluated mortality within 1 year of OPAT start, as well as intravascular access device (IVAD) occlusions (defined as documented intracatheter administration of alteplase), IVAD associated deep venous thromboses (DVT) (defined by 212 Upper Extremity DVT ICD-10 codes via custom SNOMED CT concept hierarchy grouper), anaphylaxis (defined by ICD-10 codes T78.2 and T88.6), and nephrotoxicity (defined as >0.3 increase or >1.5 times increase in baseline serum creatinine) while on OPAT. Hospital readmissions, emergency department utilization, non-anaphylactic allergic reaction (defined as documentation of new allergy to OPAT antibiotic), were evaluated while on OPAT or within 30 days of conclusion. Result: Total of 5190 OPAT episodes (10/18/2018 to 12/3/2024) in 4213 unique patients were examined (Figure 1). Bone/joint infection and bacteremia were most frequent indications for OPAT (Figure 2), with vancomycin, ceftriaxone, and cefazolin most common antibiotics (Figure 3). Rates of adverse events over time (Figure 4) were notable for high prevalence of nephrotoxicity affecting 2075 (40%) of all episodes, and demonstrating significant association with vancomycin therapy, although no difference was observed between vancomycin monotherapy and vancomycin-containing combination regimens (Table 1). The highest incidence of non-anaphylactic allergic reactions was noted with nafcillin, affecting 8.51% courses (rate 2.51/1000 Nafcillin OPAT days, p=0.018) and cefepime, affecting 4.18% courses, (rate 1.36/1000 Cefepime OPAT days, p=0.008). One-year mortality following enrollment into OPAT was 11%. Conclusions: Leveraging a robust informatics and reporting infrastructure may allow for consistent and ongoing capture of OPAT-related adverse events and outcomes. More studies are needed to validate standardized approaches for longitudinal evaluation of OPAT program safety and quality, supported by development of regional and national performance benchmarks.

Background: Seasonal viral respiratory pathogens present a significant clinical burden to pediatric patients. During the viral season, hospitals face an increased number of patients requiring isolation precautions. In surveying isolation practices among pediatric institutions, we identified a high variation in interpreting and implementing isolation precautions, including the duration of isolation. This variability resulted in practice challenges articulated by Infection Prevention and Control (IPC) and clinical teams. We sought to simplify and reduce wasteful work processes. Through the initial phase of this quality improvement project, we examined the congruency between isolation orders and signage and the IPC surveillance time needed to modify isolation practices. Method: Our interdisciplinary team developed and created a process map of isolation work processes, identifying at least 7 decision points to place isolation or to de-isolate hospitalized patients. A prioritization matrix was used to select drivers for maximum impact: 1) initiate empiric isolation for the most common viral respiratory pathogens and 2) develop and implement a tool for de-isolation. Improvement measures included isolation order and signage appropriateness (outcome), modifications of isolation orders by providers (process), and IPC time for correcting isolation or providing just-in-time training during rounds (balancing). Both outcome and balancing measures were captured using an investigator-developed survey, which was streamlined 3 times. Comprised of 25 questions, the survey is completed throughout the month by IPC during surveillance and environmental rounds, with collection spanning 2 viral seasons. Descriptive statistics are used to analyze the data for trending and practice modifications. Result: We completed 929 individual observations via survey over 8 months. The appropriateness of isolation precautions orders improved over time, with a shift in the center line (Figure 1). We identified that the rate of appropriateness decreased at the height of the viral respiratory season due to additional precautions (droplet isolation for certain viruses based on the risk of splashes or sprays per our policies). Surveillance time for correcting precaution signs and/or orders decreased from ≥ 15 to ≤ 5 minutes (Figure 2). Conclusion: Automation and use of empiric isolation precautions orders for the most common viral respiratory pathogens in our hospitalized patients has led to a reduction in wasteful workflow processes, minimized decision points, and has decreased IPC time spent correcting isolation orders and signs. In the project’s next phase, we hope to minimize patients’ time in isolation by using a nurse-driven tool to assess their clinical readiness for de-escalation of isolation during their hospitalization.

Introduction: A vital factor indicating quality of care in hospital settings is hospital-acquired infections (HAI) occurrence, particularly bloodstream infections (BSI). Currently, BSI tracking through the National Healthcare Safety Network (NHSN) focuses primarily on central-line-associated BSI (CLABSI) and MRSA BSIs. Hospital-onset bacteremia (HOB) is a more comprehensive measure of HAI-BSI from all sources. Non-reportable BSIs account for a substantial number of HAIs and contribute significantly to patient outcomes, making them an important component for quality measurement and patient care improvement. NHSN has indicated that HOB reporting will be implemented within the next few years. Methods: This study establishes a baseline measure of HOB at Stony Brook University Hospital (SBUH) for 2022 and 2023. HOB cases were defined as any inpatient having at least one positive blood culture result, with the first positive culture collected ≥ 3 days after admission. Patient demographics, length of stay (LOS), and ICU admission status were compared among HOB and community-onset BSI (CO BSI) cases. Case mix index (CMI)-adjusted rates of HOB infection were generated for each hospital location by residualizing the rate of HOB infection on average annual CMI for each unit. Bivariate analyses were used to examine which hospital locations and medical devices were most frequently associated with HOB and CO BSI cases. Causative organisms were also examined. Results: A total of 1906 inpatients had positive blood cultures in 2022, 319 (16.74%) were HOB. In 2023, 1853 inpatients had positive cultures, 268 (14.46%) were HOB. Patients with HOB were significantly younger, and Medicare recipients represented the highest proportion of HOB cases. In both years, over 60% of HOB cases were admitted to an ICU compared to about 30% of CO BSI cases, LOS was about 3 times longer, and ICU LOS was more than two times greater for HOB cases compared to CO BSI cases. CMI-adjusted HOB infection rates were highest for MICU, SICU, CICU, and Oncology units, as well as one general medicine unit. All 9 medical devices examined were significantly associated with HOB in bivariate analysis, with central and peripheral IV catheters, urinary devices, arterial lines, and enteral tubes being most frequently present. Probable contaminant organisms were detected in > 50% of all positive cultures examined, but only probable pathogens were detected in > 50% of HOB cases. Conclusions: HOB has a significant impact on SBUH inpatients. Results from our study should be used to target infection prevention initiatives moving forward.

Background: Device-associated infections, such as catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI), increase patient mortality, morbidity, and length of stay. These infections are best prevented through appropriate use and maintenance of the devices. There is often a lack of accountability regarding the appropriateness of central lines and urinary catheters. Our team’s goal was to develop an approach that validates device necessity each day to reduce device utilization and ultimately decrease CAUTIs and CLABSIs. Methods: A multidisciplinary team, including infection prevention (IP), facility leaders, unit nursing leaders, performance improvement coordinators, and providers, implemented a hospital-wide (excluding the neonatal intensive care and maternity units) daily Device Safety Huddle (DSH), in a 360-bed hospital in September 2024. IP facilitates the meeting, and unit leaders or their delegates are expected to report daily on the number of central lines and urinary catheters on their unit. Leaders also report any concerns related to site or type, actual necessity, plans for removal, and barriers to removal. IP spot checks various charts to ensure that device necessity correlates with unit reporting. The team compared device utilization rates (DUR) and infection rates for CAUTI and CLABSI pre (January - August 2024) and post-intervention (September - December 2024). Statistical analysis was applied to assess the differences between both groups. Results: DUR for urinary catheters reduced from 18.1 per 100 patient days pre-intervention to 15.1 (IRR 0.83, p < 0 .0001) post-intervention, with similar reductions calculated for central lines from 15.6 per 100 patient days to 13.8 (IRR 0.89, p < 0 .0001). Infection rates remained stable for CAUTI (0.57 vs 0.43/1000 catheter days, IRR 0.73, p=0.77) and CLABSI (0.69 vs 0.74/1000 central line days, IRR 1.07, p=0.89) post-intervention (Table 1). Conclusions: Implementing a daily DSH helped improve accountability related to device necessity and decreased device utilization. The infection rate changes are not statistically significant at this time and will continue to be evaluated for long-term impact. The inclusion of administrative and director-level leadership is essential for accountability and the success of the intervention.

Background: Adverse perioperative outcomes remain a major public health challenge despite being largely preventable. Surgical site infection (SSI) is a common preventable healthcare-associated infection (HAI) following surgery. The Barnes-Jewish Hospital anesthesiology department developed an innovative telemedicine model, the Anesthesia Control Tower (ACT), to improve intraoperative care delivery and address predisposing factors for adverse outcomes. The ACT is staffed by anesthesiologists and certified nurse anesthetists who use a customized, electronic monitoring system, bolstered with machine-learning forecasting, to provide real-time clinical decision support to anesthesia providers in the operating room (OR). In the ACT randomized control trial, alerts are generated during surgical procedures and ORs are randomized to receive ACT input based on alerts or not. We were interested in determining the effect of the ACT on infectious outcomes. Methods: We used the existing ACT study design, a randomized control trial, to determine the impact of the ACT monitoring system above on SSI, CLABSI and CAUTI. HAI surveillance was performed by IP specialists using CDC NHSN definitions for SSI, CLABSI and CAUTI. We included CABG, colon, abdominal hysterectomy, hip, and knee arthroplasty procedures performed during ACT hours of operation from July 1, 2018 to January 31, 2023 and compared outcomes among patients by randomization to receive ACT. Here, we report on the intention-to-treat analysis based on randomization status. Results: The final cohort included 8,993 procedure dates including 862 CABG procedures, 2,654 colon surgeries, 2,732 abdominal hysterectomies, 2,105 hip arthroplasties, and 833 knee arthroplasties. Baseline characteristics (e.g. age, comorbidities, wound class) were balanced by randomization status. Characteristics captured during the procedure (e.g., temperature, oxygen) were also similar by randomization status. The infectious outcomes revealed that there was no difference in likelihood of SSI (4.0% vs 4.0%), 60-day CLABSI (0.2% vs 0.3%), or 60-day CAUTI (0.0% vs 0.1%) whether the procedure was randomized to receive ACT input or not. Thirty-day mortality (2.0% vs 1.9%) and readmission (16.6% vs 15.9%) did not differ by randomization. Conclusions: In this intention-to-treat analysis of the impact of a novel anesthesiology monitoring system on HAI outcomes, we did not find a difference in the incidence of SSI, CLABSI or CAUTI. Next, we will analyze the study data in a per-protocol fashion. This RCT was conducted in a resource-rich environment with robustly implemented best practice where a second layer of anesthesiology supervision may confer little benefit. The concept of an ACT may still be helpful in resource-limited settings.

Respiratory viral infection (RVI) outbreaks pose a significant threat to health. They are associated with patient morbidity and mortality, staff absenteeism, and financial burden on the healthcare system. There is a need for strategies to reduce RVI transmission in hospitals. One proposal is implementation of continuous masking policies. However, the effectiveness of such policies in mitigating RVI spread is unclear. We conducted a systematic review of the literature to determine the effectiveness of continuous masking in reducing the incidence and transmission of RVIs amongst patients and healthcare workers (HCWs) in hospitals. We systematically searched for original articles published between 2000-2024 according to a pre-determined search criterion. Studies were screened by two reviewers in Covidence. One reviewer extracted the data from eligible studies into a pre-determined data extraction form. For studies that reported only count data, results were summarized narratively. Meta-analysis to pool unadjusted or adjusted outcome measures for studies that report a statistical comparison between masking policies and transmission of infections will be considered if appropriate. Joanna Briggs Institute tools will be used for critical appraisal. 3691 studies were identified. 17 met eligibility criteria. 12 studies were conducted in single-center adult hospitals. 4 studies were conducted in pediatric hospitals, with 2 in neonatal centers. One study was conducted on a hospital system. The studied infections were influenza A/B, parainfluenza 1-3, adenovirus, respiratory syncytial virus (RSV), traditional human coronavirus strains, human metapneumovirus, SARS-CoV-2, and rhinovirus/enterovirus. Eight studies assessed the impact of a masking policy on infection rate in patients. All 8 reported masking policies reduce RVI transmission in patients. 9 studies assessed the impact of a masking policy on infection rate in HCWs. 7 were associated with reductions in RVI transmission in HCWs, whereas 2 showed no statistically significant change. The studies identified in this systematic review were associated with a reduction in RVI transmission with the use of continuous masking amongst patients. The evidence for continuous masking was less consistent for preventing RVI transmission amongst HCW with two studies reporting it was not effective. Our findings suggest that masking policies may play a role in RVI prevention but there are significant limitations with the use of observational design and masking in conjunction with other prevention measures. However, assessment of the quality of the papers is pending. Future directions will include assessing secondary outcomes like masking adherence and assessing adjusted analyses form confounding which are critically important.

Background: Contact precautions reduce nosocomial spread of Clostridioides difficile (C. difficile). However, they can decrease patient interactions with providers and delay discharges, so it is imperative precautions are discontinued when appropriate. Patients with discordant C. difficile testing (PCR+/Toxin-) require clinical judgment to determine infection versus colonization. Our institution’s C. difficile isolation protocol categorizes duration based on C. difficile treatment and type of patient floor to reflect this. We transitioned to a new electronic medical record (EMR) in June 2024, which included additional decision support for Contact precaution discontinuation. Prior to new EMR implementation, we hypothesized that patients with discordant C. difficile testing were not being appropriately de-escalated from precautions despite meeting institutional criteria. Methods: This was a retrospective chart review of inpatients admitted to our hospital who had discordant C. difficile testing (PCR+/Toxin-) from July 1, 2023 to October 10, 2023. Patients were excluded if there was no indication of PCR+ (critical value) notification to providers or if patients were on Contact precautions with an additional indication to C. difficile. The primary outcome was the proportion of patients with discordant C. difficile testing who had Contact precautions appropriately discontinued based on internal criteria (Figure 1). Results: A total of 90 patients had discordant C. difficile testing during the study period; 10 were excluded. In the study cohort (n=80), 33.8% (27/80) did not have orders placed for Contact precautions at any time despite positive PCR (Figure 2). Of the remaining 53 patients who were placed on Contact precautions, the median start time of Contact precautions after PCR notification was one hour and 20 minutes.

Of patients who were placed on Contact precautions (n=53), 30.2% (16/53) were treated and deemed to have clinical infection, while 69.8% (37/53) were diagnosed with colonization and not treated for C. difficile infection. Overall, 84.9% (45/53) had appropriate de-escalation of Contact precautions; the remaining 8 (15.1%) had inappropriate de-escalation of Contact precautions and were all in the not treated/colonized group. Conclusion: In our single-institution study, we found higher than expected rates of appropriate Contact precaution initiation and discontinuation; however, 15% still had inappropriate precaution durations. Coupled with the surprising number of patients not initiated on precautions at any time after positive PCR, our results highlighted the need to build clear clinical decision support tools with our new EMR and continual surveillance of providers for adherence to isolation protocols post-implementation.

Background: In 2024, The Joint Commission (TJC) introduced Standard IC.07.01.01 to bolster hospitals’ preparedness for high-consequence infectious diseases (HCIDs) such as novel Influenza, Ebola, and SARS-CoV-2. The standard emphasizes the need for an effective framework for managing emerging pathogens. While a definitive list of HCIDs does not exist, TJC defines HCIDs as, “novel or reemerging infectious agents characterized by high transmissibility, limited or no medical countermeasures, high mortality, and a need for rapid identification and stringent infection control.” We outline the process of developing a policy at a National Cancer Institute-designated cancer center to ensure prompt and efficient management of suspected HCID cases. Methods: The policy development process began with a thorough review of existing hospital policies, infection control protocols, and environmental safety guidelines. Stakeholders from multiple departments including Environmental Health and Safety, Facilities Management, Employee Health and Campus police were consulted in the policy development process. A needs assessment was followed to identify gaps and areas requiring improvement. The policy was designed using key resources, including the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the National Emerging Special Pathogens Training and Education Center (NETEC). A framework based on the CDC’s “Identify, Inform, and Isolate” model was employed, with tailored procedures addressing both clinical and operational aspects of preparedness and response. Results: The final policy grouped HCIDs into five categories: (1) Viral Hemorrhagic Fevers (VHF), (2) Novel Respiratory Viruses, (3) Measles, (4) Bioterrorism Agents, and (5) Other Emerging Pathogens. For each category, the policy delineated specific identification criteria, isolation protocols, and management procedures. It also provided guidance on engineering controls, visitor management, patient placement, environmental cleaning, and transportation. Additionally, the policy included external resources on clinical treatments and broader infection control issues. Conclusion: The development of an HCID policy in accordance with TJC Standard IC.07.01.01 provides a robust framework for hospital preparedness in managing high-consequence infectious diseases. By collaborating with Infection Control teams, healthcare institutions can develop protocols that enable swift, effective responses to emerging pathogens, ensuring adaptability during outbreaks. This policy not only facilitates TJC compliance but also enhances hospital readiness for future infectious disease threats. Moreover, it offers a replicable model that can assist other healthcare organizations in strengthening their emergency response capabilities and maintaining survey readiness in an evolving healthcare landscape.

Introduction: Dust burden in healthcare institutions has been associated with invasive fungal disease (IFD) causing significant morbidity and mortality in immunocompromised patients. Systematically evaluating the impacts of architectural changes on air particulate concentration (APC) could identify risk reduction strategies.

Objectives: We estimated changes in APC in units adjacent to a temporary hard physical barrier in a previously open hospital space after its erection. We propose a model for evaluating the impact of temporary architectural alterations on APC in healthcare settings. Methods: Barriers were erected in an open area of a hospital for four weeks. The barrier partitioned the oncology floor from the atrium, which houses the emergency department waiting area. Continuous APCs were measured in multiple locations before and after the barrier was erected. We conducted an interrupted time series on the daily mean and maximum APCs, excluding the period the barrier was being installed. As a control, the same analysis was conducted on a remote location of the hospital. Results: A topographical representation of the impacted area is included in Figure 1. Regions A and B are in hallways, adjacent to the barriers, and region C is in a patient care area, separated from the barriers by an automatic door. The control region was the cafeteria, which is separated from the barrier space by several hundred feet. After barrier creation, there was an immediate APC reduction in region A from the predicted mean APC of 2µg/m3 to 1µg/m3 (difference of 0.8 µg/m3, p=0.01) (Figure 2). While the barrier was in place, there was a significant reduction in APC in region A by 0.01µg/m3 per day (p < 0 .001). There was no significant change in APC in regions B and C after the barrier was erected and while it was in place. In the control region, there was no significant change in APC at barrier placement nor afterwards. There was no change in the maximum APC at any of the measurement locations. Discussion: Our analysis demonstrated a change in APC at an adjacent area following erection of the barrier; however, APCs were not significantly changed in patient areas. This model could help objectively evaluate changes in particulate concentration. While this analysis cannot predict changes in IFD incidence, it could inform whether permanent architectural changes might reduce APC. Conclusions: We propose a model to evaluate changes in APCs from temporary architectural changes, which could inform permanent architectural changes.

Background: Surgical site infections (SSIs) following cesarean deliveries (C-sections) result in excess morbidity, mortality, and healthcare expenses in resource-limited countries such as Bangladesh. Over the past two decades, C-section rates have increased dramatically in Bangladeshi hospitals, and comprehensive data on SSI after cesarean delivery, which is vital for the improvement of maternal health outcomes, remains limited. In this study, we assessed the prevalence of SSIs including their determinants among patients undergoing C-sections in Bangladesh. Methods: From May to December 2023, we conducted a prospective observational study at six tertiary hospitals (3 public and 3 private) in Bangladesh. Participants were hospitalized pregnant women who had undergone C-sections. The WHO-guided methodology and tools were employed to acquire the data. Participants were systematically evaluated on days 1-3, 7, 14, and 30 of surgeries, with a rigorous inquiry into symptoms such as fever, abdominal pain, localized swelling and redness, wound dehiscence, and purulence or abscess. The SSI diagnosis was confirmed based on at least two present symptoms, or a physician’s assessment, or microbiological confirmation within the 30-day post-operative window. Descriptive and multivariate logistic analyses were performed to determine the prevalence and factors associated with SSI. Results: Of 1335 participants enrolled, the overall prevalence of SSIs was 19.1% (255/1335, 95%CI: 17.6-21.5), with public hospitals having almost twice as SSIs at 21.6% (215/995) compared to private hospitals (11.8%, 40/340). More than half of the patients (54.8%) were found with at least two SSI symptoms within the 7 to 14 days of follow-up. Approximately half of the patients (49.2%) had a history of previous C-sections. The C-sections performed in private hospitals were predominantly on an emergency basis (85.1%) compared to public hospitals (56.2%). The multivariate analysis identified key determinants of SSI following C-section were patients with prolonged labor > 18 hours (AOR: 2.2, 95%Cl: 1.16, 4.13), fetal distress (AOR: 1.82, 95%Cl: 1.33, 2.49), premature rupture of membrane (PROM) > 12 hours (AOR: 1.70, 95%Cl: 1.05, 2.75), and high BMI (AOR: 1.69, 95%Cl: 1.27, 2.25). Conclusions: This study highlights the burden of SSIs following C-sections in tertiary hospitals in Bangladesh, particularly in public healthcare settings. The findings highlight the critical need to enhance infection prevention and control measures to mitigate the occurance of SSIs within these healthcare settings.

Background: Surgical Site Infections (SSIs) are a major cause of morbidity resulting in devastating patient outcomes following an Abdominal Hysterectomy (HYST) procedure. No single intervention has demonstrated reduction in SSI rates, however, bundling prevention strategies have demonstrated reduction in SSI. In addition to our organization’s systemwide surgical site infection prevention bundle, we developed a supplemental bundle of focused strategies specific to abdominal hysterectomy procedures, to address a 37.26% increase in Abdominal Hysterectomy Standardized Infection Ratios (SIRs) in 2021. Methods: In 2021, a supplemental hysterectomy specific bundle was developed and implemented in three facilities within our health system that were experiencing increased HYST SIRs. After review of current literature, the following four strategies were included for the supplemental bundle for all abdominal hysterectomy procedures (open, laparoscopic, and robotic); the utilization of 500mg Metronidazole with Cefazolin as part of surgical antimicrobial prophylaxis, for cases where: anticipated bowel involvement occurs and for oncology patients with complex hysterectomies; the use of standardized vaginal and perineal preparation using either chlorhexidine (CHG) or Povidone Iodine (PVI); the use of a separate sterile closing tray; and changing of gown and gloves by surgical team, prior to going to abdomen from vaginal area. Compliance with the prevention strategies were measured during this period and SSI SIRs were reviewed monthly with overall trends monitored. The National Healthcare Safety Network (NHSN) criteria for SSI were used to assess for SSI after hysterectomy. Results: The SIR for HYST procedures in 2021 was 1.083 with 23 SSIs identified from 2339 abdominal hysterectomy procedures performed. Immediately following the implementation of the supplemental bundle at three facilities, the SIR decreased by 39% to 0.661 in 2022 with 11 SSIs identified from 1842 procedures performed. The HYST SIR outcomes were 0.782 in 2023 and currently at 0.979 through July 2024. Compliance during the intervention period ranged from 93.9% to 94.6%, and surgical antimicrobial prophylaxis compliance increased by 4% to 89.35% at these three facilities. Conclusion: Bundled interventions when employed, demonstrate benefit from the synergistic effects of multiple strategies decreasing the outcome rate of surgical site infections as compared to a single intervention. Establishing a standardized abdominal hysterectomy bundle, allows for minimal variation for patients undergoing abdominal hysterectomy procedures when adherence is at its maximum. Our goal is to expand systemwide based upon the successes from the three facilities, to achieve as close to zero postoperative infections by implementing evidence-based practices performed as a comprehensive bundle.

Background: Procedures performed at Ambulatory Surgical Centers (ASCs) have increased over the last decade in the United States. In Tennessee, surgical site infection (SSI) outbreaks in ASCs have been increasingly detected. Still, there is no mandated SSI reporting for ASCs through the National Healthcare Safety Network (NHSN) as there is for Acute Care Hospitals (ACHs). In 2023, the Tennessee Department of Health’s Healthcare-Associated Infections (TDH HAI/AR) program responded to an outbreak of 14 nontuberculous mycobacteria (NTM) periprosthetic joint infections at an ASC. Despite extrapulmonary NTM being a reportable condition in Tennessee, detection of this outbreak was delayed due to gaps in reportable conditions practices at this ASC. Here, we evaluate how NHSN reporting could have impacted the surveillance and detection of infections for this investigation. Methods: Extrapulmonary NTM cases were detected through clinical laboratory and provider reporting. Chart abstractions were performed for cases by HAI/AR epidemiologists using a tool adapted from the Centers for Disease Control and Prevention (CDC). Infections were evaluated using standardized 2023 and 2024 National Healthcare Safety Network (NHSN) definitions depending on the infection date of event. Results: Initial reporting of cases was as mentioned above, resulting in five cases reported together in June 2023, two months after the first positive specimen. Eight (57%) cases met the NHSN definition for Surgical Site Infections (SSIs); four (29%) cases met the criteria for Deep Incisional SSIs, and four (29%) met the Organ/Space SSI. Six cases (43%) were not detected within the 90-day surveillance window; however, three of these cases had documented evidence of superficial infection within those 90 days. Conclusions: Despite its slow infection progression, most NTM infections in this outbreak would have been detected through NHSN surveillance. Even in cases where NHSN SSI criteria were not met, reviewing records and entering data within the NHSN framework may have facilitated faster facility-level detection. Although the nature of NHSN reporting is not suited for rapid detection of outbreaks, the standardized definitions, regular records reviews, and established data entry system would benefit ASC surveillance such as the facility described here, which had no formal mechanism for tracking infections. Additionally, the collection of summary data required through NHSN would better identify reporting gaps prior to outbreak occurrences. The availability of SSI data for ASCs would help public health authorities identify and assist facilities in assessment and prevention activities. Patient safety would thus likely benefit from enhancing surveillance of ASCs through voluntary or

Background: Invasive candida infections (ICI)are rare but a serious complication following cardiac surgery, The incidence of ICI ranges between 1-2%. There are a few studies describing the risk factors associated with candidal infections in this population. This study aims to evaluate the risk factors of ICI post-cardiac surgery. We hypothesize that judicious antimicrobial use and comprehensive wound care play a key role in prevention of ICI. Methods: We conducted a retrospective case control study of adult patients undergoing cardiac surgeries at an academic medical center from January 2023 to June 2024. Patients who underwent heart transplantation were excluded. For each case, four controls who underwent similar surgical procedures, two before and two after the cases, were selected. ICI was defined as the detection of candida species by culture or histological examination from a normally sterile site like candidemia or mediastinitis. Cardiac surgery included valve replacement, coronary artery bypass graft and durable cardiac device insertion. Data were analyzed for demographics, type of surgery, temporary mechanical circulatory support (MCS) use and timing, chest tube duration, tracheostomy, dialysis and Candida sp, colonization, defined as the isolation of candida sp. in the urine or airways without evidence of infection. Categorical and continuous variables were presented as frequencies and medians respectively. The variables were compared using Chi-square and Mann-U-Whitney. Results: There were 36 controls, and 9 cases included in the study. Patients who were younger (54 vs 66.5 years) and who had temporary MCS (66.7% vs 8.0%) were more likely to be diagnosed with ICI. Moreover, we found that delayed chest closure, more days with chest tube in place, dialysis, tracheostomy and candida colonization after surgery were also associated with increased risk of ICI (table). However, antimicrobial use prior to surgery was not statistically significant (72.2% vs. 88.9%) In terms of clinical outcomes, there was no statistical difference in mortality between the two groups (66.7% vs 91.7%), however patients were more likely to have longer length of hospital stay (42 vs 11 days, p=0.03). Conclusion: This study identified several risk factors for ICI post-cardiac surgery including temporary MCS use, delayed chest closure, prolonged chest tube placement and tracheostomy. While antibiotic use prior to surgery was not statistically significant, candida colonization post-surgery was identified as a risk factor. These findings highlight the importance of infection prevention strategies in the environment of care, such standardizing temporary MCS device care and optimizing wound care management, as

Background: SSI results in increased mortality, morbidity, length of stay and healthcare costs. Use of nasal iodine for some surgeries has been proposed as an easy, economic alternative to 5-day preoperative chlorhexidine bath and intranasal mupirocin decolonization in SSI prevention but data on effectiveness is limited. We aim to assess the association between preoperative nasal iodine application and odds of SSI. Methods: We performed a retrospective study of all total hip replacement, total knee replacement, and spinal fusion surgeries performed between January 2023 through June 2024 in 10 facilities in a large healthcare system. Demographics, clinical risk factors, and procedural data were collated from the electronic health record and merged with SSI data obtained through routine surveillance by trained infection preventionists using standard NHSN (National Healthcare and Safety Network) definitions. Patients with SSI present at the time of surgery were excluded. Nasal iodine compliance was defined as documentation of nasal iodine administration in both nostrils on the day of surgery in the preoperative space. Surgeries where nasal iodine was documented as not given or that had absence of documentation were counted as noncompliant. Descriptive statistics were used to compare compliant and noncompliant patients. Multivariate logistic regression was performed to assess the association between nasal iodine compliance and SSI. Results: A total of 14,505 surgeries were included, of which 161 (1.1%) were complicated by SSI. 12,281 (84.6%) of patients were compliant with nasal iodine. Around 55% of the noncompliant surgeries had absent documentation. In the univariate analysis, compliance was associated with several clinical and procedural factors including older median age, female gender, White race, shorter procedure duration, elective procedure, outpatient procedure, and lower ASA score. Unadjusted SSI rate per 100 procedures was lower in those compliant with nasal iodine compared to noncompliant (1% and 1.6% respectively, p=0.01). (Table 1) After adjusting for age, gender, race, procedure type, and procedure duration, there was no significant difference in odds of SSI associated with nasal iodine compliance. (Odds ratio 0.78, p=0.23) (Table 2) Conclusion: Use of nasal iodine on day of surgery did not impact odds of SSI after adjusting for other clinical factors. This study is limited by inclusion of cases with absent documentation of nasal iodine and differences in clinical and procedural characteristics between compliant and noncompliant patients. Further studies are needed to assess effect of nasal iodine on SSI.

Background: From October 2023-June 2024 increased surgical site infection (SSI) rates were identified in our large pediatric hospital, 38% were caused by Staphylococcus aureus. Nasal S. aureus colonization is associated with increased SSI risk and preoperative nasal decolonization decreases S. aureus SSI risk. Historically, our institution recommended a five-day course of nasal mupirocin decolonization prior to selected high-risk procedure types, though this process it not possible for urgent cases and outpatient compliance is low. Nasal povidone iodine (PI) is a topical antiseptic used commonly in adults as an alternative to nasal mupirocin for S. aureus decolonization and SSI prevention. This practice is less commonly described in pediatric patients. Methods: In addition to standard SSI prevention measures, universal nasal PI application was implemented preoperatively (as a single topical application following induction of anesthesia) in July 2024 for patients ≥34 weeks corrected gestational age (CGA) undergoing the following high-risk surgical procedures: ventricular shunts, spinal fusions, and all cardiothoracic (CT) procedures. Compliance with nasal PI application was monitored based on documentation in the electronic medical record. Mean monthly total SSI rates (per 100 procedures) and mean monthly S. aureus SSI rates for these procedure types were followed pre- and post-implementation of universal nasal PI and compared via unpaired t-test. Results: Documented compliance with nasal PI application was 51% overall, ranging from 22% for ventricular shunts to 75% for CT procedures. Implementation of universal nasal PI preoperatively was associated with a non-statistically significant decrease in composite mean SSI rates (Figure 1A): 3.5 per 100 procedures pre-implementation, 2.3 post-implementation (p=0.52). A statistically significant decrease in composite mean S. aureus SSI rates was observed (Figure 1B): 1.3 per 100 procedures pre-implementation, 0.0 post-implementation (p=0.02). Conclusion: Despite modest documented compliance, implementation of a universal preoperative nasal PI program, in conjunction with standard SSI prevention measures, was associated with decreased S. aureus SSI rates in pediatric patients undergoing high-risk surgical procedures.

Figure 1. Total (1A) and Staphylococcus aureus (1B) surgical site infection (SSI) rate per 100 ventricular shunt, spinal fusion, and cardiothoracic procedures (combined) by month from January 2023 through November 2024. The solid vertical line indicates the beginning of the period with increased S. aureus SSI rates (pre-implementation period). The dashed vertical line indicates the start of the implementation period. Mean SSI rates for the pre- and post-implementation periods are indicated by the horizontal lines and compared via t-test.

Background: Surgical site infections (SSIs) are one of the most common complications of breast surgery and a major source of postoperative morbidity and mortality. The risk of developing breast SSI (BSSI) is further heightened by the insertion of implants during breast surgery. The objective of this study is to describe clinical outcomes in patients with breast SSI and to compare patients with implants to those without. Methods: Retrospective case series of adult patients with clinical BSSI at Henry Ford Health, an integrated health care organization that includes 5 hospitals and 9 emergency departments (EDs) in Southeast Michigan, from January 2021 to December 2023. Cases that met National Healthcare Safety Network (NHSN) BSSI criteria were screened for clinical infection. Demographics, comorbidities, risk factors, microbiological data, and clinical outcomes were included. Results: Eighty (54%) of 147 cases that met NHSN criteria had clinical infection, and 26 (32.5%) had implants placed (Table). Most patients were female (95%) and white (63%) with a mean age of 51.7 years and BMI >30 (35%). The majority had active breast cancer (56%) and underwent biopsy within 1 year (66%), which were significantly more common in the implant group (81% vs. 44%, p=0.002, and 85% vs 57%, p=0.002, respectively). Malignancy (55%) was the primary indication for the surgery; mastectomy with or without lymph node dissection was the most frequently performed procedure in both groups. The implant group had a significantly longer procedure duration (3.77 vs. 2.32 hours, p < 0 .001). Post-operative complications did not differ significantly among the two groups. The implant group was more likely to require hospitalization (88% vs. 44%, p < 0 .001) with a longer length of stay and surgical intervention (96% vs. 72%, p=0.012). All patients were treated with antibiotics, and outcomes were similar between the two groups. Conclusion: In this cohort of patients with BSSI, the presence of breast implants was associated with a significantly higher risk of hospitalization and surgical intervention. Identifying risk factors in these patients is essential to reduce the need for hospitalization and additional surgical procedures.