_______________________________________________________________ Healthcare-Associated Infections
The American Medical Association offers several health literacy resources for healthcare professionals on its website (https:// www.ama-assn.org), and the U.S. Department of Health and Human Services offers valuable information on cultural compe- tency from the Health Resources and Services Administration (HRSA) (https://www.hrsa.gov/about/organization/bureaus/ ohe/health-literacy/culture-language-and-health-literacy), the Office of Minority Health (https://minorityhealth.hhs.gov/ omh/browse.aspx?lvl=1&lvlid=6), and the National Center for Cultural Competence (https://nccc.georgetown.edu). PREPAREDNESS AND CONTROL OF OUTBREAKS Another responsibility of an infection control team is establish- ing response plans for outbreaks and epidemics and controlling them should they occur. An outbreak is defined by the WHO as “the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area, or season” [337]. The number of individuals affected can vary from a few to 100 or more. Outbreaks and epidem- ics account for approximately 5% to 10% of HAIs, and most hospitals lack adequate equipment, isolation space, and staff to treat a large increase in the number of patients with an infectious disease [42; 89]. The two primary concerns are to confirm the existence of the outbreak and to establish control measures to confine the spread [337]. An outbreak should be identified and investigated as early as possible to prevent morbidity and mortality. Any healthcare professional who suspects an outbreak should notify infection control staff, and an outbreak team should be established. Investigating an outbreak involves [18; 338]: • Establishing the existence of an outbreak • Verifying the diagnosis • Defining and identifying cases • Describing and orienting the data in terms of time, place, and person • Developing and evaluating hypotheses • Refining hypotheses and carrying out additional studies • Implementing control and prevention measures • Communicating findings The outbreak team should collaborate with all appropriate healthcare workers to identify either the carriers or the com- mon sources of the infection and to review aseptic practices and disinfectant use for a breach in compliance. Data on potential cases should be reviewed and a case definition should be developed. The case definition should include [18; 338]: • Unit of time and place • Specific biologic and/or clinical criteria • Inclusion/exclusion criteria
• Gradient of definition (definite, probable, or possible) • Differentiation between colonization and infection • Specific criteria to identify the index case, if relevant information is available Data should be collected from all available sources, such as patient charts, microbiology reports, pharmacy reports, and log books from patient units. Describing the outbreak in terms of individuals, place, and time helps to create an epidemic curve, which shows the distribution of cases by time of onset [18]. An attack rate can then be defined as the number of people at risk who are infected compared with the total number of people at risk. Developing and evaluating hypotheses will yield the source of the outbreak and/or the index case. The data should be reviewed carefully to evaluate the characteristics and similari- ties among affected individuals. The team must then determine the extent of the outbreak. Cohort isolation is implemented as needed ( Table 21 ) [25; 339]. Throughout the investiga- tion, the team should communicate routinely with hospital administration. At completion, data on the outbreak should be documented and published, as the information can provide valuable education to the healthcare community at large and can help staff prepare for future outbreak investigations [340]. Case Example The following case outlines an investigative process and illus- trates that the source of an outbreak may be unusual [341]. A cardiac surgeon noticed a cluster of cases of sternal wound dehiscence among his patients who had had surgery. Specimens from the wounds were obtained for culture. Microbiologic evaluation indicated that the infections were predominantly caused by Enterobacter cloacae, and molecular typing and serotyping demonstrated that the isolates were similar. No infections had developed after operations the surgeon had performed at other hospitals. No breach in aseptic technique was identified. All of the infected patients had been operated on in the same operating room, and the environment was screened. No source was found. Further questioning of the surgeon’s operative practice revealed one difference from other cardiac surgeons: he used semi-frozen sodium lactate solution to achieve cardioplegia. Swabbing of the freezer used for the solution identified E. cloacae of the same typing as that found in the wound infections. The hypothesis was that contamina- tion of the freezer led to contamination of the ice/slush solution, and the micro-organism was transmitted to the patients. The freezer was replaced, a rigorous cleaning schedule was instituted, and no further cases have occurred.
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