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Community-acquired in name only: A cluster of carbapenem-resistant Acinetobacter baumannii in a burn intensive care unit and beyond
- Erica S. Shenoy, Virginia M. Pierce, Mohamad R. A. Sater, Febriana K. Pangestu, Ian C. Herriott, Melis N. Anahtar, Juliet T. Bramante, Douglas S. Kwon, Fred R. Hawkins, Jr, Dolores Suslak, Lauren R. West, Miriam H. Huntley, David C. Hooper
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue 5 / May 2020
- Published online by Cambridge University Press:
- 28 February 2020, pp. 531-538
- Print publication:
- May 2020
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Objective:
To describe an investigation into 5 clinical cases of carbapenem-resistant Acinetobacter baumannii (CRAB).
Design:Epidemiological investigation supplemented by whole-genome sequencing (WGS) of clinical and environmental isolates.
Setting:A tertiary-care academic health center in Boston, Massachusetts.
Patients or participants:Individuals identified with CRAB clinical infections.
Methods:A detailed review of patient demographic and clinical data was conducted. Clinical isolates underwent phenotypic antimicrobial susceptibility testing and WGS. Infection control practices were evaluated, and CRAB isolates obtained through environmental sampling were assessed by WGS. Genomic relatedness was measured by single-nucleotide polymorphism (SNP) analysis.
Results:Four clinical cases spanning 4 months were linked to a single index case; isolates differed by 1–7 SNPs and belonged to a single cluster. The index patient and 3 case patients were admitted to the same room prior to their development of CRAB infection, and 2 case patients were admitted to the same room within 48 hours of admission. A fourth case patient was admitted to a different unit. Environmental sampling identified highly contaminated areas, and WGS of 5 environmental isolates revealed that they were highly related to the clinical cluster.
Conclusions:We report a cluster of highly resistant Acinetobacter baumannii that occurred in a burn ICU over 5 months and then spread to a separate ICU. Two case patients developed infections classified as community acquired under standard epidemiological definitions, but WGS revealed clonality, highlighting the risk of burn patients for early-onset nosocomial infections. An extensive investigation identified the role of environmental reservoirs.
Impact of Hurricane Sandy on Hospital Emergency and Dialysis Services: A Retrospective Survey
- Chou-jui Lin, Lauren C. Pierce, Patricia M. Roblin, Bonnie Arquilla
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- Journal:
- Prehospital and Disaster Medicine / Volume 29 / Issue 4 / August 2014
- Published online by Cambridge University Press:
- 28 July 2014, pp. 374-379
- Print publication:
- August 2014
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Objective
Hurricane Sandy forced closures of many free-standing dialysis centers in New York City in 2012. Hemodialysis (HD) patients therefore sought dialysis treatments from nearby hospitals. The surge capacity of hospital dialysis services was the rate-limiting step for streamlining the emergency department flow of HD patients. The aim of this study was to determine the extent of the HD patients surge and to explore difficulties encountered by hospitals in Brooklyn, New York (USA) due to Hurricane Sandy.
MethodsA retrospective survey on hospital dialysis services was conducted by interviewing dialysis unit managers, focusing on the influx of HD patients from closed dialysis centers to hospitals, coping strategies these hospitals used, and difficulties encountered.
ResultsIn total, 347 HD patients presented to 15 Brooklyn hospitals for dialysis. The number of transient HD patients peaked two days after landfall and gradually decreased over a week. Hospital dialysis services reported issues with lack of dialysis documentation from transient dialysis patients (92.3%), staff shortage (50%), staff transportation (71.4%), and communication with other agencies (53.3%). Linear regression showed that factors significantly associated with enhanced surge capacity were the size of inpatient dialysis unit (P = .040), having affiliated outpatient dialysis centers (P = .032), using extra dialysis machines (P = .014), and having extra workforce (P = .007). Early emergency plan activation (P = .289) and shortening treatment time (P = .118) did not impact the surge capacity significantly in this study.
ConclusionThese findings provide potential improvement options for receiving hospitals dialysis units to prepare for future events.
. ,Lin C ,Pierce LC ,Roblin PM .Arquilla B Impact of Hurricane Sandy on Hospital Emergency and Dialysis Services: A Retrospective Survey . Prehosp Disaster Med.2014 ;29 (4 ):1 -6
Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center
- Vikas S. Shah, Lauren C. Pierce, Patricia Roblin, Sarah Walker, Marte N. Sergio, Bonnie Arquilla
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- Journal:
- Prehospital and Disaster Medicine / Volume 29 / Issue 1 / February 2014
- Published online by Cambridge University Press:
- 13 December 2013, pp. 100-106
- Print publication:
- February 2014
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Introduction
Pediatric Intensive Care Unit (PICU) resources are overwhelmed in disaster as the need to accommodate influx of critically-ill children is increased. A full-scale chlorine overexposure exercise was conducted by the New York Institute for All Hazard Preparedness (NYIAHP) to assess the appropriateness of response of Kings County Hospital Center's (KCHC's) PICU surge plan to an influx of critically-ill children. The primary endpoint that was assessed was the ability of the institution to follow the PICU surge plan, while secondary endpoints include the ability to provide appropriate medical management.
MethodsThirty-six actors/patients (medical students or emergency medicine residents) were educated on presentations and appropriate medical management of patients after a chlorine overexposure, as well as lectures on drill design and expected PICU surge response. Victims presented to the hospital after simulated accidental chlorine overexposure at a public pool. Twenty-two patients with 14 family members needed evaluation; nine of these patients would require PICU admission. Three of nine PICU patients were low-fidelity mannequins. In addition to the 36 actor/patient evaluators, each area had two to four expert evaluators (disaster preparedness experts) to assess appropriateness of global response. Patients were expected to receive standard of care. Appropriateness of medical decisions and treatment was assessed retrospectively with review of electronic medical record.
ResultsThe initial PICU census was three of seven; two of these patients were transferred to the general ward. Of the nine patients that required Intensive Care Unit (ICU) admission, six actor/patients were admitted to the PICU, one was admitted to the Surgical Intensive Care Unit (SICU), one went to the Operating Room (OR), and one was admitted to a monitored-surge general pediatric bed. The remaining 13 actor/patients were treated and released. Medical, nursing, and respiratory staffing in the PICU and the general ward were increased by two main mechanisms (extension of work hours and in-house recruitment of additional staff). Emergency Department (ED) staffing was artificially increased prior to the drill. With the exception of ocular fluid pH testing in patients with ocular pruritus, all necessary treatments were given; however, an unneeded albuterol treatment was administered to one patient. Chart review showed adequate discharge instructions in four of 13 patients. Nine patients without respiratory complaints in the ED were not instructed to observe for dyspnea. All patients were in the PICU or alternate locations within 90 minutes.
DiscussionThe staff was well versed in the major details of KCHC's PICU surge plan, which allowed smooth transition of patient care from the ED to the PICU. The plan provided for a roadmap to achieve adequate medical, nursing, and respiratory therapists. Medical therapy was appropriate in the PICU; however, in the ED, patients with ocular complaints did not receive optimal care. In addition, written discharge instruction and educational material regarding chlorine overexposure to all patients were not consistently provided. The PICU surge plan was immediately accessible through the KCHC intranet; however, not all participants were cognizant of this fact; this decreased the efficiency with which the roadmap was followed. An exaggerated ED staff facilitated evaluation and transfer of patients.
ConclusionDuring disasters, the ability to surge is paramount and each hospital addresses it differently. Hospitals and departments have written surge plans, but there is no literature available which assesses the validity of said plans through a rigorous, structured, simulated disaster drill. This study is the first to assess validity and effectiveness of a hospital's PICU surge plan. Overall, the KCHC PICU surge plan was effective; however, several deficiencies (mainly in communication and patient education in the ED) were identified, and this will improve future response.
,Shah VS ,Pierce LC ,Roblin P ,Walker S ,Sergio MN .Arquilla B Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center . Prehosp Disaster Med.2014 ;29 (1 ):1 -7 .