Horizontal Infection Control

Presented by: Sophia Bragg, Katie Dube, Jackie Gadziala, Jeremy Garde, Sierra Lynn,
Shayna Prok, Samantha Wieland, Brett Wilson, Isabel Wirth
Jackie Gadziala……………...Introduction & Summary of Current Practice
Katie Dube…………………….Summary of Literature
Shayna Prok…………………..Summary of Literature
Brett Wilson………………….Recommendations for Implementation
Jeremy Garde………………..Recommendations for Implementation
Sophia Bragg………………….Cost Analysis
Sierra Lynn…………………….Cost Analysis
Isabel Wirth…………………..Risks vs. Benefits
Sam Wieland………………….Evaluation of Solution & Summary

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 Introduction
Vertical vs Horizontal Infection Control
Vertical infection control
◦ Narrow approach focusing on reducing a
specific infection
◦ Short term approach with higher resource
utilization
◦ Commonly used for MDRO’s such as
MRSA, VRE, C. difficile
◦ Better for outbreak or higher rates of a
specific pathogen within a hospital-
COVID requires vertical infection control!
◦ Most common is the use of contact
precautions
Horizontal infection control
◦ Broad approach to reducing all
infections due to pathogens; all are
created equally
◦ Lower resource utilization with long
term approach
◦ Better for hospitals with sporadic HAIs
instead of outbreaks
◦ Common practices are hand hygiene,
CHG baths for all patients,
environmental cleaning, selective
digestive tract decontamination
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 (Godbout et al., 2019).
(Haessler et al., 2020).

Introduction (Martin et al., 2016).

(Edmond et al., 2015).
(Traa et al., 2014).

◦ Current issues
◦ Allocation of resources - How can we be most efficient
with finances and equipment?
◦ Disrupted patient care - How do patients feel on
isolation precautions?
◦ Significance to nursing and patient outcome

https://www.cleanlink.com/news/article/Arizona-Infection-
Control-Expert-Honored---25754 4
 In hospitalized patients (P), does horizontal infection control (I) compared to the vertical infection control of active
surveillance testing and isolation (C) reduce hospital acquired infections of MRSA (O) throughout the length of the
patient’s stay in the hospital (T)?

Population: hospitalized patients receiving critical care

Intervention: horizontal infection control methods

Comparative intervention: vertical infection control methods of active surveillance testing and isolation

Outcome: reduced hospital acquired infections of MRSA

Time: throughout the length of the patient’s stay in the hospital

What is the best practice for infection control?

 (Godbout et al.,
2019).
(Haessler et al.,
2020).

Summary of Current Practice (Martin et al., 2016).

(Edmond et al.,
2015).
(Traa et al., 2014).

◦ Hand hygiene, glove use, CHG baths, sharp safety,

disinfecting environmental surfaces
◦ HAI prevention
◦ Overuse of contact precautions
◦ Frequent testing and lab work
◦ Consistent antibiotic administration in critically ill
patients
◦ Selective decontamination
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 (Edmond et. al, 2015)
(Godbout et. al, 2019)
(Haessler et. al, 2019)
(Martin et. al, 2016)

Discontinuation of Contact Precautions

Summary
◦ Discontinuation of contact precautions has had no effect on number of hospital
acquired infections such as MRSA
Strengths
◦ Advocates for maximization of horizontal infection techniques in further research
◦ All studies are reliable
◦ High compliance
Limitations
◦ Hawthorne Effect
◦ Potential confounding factors

https://news.northeastern.edu/2020/05/05/nurses-are-taking-car
e-of-covid-19-patients-whos-taking-care-of-the-nurses/

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 (Harris et. al, 2020) (Watson
et. al, 2016)

Environmental Cleaning
Summary
◦ Hospital-wide environmental and patient cleaning
protocol is associated with a reduction in MRSA
rates
Strengths
◦ Standardized data collection process
◦ Statistically significant reduction in MRSA rates
Limitations
◦ Multiple cleaning methods were tested, which limits
ability to determine most beneficial cleaning method https://www.allsafeindustries.com/d7-multi-use-disinf
ectant-decontaminant-2-gallon-kit.aspx

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 (Mergenhagen et al., 2020).

Antimicrobial Stewardship
Summary:
◦ Use of MRSA nare screenings in hospitals
◦ Negative MRSA nasal swab had high predictive values

Strengths:
◦ Reliable
◦ Large sample size
◦ Results were statistically significant

Limitations:
◦ Some positive cultures may not be true positives
◦ Unknown if “sterile” samples actually collected in true sterile fashion
◦ Patients could have been colonized with MRSA in other locations

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 (Melsen et al., 2011).

Selective Decontamination of the

Oral/Digestive Tract
Summary:
○ Use of SOD and SDD reduced 28-day mortality from hospital-acquired
microorganisms
○ Antibiotic resistance was not found in patients treated
○ Reduction of ICU stay and duration of mechanical ventilation

Strengths:
○ Statistically significant results
○ Large sample size included

Limitations
○ Baseline differences present in individual patients
○ Undetermined explanation of differing efficacy of SOD and SDD in
surgical patients

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 Sources: (Harris et al., 2020),

Recommendations for (Watson et al., 2016)

Implementation
◦ Decontamination training
◦ Yearly training on infection control
◦ Implemented yearly with retrospective analysis of year prior on efficacy of
training

◦ Environmental cleaning
◦ Protocols that require cleaning frequently touched equipment throughout the day
◦ Bleach germicidal cleaner
◦ Denatured bacterial proteins
◦ Decon7
◦ Decontaminate used for bio and chemical warfare
◦ Implemented immediately on ICU floors with random monthly audits and check-ins by infection control
until MRSA is eliminated for at least a 6 month period

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 Sources: (Edmond et al., 2015),
(Haessler et al., 2020)

Recommendation for
Implementation
◦ Stopping contact precautions for
asymptomatic patients in the ICU
◦ Immediately phasing out the
excessive use of materials and
supplies required for contact
precautions

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 (Melson et al., 2011)

Recommendations for
Implementation
◦ Nurses would be required to attend 2 hour
training on the implementation of antibiotic
decontamination. The training would focus on:

◦ Digestive Tract Decontamination protocols

◦ Specific antibiotic use and implementation
◦ System tracking and charting
◦ Oral Decontamination
◦ Antibiotic Stewardship

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 Recommendations for Implementation
Timeline for Banner ICU
Begin the use of environmental cleaning agents;
the implementation of 2 hour classes for nurses
on environmental decontamination as well as the 1 year audit with a goal of 75% decrease in
implementation of antibiotic decontamination by MRSA incidence from the start of
the nurse educator; discontinuing the use of implementation; yearly decontamination
contact precautions for asymptomatic individuals training and antibiotic decontamination
classes continued. January 1,
June 1,
2024
2022

January January
1, 2022 6 month audit on the incidence of MRSA 1, 2023 2 years after implementation of the
within Banner ICU with a goal of 50% decontamination training for all nurses,
decrease in MRSA incidence, and to ensure as well as the proper use of
antibiotic stewardship in the oral and gut environmental cleaning products and
decontamination protocols antibiotic decontamination, there will be
no new confirmed cases of hospital
acquired MRSA infections
*Training and the cessation contact precautions
will be conducted over the 6 month period, along
with monthly observations to maintain compliance
with environmental cleaning
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 (Godbout et. al., 2019), (Haessler et. al. 2020),
(Martin et. al., 2016), (Watson et. al., 2016).

Cost Analysis
◦ Discontinuation of vertical infection control saved the hospital
money
◦ Cost of isolation precautions per day: $35

◦ Implementation of horizontal infection control

◦ Avoided healthcare infection costs of $1,655,143

◦ Annual savings of about $500,000-$600,000

◦ Horizontal precautions outweighed vertical expenses and
the cost of training employees on new precautions
15
 Godbout et. al, 2019), (Haessler et al., 2020),
(Martin et. al., 2016), (Watson et. al., 2016)

Cost Analysis
◦ Discontinuing contact precautions
◦ Box of 50 isolation gowns - $70 (amazon.com)
◦ Monthly difference of $60,792
◦ Implementing new horizontal precautions
◦ Decon-7 4 gallon kit - $199 (ASI.com)
◦ Nares screening: $103,000 per 1000 patients
◦ Avoided overall healthcare costs: $1,655,143

◦ So why not save money!

https://hbr.org/resources/images/article_assets/2020
/03/Mar20_25_1203497834.jpg

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 (Godbout et al.,
2019).
(Haessler et al.,
2020).
(Martin et al., 2016).

Risks vs. Benefits: Risks (Watson et al.,

2016).
(Mergenhagen et al.,
2020).
Melsen et al., 2011).
◦ Institution: (Edmond et al.,
2015).
(Harris et al., 2020).
◦ Deviation from the widely-used hospital protocol of contact precautions (Traa et al., 2014).
◦ Reliance on communication and teamwork between many areas of the
hospital
◦ Nurse:
◦ Places nurse in a more vulnerable position for acquiring easily
transmissible infections
◦ Relies strongly on nurse’s individual horizontal infection control habits
◦ Patient:
◦ Decreases individuality and specificity of patient care
◦ HAI status dependent on nurses’ consistency with horizontal infection
control measures
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 (Godbout et al.,
2019).
(Haessler et al.,
2020).
(Martin et al.,

Risks vs. Benefits: Benefits 2016).

(Watson et al.,
2016).
(Mergenhagen et
al., 2020).
◦ Institution: Melsen et al.,
2011).
(Edmond et al.,
◦ Significant decreases in inpatient costs, cost of materials, and HAIs 2015).
(Harris et al.,
◦ Utilizes several different factors within the hospital environment for horizontal 2020).
(Traa et al., 2014).
infection control
◦ Nurse:
◦ Promotes consistent routine of hand hygiene before and after every patient
encounter
◦ Saves time by eliminating donning and doffing proper contact precaution PPE
resulting in more time for patient care
◦ Patient:
◦ Decreased days of isolation and feelings of loneliness
◦ Widespread infection control for all patients on the floor
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 (Godbout et al., 2019).
(Haessler et al., 2020).
(Martin et al., 2016).
(Watson et al., 2016).
(Mergenhagen et al., 2020).
Melsen et al., 2011).
(Edmond et al., 2015).
Evaluation of Solution (Harris et al., 2020).
(Traa et al., 2014).

● The rate of hospital-acquired MRSA and VRE infections will decrease by at

least 75% after..
○ Stopping excessive use of contact precautions for VRE and MRSA
○ Implementing environmental cleaning with EPA registered products
○ Promoting antibiotic stewardship
○ Education on selective decontamination of oral/digestive tract for ICU
patients
● ...within one year of implementation.

● Hospital costs for infection prevention will be reduced by at least $500,000

after the implementation of these interventions within one year.

https://1q4yri1nlknh3om1xh1oqe5w-wpengine.netdna-ssl.com/wp-cont
ent/uploads/2020/09/InfectionControl_Icon-01.png
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 (Godbout et al., 2019).
(Haessler et al., 2020).
(Martin et al., 2016).
(Edmond et al., 2015).
(Traa et al., 2014).

Summary
◦ PICO(T) question: In hospitalized patients receiving critical
care (P), does horizontal infection control (I) compared to the
vertical infection control of active surveillance testing and
isolation (C) reduce hospital acquired infections of MRSA (O) https://www.danielshealth.com/sites/danielshealth.com/files/
Embedded%20Page%20Images/Circle%20Images%20-%20He
althcare/Circle-Hand-Washing2.png

throughout the length of the patient’s stay in the hospital (T)?

◦ Horizontal vs Vertical
◦ Use of contact precautions may also contribute to social
isolation, disrupted patient care, increased cost and resources
◦ Hand hygiene and CHG baths have been implemented into
practice already
https://images.squarespace-cdn.com/content/v1/5e2870023cdf2d
4dd7a61b0c/1598032964849-9K1E66IKHCIY1G69C0GQ/PE.png
?format=1000w

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 (Godbout et al., 2019).
(Haessler et al., 2020).
(Martin et al., 2016).
(Watson et al., 2016).
(Mergenhagen et al., 2020).
Melsen et al., 2011).
(Edmond et al., 2015).

Summary (Harris et al., 2020).

(Traa et al., 2014).

Supportive Studies
◦ No difference or a decrease in rates of MRSA and VRE infections
◦ MRSA nasal swabs allow for antimicrobial stewardship https://cdn-icons-png.flaticon.com/512/
1802/1802511.png
◦ Enhanced environmental cleaning reduced MRSA/VRE infections
◦ Selective digestive tract decontamination decreased the occurrence of infection

Best Practice
◦ Vertical infection prevention is best for outbreaks and short-term
◦ Horizontal infection prevention is best for long-term and non-outbreaks such as with MRSA and
VRE
◦ Contact precautions provide no benefit to reducing transmission among patients in the hospital
and contribute to higher costs
◦ More rigorous horizontal infection control methods should be implemented in hospitals and
most vertical methods can be removed

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 (Godbout et al., 2019).
(Haessler et al., 2020).
(Martin et al., 2016).
(Watson et al., 2016).
(Mergenhagen et al., 2020).
Melsen et al., 2011).

Summary (Edmond et al., 2015).

(Harris et al., 2020).
(Traa et al., 2014).

● Application to facility
○ Education and implementation
○ Discontinuation of contact precautions https://cdn-icons-png.flaticon.com/512/2201/2201508.p
ng
● Cost analysis
○ Discontinuing vertical infection control methods such as
isolation saves TONS of money for the institution
○ Costs associated with horizontal infection strategies are
offset by the much greater cost reduction when discontinuing
vertical methods
● Risks vs Benefits

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nm-NesZ6o/resized.png
References
Edmond, M.B., Masroor, N., Stevens, M.P., Ober, J., and Bearman, G. (2015). The impact of discontinuing contact precautions for VRE and MRSA on

device-associated infections. Infection Control & Hospital Epidemiology, 36(8), 978-980. https://doi.org/10.1017/ice.2015.99

Godbout, E.J., Rittmann, B.J., Fleming, M., Albert, H., Major, Y., Nguyen, H.J., Noda, A.J., Cooper, K., Doll, M., Stevens, M.P., Bearman, G. (2019). Impact of

discontinuation of contact precautions on central-line associated bloodstream infections in an academic children’s hospital. Infection Control & Hospital

Epidemiology, 40: 473–475, https://doi.org/10.1017/ice.2019.19

Haessler, S., Martin, E. M., Scales, M. E., Kang, L., Doll, M., Stevens, M. P., Uslan, D. Z., Pryor, R., Edmond, M. B., Godbout, E., Abbas, S., & Bearman, G. (2020).

Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: an interrupted time series analysis.

American Journal of Infection Control, 48(12), 1466-1773. https://doi.org/10.1016/j.ajic.2020.06.219

Harris, D., Taylor, K., Napierkowski, K., & Zechmann, B. (2020). Indoor finish material influence on contamination, transmission, and eradication of

methicillin-resistant staphylococcus aureus (MRSA). Health Environments Research & Design Journal, 14(1), 118-129. doi:10.1177/1937586720952892

Martin, E. M., Russell, D., Rubin, Z., Humphries, R., Grogan, T. R., Elashoff, D., & Uslan, D. Z. (2016). Elimination of routine contact precautions for endemic

methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococcus: A retrospective quasi-experimental study. Infection Control & Hospital

Epidemiology, 37(11), 1323–1330. https://doi.org/10.1017/ice.2016.156

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References
Melsen, W.G., De Smet, A. M. G. A., Kluytamans, J. A. J. W., Bonten, M. J. M. (2011) Selective decontamination of the oral and digestive tract in surgical versus

non-surgical patients in intensive care in a cluster-randomized trial. British journal of surgery. 99(2), 232-237.

https://doi-org.ezproxy2.library.arizona.edu/10.1002/bjs.7703

Mergenhagen, K. A., Starr, K. E., Wattengel, B. A., Lesse, A. J., Sumon, Z., & Sellick, J. A. (2020). Determining the Utility of Methicillin-Resistant Staphylococcus

aureus Nares Screening in Antimicrobial Stewardship. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America,

71(5), 1142–1148. https://doi.org/10.1093/cid/ciz974

Traa, M. X., Barboza, L., Doron, S., Snydman, D. R., Noubary, F., & Nasraway, S. A., Jr (2014). Horizontal infection control strategy decreases methicillin-resistant

Staphylococcus aureus infection and eliminates bacteremia in a surgical ICU without active surveillance. Critical care medicine, 42(10), 2151–2157.

https://doi.org/10.1097/CCM.0000000000000501

Watson, P. A., Watson, L. R., & Torress-Cook, A. (2016). Efficacy of a hospital-wide environmental cleaning protocol on hospital-acquired methicillin-resistant

Staphylococcus aureus rates. Journal of infection prevention, 17(4), 171–176. https://doi.org/10.1177/1757177416645342

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Picture References
https://news.northeastern.edu/2020/05/05/nurses-are-taking-care-of-covid-19-patients-whos-taking-care-of-the-nurses/
https://www.allsafeindustries.com/d7-multi-use-disinfectant-decontaminant-2-gallon-kit.aspx
https://www.cleanlink.com/news/article/Arizona-Infection-Control-Expert-Honored---25754

https://hbr.org/resources/images/article_assets/2020/03/Mar20_25_1203497834.jpg

https://1q4yri1nlknh3om1xh1oqe5w-wpengine.netdna-ssl.com/wp-content/uploads/2020/09/InfectionControl_Icon-01.png

https://www.danielshealth.com/sites/danielshealth.com/files/Embedded%20Page%20Images/Circle%20Images%20-%20Healthcare/Ci
rcle-Hand-Washing2.png

https://cdn-icons-png.flaticon.com/512/1802/1802511.png

https://d4y70tum9c2ak.cloudfront.net/contentImage/pZZqQsOeGFckG27ApAiCZXMI448LD2Keu5nm-NesZ6o/resized.png

https://images.squarespace-cdn.com/content/v1/5e2870023cdf2d4dd7a61b0c/1598032964849-9K1E66IKHCIY1G69C0GQ/PE.png?f
ormat=1000w

https://cdn-icons-png.flaticon.com/512/2201/2201508.png

- All icons are taken from Powerpoint and do not need a citation

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