· Use EBP articles no more than 5 years old. 
· Make sure you put your name at the top and include your article citation in 7th ed. APA format of your assignment – see exemplar. 
· Do not give research terms on your assignment i.e. this is a cross-sectional study or has validity unless you’re ready to explain how this will help you solve your problem. These terms are used so that you know if an article is valid and reliable. OK, so now that you found this, your job is to find out how this project will help you solve your problem. 
o The paper is set up to determine the strength, weaknesses, opportunities, and threats of the project itself. 
o By answering these questions, you will help guide and collaborate with your peers with constructive feedback on how to solve your problem collectively as a team.
§ Strength – Example: Did they have the support of the peers, manager, CEO. Did this project improve patient satisfaction, quality, efficiency? Usually found in the literature review and results.
§ Weakness – Example: This is the opposite. Why was this plan weak: Not enough education, no support, not enough money because of the expense? Usually found in the problem of the literature review, results, and limitations.
§ Opportunity – Example: If there wasn’t enough education, is this an opportunity? A better survey or tool? Usually found in results or limitations and future implications.
§ Threat – Example: Increased infection, possible death, etc. Usually found in the literature review. 
o It is your job to know your article and have the ability to articulate what your article is about with your peers and with your instructor. 
o During the virtual class, you may be asked to elaborate on your article. So know your article! 
· Please note that the exemplar provided received maximum points.

Student Name: XXXXXXXX
EPB Journal Article in APA format:
Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department patient flow using lean thinking. International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care, 30(4), 250–256. https://doi.org/10.1093/intqhc/mzy017

Is this an Evidence Based Article? Name of Journal and Year article was written?

Yes

Name of Journal: International Journal for Quality in Health Care

Year: 2018

.2 points

State the problem
What was the goal of the project?

Does this project correlate with your problem? State how?

What are you trying to achieve? Does this article support this goal?

Problem: Delays in the ED compromise quality of care and patient safety while simultaneously increasing mortality and healthcare costs. Internal inefficiencies and poor resource utilization may contribute to delays in care and overcrowding.

Goal: The goal of this project was to achieve a target time of 160 minutes (total), per patient in the ED.
· 80 minutes of “added value” (i.e. specific amount of time with a nurse and doctor for assessment, treatment, and education)
· 60 minutes for lab results
· 20 minutes for treatment steps that could not be eliminated using the Lean process

The goal of our group project is to propose a plan to decrease wait times and improve flow to care areas. The study outlined in this article directly correlates with our group project in that its aim was to tackle the issue of increased wait times leading to delay of care and negative outcomes, including decreased patient satisfaction and the increased risk for mortality. The goal of our group project is to propose a plan to reduce wait times in order to improve patient outcomes, which is exactly what the article’s researchers set out to do by proposing the use of lean principles to eliminate the unnecessary steps/processes that add to wait times.

.2 points

Strengths (Internal)
What’s was good about your article?

Staff Input: This project was heavily supported by the ED staff and administration. In fact, the ED staff were empowered to make the necessary changes by identifying steps (waste) that slowed flow and hindered the care process. They were also tasked with recognizing processes that could be standardized to improve efficiency in care.
Leadership Style: Furthermore, the researchers encouraged a “bottom-up” approach (democratic leadership) to achieve a more enthusiastic acceptance and implementation of the plan. The ED executive team acted as consultants to help support and foster the new process to reduce internal resistance.
Cost: The implementation of the entire project was inexpensive because it did not require third party support or additional supplies.
Did this implementation take place on a unit or area like yours: Yes, this project was implemented in an ED unit.

.4 points

Weakness (Internal)

Staff Support: According to the researchers, the most difficult problem they faced was staff reluctance to abandon their old practices and proceed with implementing the new process of standardization (which required 3 weeks of constant surveillance).

Size: This study was performed in a single ED unit that did not provide services to pediatric or obstetric patients, so it is unknown how well these results might carry over to other specialized ED units. Furthermore, to ensure proper control, the study was limited to a specific unit in the ED, MAT-3, which was the busiest unit in the ED and designated solely for urgent cases.

.4 points

Opportunities (External)

Patient Satisfaction: The results of this study showed that the ED staff was able to reduce wait times, overall care times, and improve patient flow using the lean process to eliminate wasteful steps. However, the researchers could have also measured patient satisfaction to determine if the lean process also improved the correlation between wait times and patient satisfaction.
Staff Satisfaction: The authors recognized that additional research should be completed to analyze how the lean process affects staff members in terms of work satisfaction, turnover, and improved use of skills.
Baseline Data: The researchers found no significant differences in the revisit rate, mortality rate, or leave without being seen rate (LWBS) after implementing the lean process. Suggestions for additional research meant to address these variables were not provided but should be explored, especially due to their relationship with patient safety.

.4 points

Threats – (External)

Validity: The researchers acknowledged that one of the greatest limitations of their study was its external validity since the study was performed in only one ED unit. Their methodology might not produce the same results in a more efficiently run ED unit.
Time: The researchers also agreed that the cultural change needed to fully adapt to this new standardized process would be an ongoing endeavor that would require additional time after the conclusion of the study. The researchers discounted the first 6 months of data because they anticipated that the staff would be more willing to embrace the new process, resulting in a false-positive outcome. Their aim was to observe how time also impacted the lean process in the ED unit in the following months.

Staff Buy In: Finally, the researchers also felt that the cultural/local interpretation of lean principles might differ depending upon location and/or unit. Previous studies concluded that the lean process did not provide clinically relevant results in ED units due to lack of staff buy in resulting from misinterpretation of lean principles. In other words, the staff must understand that the lean process is not a solution but a methodology.

.4 points

Total Points = 2 points

ORIGINAL ARTICLE

INTRODUCTION
Special New-born Care Unit is a facility established in some
states of India with relatively higher infant mortality rate.
These units are equivalent to Neonatal Intensive Care Units
(NICU, in their objectives and functioning. Therefore, they
would be referred as NICU in this article. Regionalized neonatal/
perinatal care with good network at various levels is emerging as
an effective strategy to manage neonatal disease burden [1, 2].

Therefore, the State of Chhattisgarh (a state in Central
India) has also established 16 functional NICUs, one each
at 15 district hospitals (secondary-level healthcare facility),
and one at a medical college, with support from UNICEF.

Evidence-based awareness generation improves
infection control practices in Neonatal Intensive Care
Units at secondary-level government hospitals in
Central India
Anudita Bhargava, MD, PDCC, PhD;1 Ajay Trakroo;2 Debabrata Dash, MD;1 R. Prasanna;3 Ritu Pandey, MSc1

1 All India Institute of Medical Sciences, Raipur
2 UNICEF, Chhattisgarh
3 Health Services, Chhattisgarh

Corresponding author:
Dr. Anudita Bhargava, Additional Professor, Department of Microbiology, All India Institute of Medical Sciences, Raipur – 492099, Chhattisgarh, India
Telephone: 91-851-888-1903
Email: [email protected]; [email protected]

Acknowledgements: We acknowledge the help of Dr. Amar Singh Thakur, State Health Services, Chhattisgarh, for administrative support of allowing participation of
various NICUs, Mr. Amit Dwivedi of UNICEF for coordinating between AIIMS, Raipur, UNICEF and State Health Services, Chhattisgarh and Ms. Akanksha Rai of Ekam
Foundation (NGO) for the logistic support in conducting this study.

Funding: This work was supported by UNICEF, India (Grant No CG/2016/RCH/663 DT 07/12/2016).

Contributions: AB & AT conceptualized the study. AB, DD & RP1 performed and analyzed the laboratory work. RP2 provided administrative support. AB & DD wrote the
manuscript. RP1 – Ritu Pandey, RP2 – R. Prasanna.

However, the presence of Hospital Acquired Infections
(HAI) and emergence of drug resistance microbes at these
NICUs has challenged its gains and positive contributions.
The presence of HAI is attributed to inadequate infection
control practices (ICPs) whereas the unmonitored and lack of
evidence-based use of antibiotics is causing the emergence
of drug resistance microbes.

The efforts were thus made to identify the gaps in the
knowledge and practices regarding standard ICPs. The
requirement of training in standard ICPs and sub-optimum ICPs
across all levels of team members was a major gap identified
from the discussions with the NICU team members.

ABSTRACT

Background: Healthcare-associated infections are preventable yet a significant cause of neonatal mortality. Neonatal Intensive Care Units (NICU) are established in
resource poor settings in India to reduce the neonatal mortality rate. However, inadequate infection control practices (ICP) at these NICUs may defeat its purpose. A study
was designed to conduct an environmental microbiological surveillance of the NICUs to identify the infectious microbes and to use the results as an evidence to generate
awareness among the NICU team members to improve ICP.

Methods: Environmental swabs were collected in pairs (before and after cleaning) from the NICUs in three rounds of sampling and were subjected to culture.

Results: Of the 1,284 swabs collected, 29.7% showed positive bacterial or fungal growth. Among the positive cultures 37% had known pathogens. Commonest were
Pseudomonas spp. and Acinetobacter spp. followed by enteric bacilli. 15% of the non-fermenting gram-negative bacilli and 43% of coliforms were Multi Drug Resistant
(MDR). The reports with possible solutions were shared with the respective NICU and a significant reduction in bio-load between pre and post-cleaning swabs (p<.001) were noted. Significant reduction (p<.001) in bio-load was recorded in the swabs collected in rounds two and three. Conclusion: Environmental Microbiological Surveillance of intensive healthcare setting and sharing of the reports with possible solutions specific to the recorded findings, found to be an effective tool in motivating the NICU team members for improved ICP. KEYWORDS: NICU; infection control practices; surveillance; awareness Canadian Journal of Infection Control | Summer 2018 | Volume 33 | Issue 2 | 106-110 106 Among many published studies reporting the importance and role of NICUs in India in facilitating quality neonatal care [3-5], none were found to have delved into the hospital associated infections and infection control practices. A study thus was planned with 13 NICUs that were fully functional by then. As a first step, the study focused on microbiological environmental surveillance of NICUs, to generate and demonstrate the existence of microbes in the NICU environment; and the need for initiation and maintenance of adequate ICPs. This article discusses the results of the Microbiological Environmental Surveillance and its impact on ICPs. METHODS The study was conducted from February 2017 through August 2017 at the Department of Microbiology of All India Institute of Medical Sciences (AIIMS), Raipur, a tertiary level healthcare center-cum teaching institute, located at Raipur, the capital city of the State of Chhattisgarh. The study was approved by the institutional ethics committee. The study started in February 2017 with a workshop for two days, which was attended by the Pediatrician-in-charge and the Chief Staff Nurse from each of the 13 NICUs. The hands-on sessions for various infection control practices were organized on the first day of the workshop. Day two was dedicated to sample collection, its packing and transportation to the laboratory. Microbiological environmental samples from 13 NICUs were collected from high touch areas and patient care items by swabbing. Commercially available sterile swabs (Himedia, Mumbai) were used for the purpose. The surfaces swabbed included nursing station, cradle bar/frame, phototherapy hood, warmer basinet, suction tube, suction jar, oxygen humidifier, oxygen concentrator, oxygen hood, ventilator tubing, C-PAP instrument, ambu-bag, nebulizer mask, infusion pump, intravenous stand, water tap handle, door handle, medicine trolley, procedure trolley, and computer keyboard. Through the period of the study three rounds of sample collection were undertaken. In each round the samples from every NICU was collected once. The duration between two rounds of sample collection at any of the participating NICU varied between 20 to 25 days. In each round of sample collection, following were collected: a) A pair of surface swabs from each site – one pre-cleaning and another after 30 minutes of cleaning procedure. b) Samples of disinfectant being used at the time of sample collection. The collected samples were then transported (as per standard protocol) to the Department of Microbiology of AIIMS, Raipur by specially trained team members [6]. The swabs were cultured on Blood agar and MacConkey agar, incubated at 37°C for 18-24 hours. The results were categorized as: no growth (NG), growth of contaminants (C) or growth of pathogenic bacteria (P). The pathogenic bacteria were identified to the species level by standard laboratory protocol. For all identified pathogenic bacteria antibiotic sensitivity test (AST) was conducted as per CLSI guidelines [7, 8]. The antibiotic sensitivity pattern was recorded. The MDR organisms thus identified were stocked for future studies. The disinfectant was tested by in-use test [9]. Statistical analysis Statistical analysis was done by applying chi-square test using on-line statistics calculator “open epi”. The p-value less than 0.01 (1%) was considered as statistically significant [10]. RESULTS Among the total 1,284 swabs cultured, 381 (29.7%) showed positive bacterial/fungal growth. Out of these 381, 141 (37%) grew pathogenic bacteria while 240 (67%) were contaminants (Non-pathogenic) or environmental saprophytes. Mixed growth was noted in 33 (8.6%) samples. Among the 1,284 swabs, 655 were collected prior to cleaning while 629 were post-cleaning swabs (Table 1). Nearly 30% of the samples showed growth of microorganisms. This comprised 19% non-pathogenic bacteria/fungus and 11% pathogenic bacteria. The number of pre-cleaning swabs showing no-growth (NG) were 52%, 59%, and 71% in the first, second and third round of sampling, respectively. The number of post-cleaning swabs showing no-growth was 78% in the first round of sampling, 81% in the second and 82% in the third round of sampling. The number of pre-cleaning swabs showing growth decreased from 48% in the first round of sampling to 41% in the second and 29% in the third round of sampling. Growth in post-cleaning swabs decreased from 22% in the first round to 18% in the third round of sampling. There was statistically significant difference in the results of the pre-cleaning swab cultures of the three rounds of sampling. There was, however, no significant difference in the results of the post-cleaning swab cultures in all three rounds of sampling (chi-square =1.141). TABLE 1: Observation of surface swab cultures from NICUs of Central India Swabs Total No growth Pathogen Contaminants N % N % N % Pre-cleaning random swabs 655 396 60.4 95 14.5 164 25.2 Post-cleaning swabs 629 507 80.6 46 7.3 76 12.1 Total 1284 903 70.3 141 10.9 240 18.7 Canadian Journal of Infection Control | Summer 2018 | Volume 33 | Issue 2 | 106-110 107 The chi-square value of difference in NG samples between pre-cleaning and post-cleaning swabs was 30.98, 28.16, and 6.02 in the first, second and third rounds of sampling, respectively. Among the patient care items, respiratory equipment including suction tube and suction jar, followed by oxygen concentrator showed maximum bioburden of both contaminants and pathogenic bacteria. The nursing station, medicine trolley, followed by procedure trolley and computer keyboard had the highest bioburden among the non-patient care high touch surfaces of the environment. A predominance of gram negative bacilli was noted in the analysis of the spectrum of bacteria isolated from different sites. Among gram negative bacilli non-fermenters Pseudomonas aeruginosa and Acinetobacter spp. were the commonest, followed by the members of enterobacteriacae family. Among the family of enterobacteriacae, maximum were Klebsiella pneumoniae subspp. pneumoniae, followed by Enterobacter aerogenes, Citrobacter spp. and Escherischia coli (Fig. 1). The analysis of antibacterial sensitivity pattern of the pathogenic bacteria revealed that 25.6% of the isolates were Multi-Drug Resistant (MDR), i.e., showing resistance to three or more than three classes of antimicrobial agents (Fig.1). Further evaluation of the organism-wise antibiotic sensitivity pattern indicated that 15% of the non-fermenting gram negative bacteria were MDR, whereas 43% of the gram negative bacilli belonging to Enterobacteriacae family were MDR (Fig.1). Of the disinfectants used at the NICUs, 87% were found to be acceptable, while 13% were unacceptable. DISCUSSION Neonates are vulnerable to various infections due to their weak immune system and this vulnerability depends on the maturity status of the neonate, birth weight, maternal health etc. The NICUs are therefore set up at district and block levels in resource poor settings of India, to provide specialized care to an increasing load of newborns due to a rise in institutional delivery and referrals under Integrated Management of Childhood Illness (IMNCI). Such regionalized neonatal care units with good network at various levels are emerging as an effective strategy to manage neonatal disease [1, 2]. Additionally, where advanced care units do not exist, the secondary level units can help lower NMR significantly [11, 12]. Towards mid-2016, 13 NICUs became functional in the state of Chhattisgarh. It is thus important that the environment inside the NICU has minimum bioburden, which can be attained only by following standard infection control practices. Inadequate infection control practices make NICUs vulnerable to various hospital- acquired infections (HAIs). FIGURE 1: Spectrum of pathogenic bacteria and their antibiotic susceptibility pattern 57 39 20 15 12 7 13 48 33 10 8 8 4 99 6 10 7 4 3 4 0 10 20 30 40 50 60 Pseudomonas aeruginosa Acinetobacter spp. Klebsiella pneumoniae subspp. Pneumoniae Enterobacter aerogenes Citrobacter Spp Escherischia coli Miscellaneous Total Sensitive Resistant A total of five swabs showed the growth of Candida albicans. Majority of contaminants were Coagulase-negative Staphylococcus (CoNS). The spectrum of microorganisms isolated were approximately similar for all NICUs. Canadian Journal of Infection Control | Summer 2018 | Volume 33 | Issue 2 | 106-110 108 During past years, several studies have been published to evaluate the impact of these NICUs. A study by Neogi et al. observed that aseptic practices critically determine the outcome of treatment a newborn received in the NICU [3]. In a review of 125 articles, Srivastava and Shetty emphasized the importance of raising awareness among the team members regarding infection control practices, especially in resource poor settings [13]. The NICUs in the present study are also located in resource poor settings with inadequate awareness regarding infection control practices among the team members and use of antibiotics as the only weapon to combat infections. In the Indian context, the authors could not find any study that used laboratory-based evidence to indicate the presence of micro-organisms (bioburden) in the NICU and the impact of good ICPs in reducing it. The present study was planned according to the CDC recommended situations-research and quality assurance to evaluate the effect of infection control practices and commissioning newly established special care areas like NICUs [14, 15, 16, 17]. In the present study, about one third of the high touch surface swabs showed presence of either contaminants or pathogenic bacteria. A total of 11% of the swabs showed growth of pathogenic bacteria, among which 25.6% were MDR organisms. Isolation of such a high number of MDR bacteria was a cause of serious concern since they could be potential source of HAI to the neonates. Among the pathogenic bacteria reported there was a preponderance of gram negative bacilli comprising non- fermenters like Pseudomonas aeruginosa, Acinetobacter species and members of enterobacteriaceae family, including Klebsiella pneumoniae subspp. pneumoniae, Escherischia coli, Enterobacter spp. and Citrobacter spp. etc. A review of 125 HAI related studies in India reported that gram positive cocci, viruses and fungi were predominant pathogens found from the advanced units, whereas gram-negative enteric rods, non-fermenting gram negative rods and fungi were commonly reported in patient samples collected from resource-limited settings [13]. These findings can be related to the presented study since these NICUs are also located in resource poor settings and showed predominance of non-fermenting gram-negative rods and enteric bacilli in the environment, which may be a potential source of HAIs among the neonates. Another study by Pawa et al. from North India observed MDR Klebsiella spp. (68%) as the commonest pathogen (causing nosocomial septicemia and pneumonia), followed by Pseudomonas aeruginosa (13%) [18]. In a study from South India by Kamath et al., Extended Spectrum Beta Lactamase (ESBL) producing Klebsiella spp. was observed as the commonest nosocomial pathogen, followed by Methicillin Resistant Staphylococcus aureus (MRSA) [19]. Coagulase Negative Staphylococcus (CoNS) constituted the majority of contaminants. These bacteria can also act as a pathogen in neonates. Earlier studies established that 8-24% of CoNS isolated from blood were true pathogen. There is also a substantial body of evidence to demonstrate increasing antibiotic resistance by CoNS among neonates [20, 21, 22]. Thus isolation of large number of CoNS from the NICU environment reported in the present study is highly significant as it can be a potential pathogen, and secondly its widespread presence in the environment indicates suboptimum ICPs, especially poor hand hygiene among the team members. The reported study observed that the growth of microorganisms decreased in the samples collected in the second and third round. During the first round of sampling, 48% of the swabs collected prior to cleaning showed bacterial growth. It reduced to 40% in the second round of sampling, and to 28% in the third round. The observed reduction in bacterial growth in the second and third rounds was statistically significant (χ2= 16.55; p <.001). The authors of the study prepared customized instructions as per the WHO and CDC guidelines to improve infection control practices for each NICU separately, which dealt specifically with the deficit/s found in each NICU’s surveillance report. These customized instructions were not only based on the laboratory test results, but also on the resources that the NICUs had: e.g., which disinfectant or decontaminant was available, availability of PPE (Personal protective equipment), availability and skill of human resources and the work-load in each NICU. The team members at every NICU followed the ICP related specific instructions shared with them, which helped significantly in reducing the bioburden, thereby reducing the probability of HAIs in the respective units. Significant reduction in the bioburden was also recorded in the post cleaning swabs as compared to swabs collected prior to cleaning. This was a consistent phenomenon across three rounds of sample collection. In the first and second rounds of sampling the difference between the pre and post-cleaning swab cultures were statistically significant with χ2 values of 30.98 and 28.16 respectively. In the third round of sampling the difference in bioburden between pre and post-cleaning swabs reduced substantially. It indicates that the efforts of the NICU team members improved towards maintaining cleanliness consistently as per standard ICP protocol, resulting in reduced difference in bioburden in pre and post-cleaning swabs. The equipment showing highest bioburden included suction tubing and suction jar followed by phototherapy hood, warmer basinet, other respiratory care items such as oxygen concentrator, oxygen humidifier, C-pap and oxygen hood, etc. Considering it as a potential source of infection to the neonates admitted in the unit, authors provided specific cleaning instructions to the NICU team members. By the third round of sampling, significant reduction in bioburden was also reported in the swabs collected from the surfaces of the NICU equipment. Among the non-patient items, highest bioburden was observed from nursing station and medicine trolley. Approximately 72% of swabs collected in the third round did not show any bacterial growth. It indicates improvement and consistency in the infection control practices followed for cleaning of equipment and non-patient care items in line with the specific suggestions made by the authors. An earlier study by Gupta et al. has found that in the NICU, baby placements, resuscitation equipment, and cleansing Canadian Journal of Infection Control | Summer 2018 | Volume 33 | Issue 2 | 106-110 109 solutions are significantly associated with HAI [23]. It is similar to the findings of the present study, which has also observed heavy contamination of respiratory care equipment with various microbes including MDR bacteria. With regard to the presence of microbes reported in samples from inanimate environment and fomites, it is of importance to refer to a study by Brito et al., which concluded that lower sink: cot ratio (poor hand washing facility) and higher monthly admission rate resulted in higher rates of HAI [24]. The aim of the present study is to conduct an environmental microbiological surveillance of the NICUs to identify the infectious microbes and their niches and to use the results as evidence to generate awareness among the NICU team members to improve infection control practices, which was successfully attained. Limitations of the study The authors of the study depended on NICU team members for sample collection and its packing, while transportation from the NICUs to the microbiology laboratory at AIIMS Raipur was supported by a logistical partner. CONCLUSION Environmental Microbiological Surveillance of a new intensive healthcare setting would be an effective tool in motivating the team members for better infection control practices, thereby helping in reducing HAI and thus morbidity and mortality among neonates admitted in such units. The Environmental Microbiological Surveillance is also helpful in identifying the MDR microorganisms present in the healthcare environment and prevent its spread to the vulnerable neonates, well in time. REFERENCES 1. Mullem CV, Conway A, Mounts K, Weber D, Browning C. Regionalization of perinatal care in Wisconsin: A changing health care environment. Wis Med J. 2004; 103(5): 35-38. 2. Kirby RS. Perinatal mortality: The role of hospital of birth. J Perinatol. 1996;16(1): 43-49. 3. Neogi SB, Malhotra S, Zodpey S, Mohan P. Assessment of special care newborn units in India. J Health Popul Nutr. 2011;29(5): 500-509. 4. Malhotra S, Zodpey SP, Vidyasagaran AL, Sharma K, Raj SS, Neogi SB, et al. Assessment of essential newborn care services in secondary-level facilities from two districts of India. J Health Popul Nutr. 2014;32(1): 130-141. 5. Tripathi G, Mishra N. The impact of special care newborn units on routine neonatal care practices in central India: Observational study. Int J Contemp Pediatr. 2016;3(4): 1252-1255. 6. World Health Organization. Guidelines for the Safe Transport of Infectious Substances and Diagnostic Specimens. http://www.who.int/ csr/emc97_3.pdf. 1997. 7. Barrow G, Feltham RA, Barrow GI, Feltham RKA, ed. Cowan and Steel’s Manual for the Identification of Medical Bacteria. 3rd ed. Cambridge, UK: Cambridge University Press; 1993. 8. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: 27th Informational Supplement. Wayne, PA: Clinical and Laboratory Standards Institute; 2017. 9. Prince J, Ayliffe GAJ. In-use testing of disinfectants in hospitals. J Clin Pathol. 1972;25(7): 586-89. 10. OpenEpi. http://www.openepi.com/RbyC/RbyC.htm. Accessed December 12, 2017. 11. Were FN, Mukhwana BO, Musoke RN. Neonatal survival of infants less than 2000 grams born at Kenyatta National Hospital. East Afr Med J. 2002;79(2): 77-79. 12. Sen A, Mahalanabis D, Singh AK, Som TK, Bandyopadhyay S. Impact of a district level sick newborn care unit on neonatal mortality rate: 2-year follow-up. J Perinatol. 2009;29(2): 150. 13. Srivastava S, Shetty N. Healthcare-associated infections in neonatal units: Lessons from contrasting worlds. J Hosp Infect. 2007;65(4): 292- 306. 14. Healthcare-associated infections. Centers for Disease Control and Prevention. https://www.cdc.gov/hai/index.html. Accessed December 25, 2017. 15. Gerberding JL. Nosocomial transmission of opportunistic infections. Infect Control Hosp Epidemiol. 1998;19(8): 574-77. 16. Bartlett MS, Vermund SH, Jacobs R, Durant PJ, Shaw MM, Smith JW, et al. Detection of Pneumocystis carinii DNA in air samples: Likely environmental risk to susceptible persons. J Clin Microbiol. 1997;35(10): 2511-13. 17. Maki DG, Alvarado CJ, Hassemer CA, Zilz MA. Relation of the inanimate hospital environment to endemic nosocomial infection. N Engl J Med. 1982;307(25): 1562-66. 18. Pawa AK, Ramji S, Prakash K, Thirupuram S. Neonatal nosocomial infection: Profile and risk factors. Indian Pediatr. 1997;34(4): 297-302. 19. Kamath S, Mallaya S, Shenoy S. Nosocomial infections in neonatal intensive care units: Profile, risk factor assessment and antibiogram. Indian J Pediatr. 2010;77(1): 37-39. 20. Al-Mazroea AH. Incidence and clinical significance of coagulase negative Staphylococci in blood. J Taibah Univ Med Sci. 2009;4(2): 137-47. 21. Sidhu SK, Malhotra S, Devi P, Tuli AK. Significance of coagulase negative Staphylococcus from blood cultures: Persisting problems and partial progress in resource constrained settings. Iran J Microbiol. 2016; 8(6):366-371. 22. Koksal F, Yasar H, Samasti M. Antibiotic resistance patterns of coagulase- negative staphylococcus strains isolated from blood cultures of septicemic patients in Turkey. Microbiol Res. 2009;164(4): 404-410. 23. Gupta AK, Anand NK, Manmohan, Lamba IM, Gupta R, Srivastava L. Role of bacteriological monitoring of the hospital environment and medical equipment in a neonatal intensive care unit. J Hosp Infect. 1991;19(4): 263-271. 24. Brito DVD de, Silva H de A, Oliveira EJ, Arantes A, Abdallah VOS, Jorge MT, et al. Effect of neonatal intensive care unit environment on the incidence of hospital-acquired infection in neonates. J Hosp Infect. 2007; 65(4): 314-318. Canadian Journal of Infection Control | Summer 2018 | Volume 33 | Issue 2 | 106-110 110 Copyright of Canadian Journal of Infection Control is the property of Infection Prevention & Control Canada (IPAC Canada) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.