Nosocomial infections, diagnosis-related groups, and study on the efficacy of nosocomial infection control. Economic implications for hospitals under the prospective payment system

Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements

OBJECTIVEThe financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.DESIGNMatched case-control study.SETTINGA large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.PATIENTSAll patients discharged in 2013 and 2014.METHODSUsing electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.RESULTSIn most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (P<.01), while payments increased $1,901 (P<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (P<.01), while payments increased $7,895 (P<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.CONCLUSIONSHospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.Infect Control Hosp Epidemiol 2018;39:509-515.

Multidrug-Resistant Organisms Detected More Than 48 Hours After Hospital Admission Are Not Necessarily Hospital-Acquired

BACKGROUND Infections and colonization with multidrug-resistant organisms (MDROs) identified >48 hours after hospital admission are considered healthcare-acquired according to the definition of the Centers for Disease Control and Prevention (CDC). Some may originate from delayed diagnosis rather than true acquisition in the hospital, potentially diluting the impact of infection control programs. In addition, such infections are not necessarily reimbursed in a healthcare system based on the diagnosis-related groups (DRGs). OBJECTIVE The goal of the study was to estimate the preventable proportion of healthcare-acquired infections in a tertiary care hospital in Switzerland by analyzing patients colonized or infected with MDROs. METHODS All hospitalized patients with healthcare-acquired MDRO infection or colonization (HAMIC) or according to the CDC definition (CDC-HAMIC) were prospectively assessed from 2002 to 2011 to determine whether there was evidence for nosocomial transmission. We utilized an additional work-up with epidemiological, microbiological, and molecular typing data to determine the true preventable proportion of HAMICs. RESULTS Overall, 1,190 cases with infection or colonization with MDROs were analyzed; 274 (23.0%) were classified as CDC-HAMICs. Only 51.8% of CDC-HAMICs had confirmed evidence of hospital-acquisition and were considered preventable. Specifically, 57% of MRSA infections, 83.3% of VRE infections, 43.9% of ESBL infections, and 74.1% of non-ESBL MDRO infections were preventable HAMICs. CONCLUSIONS The CDC definition overestimates the preventable proportion of HAMICs with MDROs by more than 50%. Relying only on the CDC definition of HAMICs may lead to inaccurate measurement of the impact of infection control interventions and to inadequate reimbursement under the DRG system. Infect. Control Hosp. Epidemiol. 2016;1-6.

Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital

BACKGROUND

Although surgical site infections (SSIs) are known to be associated with increased length of stay (LOS) and additional cost, their impact on the profitability of surgical procedures is unknown.

AIM

To determine the clinical and economic burden of SSI over a two-year period and to predict the financial consequences of their elimination.

METHODS

SSI surveillance and Patient Level Information and Costing System (PLICS) datasets for patients who underwent major surgical procedures at Plymouth Hospitals NHS Trust between April 2010 and March 2012 were consolidated. The main outcome measures were the attributable postoperative length of stay (LOS), cost, and impact on the margin differential (profitability) of SSI. A secondary outcome was the predicted financial consequence of eliminating all SSIs.

FINDINGS

The median additional LOS attributable to SSI was 10 days [95% confidence interval (CI): 7-13 days] and a total of 4694 bed-days were lost over the two-year period. The median additional cost attributable to SSI was £5,239 (95% CI: 4,622-6,719) and the aggregate extra cost over the study period was £2,491,424. After calculating the opportunity cost of eliminating all SSIs that had occurred in the two-year period, the combined overall predicted financial benefit of doing so would have been only £694,007. For seven surgical categories, the hospital would have been financially worse off if it had successfully eliminated all SSIs.

CONCLUSION

SSI causes significant clinical and economic burden. Nevertheless the current system of reimbursement provided a financial disincentive to their reduction.

Three methods for estimating days of hospitalization because of hospital-acquired infection: a comparison

OBJECTIVES

The objective of this study is to compare the three methods internationally used for estimating days of hospitalization attributable to hospital infections by applying them to the same population. The methods are: (1) unmatched comparison group; (2) matched control method-based; and (3) Appropriateness Evaluation Protocol method. A study of the prevalence of infections was performed among patients during hospitalization for an ordinary single sampling department. The survey was completed within eight working days between 15 and 24 October 2007. All patients admitted at least 24 hours to the survey day in each department were included in the study, as well as patients discharged/transferred to another hospital or department. During the prevalence study 621 patients were observed, 70 of which with infection (equal to 11.27%).

METHOD

The 70 uninfected patients needed for comparison using method 1 were selected through a procedure based on propensity score on demographic variables and clinical trials of patients. The Shapiro-Wilk test was used to verify the normality of quantitative variables. In comparing the three methods Kruskall-Wallis test was used (alpha = 0.05), while comparisons between pairs of methods were performed with the Mann-Whitney test (alpha = 0.017).

RESULTS

Estimation results of recovery days with infection using the three comparison tests showed that there is a statistically significant difference between the three methods (P = 0.016) and there is a significant difference between 1 versus 3 (P = 0.013) and between 2 and 3 (P = 0.017), whereas between 1 and 2 no difference was found (P = 0.82).

CONCLUSION

In conclusion, the three methods are not showing the same estimations and thus may not be exchangeable.

Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections

BACKGROUND

Limited data describe the sustained impact of hand hygiene programs (HHPs) implemented in teaching hospitals, where the burden of healthcare-associated infections (HAIs) is high. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs.

METHODS AND FINDINGS

A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Compliance was measured by direct observation and the use of hand rub products. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. The economic impact was estimated based on a case-control study in Taiwan. We observed 8,420 opportunities for hand hygiene during the study period. Compliance improved from 43.3% in April 2004 to 95.6% in 2007 (p<.001), and was closely correlated with increased consumption of the alcohol-based hand rub (r = 0.9399). The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate.

CONCLUSIONS

Implementation of a HHP reduces preventable HAIs and is cost effective.

Cost of hospital-acquired infection

The authors assessed the costs of hospital-acquired infections using rigorous econometric methods on publicly available data, controlling for the interdependency of length of stay and the incidence of hospital acquired infection, and estimated the cost shares of different payers. They developed a system of equations involving length of stay, incidence of infection, and the total hospital care cost to be estimated using simultaneous equations system. The main data came from the State of New Jersey UB 92 for 2004, complimented with data from the Annual Survey of Hospitals by the American Hospital Association and the Medicare Cost Report of 2004. The authors estimated that an incidence of hospital acquired infection increases the hospital care cost of a patient by $10,375 and it increases the length of stay by 3.30 days, and that a disproportionately higher portion of the cost is attributable to Medicare. They conclude that reliable cost estimates of hospital-acquired infections can be made using publicly available data. Their estimate shows a much larger aggregate cost of $16.6 billion as opposed to $5 billion reported by the Centers for Disease Control and Prevention but much less than $29 billion as reported elsewhere in the literature.

Malnutrition is an independent factor associated with nosocomial infections

The aim of the present prospective study was to determine if malnutrition, measured using a simple validated score, is an independent risk factor for nosocomial infections (NI) in non-selected hospital in-patients. Between 29 and 31 May 2001, a survey on the prevalence of NI was conducted on all 1637 in-patients (61 (sd 25) years old) in a French university hospital as part of a national survey. Actual and usual body weights were recorded in all in-patients, and serum albumin levels were measured on all blood samples taken during the week before the study. Nutritional status was evaluated by using the nutritional risk index (NRI). Albumin values were obtained in 1084 patients, and complete weight information was obtained in 911. Therefore, NRI was calculated in 630 patients (61 (sd 20) years old): 427 (67·8%) were malnourished. NI prevalence was 8·7%: 4·4% in non-malnourished patients, 7·6% in moderately malnourished patients and 14·6% in severely malnourished patients. In univariate analysis, the odds ratios for NI were 1·46 (95% CI 1·2, 2·1) in moderately malnourished patients and 4·8 (95% CI 4·6, 6·4) in severely malnourished patients. In multivariate analysis, age, immunodeficiency and NRI class influenced NI risk. Vascular and urinary catheters, and surgical intervention, were the extrinsic factors associated with NI, with odds ratios ranging from 2·0 (95% CI 1·8, 2·6) for vascular catheters to 10·8 (95% CI 8·8, 12·6) for association of the three factors. In conclusion, in non-selected hospitalized patients, malnutrition assessed with a simple and objective marker is an independent risk factor for NI. An early screening for malnutrition may therefore be helpful to reduce the high prevalence of NI.

Cost analysis of a hospital-wide selective screening programme for methicillin-resistant Staphylococcus aureus (MRSA) carriers in the context of diagnosis related groups (DRG) payment

The costs of a hospital-wide selective screening programme were analysed for a period of 19 months. During this time, 539 inpatients were screened, of whom 111 were MRSA-positive. Based on microbiological costs (staff and materials) and the costs of preventive contact isolation for 2 days until microbiological results were available (including material costs for medical consumable goods and the costs of additional nursing time), a total of 26,241.51 Euro was spent for the 539 patients screened. Based on cost units, the costs were 39.96 Euro for a patient found to be MRSA-negative and 82.33 Euro for a patient found to be MRSA-positive. Under the prospective diagnosis related groups (DRG) payment system in Germany, the costs of a prolonged hospital stay resulting from a hospital-acquired MRSA infection (HA-MRSA-I) are not reimbursed adequately by revenues, with a calculated average cost-revenue loss/patient with HA-MRSA-I of 5705.75 Euro. The screening programme was able to prevent 48% of predicted HA-MRSA-Is (35.2 patients with infection), thereby saving a predicted 200,782.73 Euro. After subtracting the screening costs, there was a net saving of 110,236.56 Euro annually. A sensitivity analysis of the break-even points for different screening frequencies and different MRSA incidence rates indicated that the screening programme became cost-effective at a low MRSA incidence rate, meaning that it can be recommended for most hospitals with an MRSA problem.

Healthcare workers' hand decontamination practices: compliance with recommended guidelines

AIM

This paper reports a study of healthcare workers' handwashing/hand hygiene practices from a behavioural perspective.

BACKGROUND

Hospital acquired infection poses a very real and serious threat to all who are admitted to hospital. Pathogens are readily transmitted on healthcare workers' hands, and hand hygiene substantially reduces this transmission. Evidence-based guidelines for healthcare workers' hand hygiene practices exist, but compliance with these is internationally low.

METHODS

A quasi-experimental design with a convenient sample was used. The Predisposing, Reinforcing, Enabling Constructs in Educational Diagnosis and Evaluation Health Education Theory was used as the theoretical framework, and the data were collected in 2001. Healthcare workers' handwashing practices (observation of behaviour, n = 314) and their predisposition (attitudes, beliefs and knowledge) towards compliance with hand hygiene guidelines (questionnaire, n = 62) were studied. Nurses, doctors, physiotherapists and care assistants involved in direct patient care in the study unit participated in the study. The interventional hand hygiene programme aimed to predispose healthcare workers to adopt hand hygiene behaviour (poster campaign and educational handout), reinforce (feedback on pretest results) and enable the behaviour (provision of an alcohol hand rub beside each patients bedside).

RESULTS

Implementation of the multifaceted interventional behavioural hand hygiene programme resulted in an overall improvement in compliance with hand hygiene guidelines (51-83%, P < 0.001). Furthermore, healthcare workers believed that their skin condition improved (P < 0.001). An increase in knowledge about handwashing guidelines was also found.

CONCLUSIONS

In order to be effective, efforts to improve compliance with handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients) need to be provided at each patient's bedside. Issues surrounding healthcare workers' skin irritation need to be addressed urgently.

Comparative impact of hospital-acquired infections on medical costs, length of hospital stay and outcome between community hospitals and medical centres

To understand the impact of hospital-acquired infections on mortality and medical costs in modern medical care systems in different healthcare settings, we performed a case-control study at a medical centre and two community hospitals. A total of 144 and 129 adult case-control pairs who received care in a 2000-bed tertiary referral medical centre and two 800-bed community hospitals, respectively, between October 2002 and December 2002 were enrolled. Prolongation of hospital stay, extra costs and complications associated with hospital-acquired infections were analysed. Patients in the medical centre had more severe underlying disease status (P < 0.001), more malignancies (P < 0.001), more multiple episodes of hospital-acquired infection (p = 0.03), and more infections with multidrug-resistant bacteria (P < 0.001) than patients in community hospitals. The additional length of hospital stay and extra costs were similar for patients with hospital-acquired infections in the community hospitals and the medical centre (mean 19.2 days vs. 20.1 days, P = 0.79; mean 5335 US dollars vs. 5058 US dollars, P = 0.83; respectively). The additional length of hospital stay and extra costs in both the medical centre and the community hospitals were not related to the sites of infection or the bacterial pathogens causing hospital-acquired infections, although medical costs attributable to hospital-acquired fungal infections due to Candida spp. were much higher for patients in the medical centre. Prevalence of hospital-acquired-infection-related complications, such as adult respiratory distress syndrome, disseminated intravascular coagulation, organ failure or shock, was similar between the two groups, but patients in the medical centre had a higher mortality rate because of their underlying co-morbidities.

Developing countries have their own characteristic problems with infection control

Infection control in developing countries differs markedly from that in the developed countries. It is important that both local and international authorities take these differences into account when formulating policies for use in developing countries. This review examines these issues and sets out some suggestions for improvements. The advantages of involving local experts in the development of such policies are emphasized.

Three scenarios of clinical claim reimbursement for nosocomial infection: the good, the bad, and the ugly

We studied the extent to which hospitals can expect to receive reimbursement for costs relating to nosocomial infections (NI) under the diagnosis-related groups (DRG) system of clinical claims and calculated the loss of reimbursement due to missed or incorrect registration of infective complications on hospital discharge records (HDR). We calculated clinical claim reimbursement in three scenarios: the good, in which all NI are recorded on HDR; the bad, in which a proportion of NI recorded on HDR observed at the 41 participating hospitals; the ugly, in which none of the NI are recorded on HDR. We analysed in which patients the recording of infective complications changed the DRG clinical claim and the economic consequences on reimbursements. Compared with the ugly scenario, the bad scenario, which is closest to what actually occurs, with only 55.9% of NI (180/322) properly recorded, produced an increased DRG clinical claim in 30 cases, of on average 403 for every NI. Compared with the ugly scenario, the good scenario, produced an increased DRG clinical claim in 45 cases with an average reimbursement of 618. The difference between the bad and the good scenarios shows an average loss of 215 for every case. Our calculated good scenario could cover only 3.8% of direct costs per case attributable to NI. Real, tangible benefits in health, both social and economic, will only accrue from the monitoring and control of NI in hospitals.

Do isolation rooms reduce the rate of nosocomial infections in the pediatric intensive care unit?

PURPOSE

To determine the effect of isolation rooms on the direct spread of nosocomial infections (NIs) owing to cross-colonization in a pediatric intensive care unit (PICU).

MATERIALS AND METHODS

This 6-month comparative clinical study used retrospective data from 1992 (an open single-space unit) and prospective surveillance from 1995 (individual rooms) to assess the effectiveness of the latter design on the control of NIs in critically ill pediatric patients. Patients admitted to the PICU for at least 48 hours underwent a microbiologic survey.

RESULTS

The average number of NIs per patient was higher in 1992 (3.62 +/- 0.7, 78 patients) compared with 1995 (1.87 +/- 0.2, 115 patients). Bacterial NIs were caused by gram-positive cocci (33.3%) and aerobic gram-negative bacilli (66.6%). Fungemia in all cases was caused by Candida albicans. Similarly, length of stay was significantly higher in 1992 compared with 1995 (25 +/- 6 and 11 +/- 6 days, respectively; P <.05). There was a significant reduction of respiratory and urinary tract episodes of NI as well as catheter-related infections in the separate room arrangement.

CONCLUSIONS

Our preliminary analysis suggests a possible beneficial effect of single isolation rooms in reducing NI rate in the PICU. Hence, the influence of room isolation on NIs in pediatric intensive care warrants further investigation.

[Nosocomial bacteremia in the adult patient. Study of associated costs]

OBJECTIVE

Nosocomial infection causes a prolonged hospital stay and an increase in care costs. The objective of this study was to determine the length of stay excess and costs attributable to nosocomial bacteremia.

PATIENTS AND METHODS

Retrospective study of clinical records of 148 patients with nosocomial bacteremia during 1996. A matched case-control study was performed. For matching, the following parameters were used: RDG, year of admission, age 10 years, main diagnosis and number of secondary diagnoses. Costs were determined by excess length of hospital stay and calculating alternative costs.

RESULTS

Matching was obtained for 100 cases (67.5%) and cost estimation was performed. Compared with cases, non-matched cases showed differences regarding significant issues for cost, such as hospital stay ( p = 0.01), number of empirical (p = 0.001) or definitive antibiotics (p = 0.03). The median hospital stay for cases was longer than for controls (35 vs 15.5 days, respectively; p = 0.000). When only survivor case-control pairs were considered (n = 75), cases remained in hospital for a median of 36 vs 15 days for controls (p = 0.000). Hospital stay days attributable to nosocomial bacteremia were 19.5 for all matched and 21 for matched survivor cases. Only 76% of cases had stay days attributable to bacteremia. Significant differences between cases and controls included: the mean total costs of admission (p = 0.000), cost of stay (p = 0.001), pharmaceutical expenses (p = 0.000), and cost of microbiological studies (p = 0.000), laboratory work-up (p = 0.001) and radiological studies (p = 0.000). Hospital stay represented more than 60% of costs, followed by pharmaceutical expenses. Cost differences between bacteremic patients and controls, calculated in function of stay median, was 4.424 euros (p = 0.000) and 4.744 euros (p = 0.000) for alternative costs. Ten cases showed a difference that represented more than half of the total difference.

CONCLUSIONS

Nosocomial bacteremia represent a stay prolongation and a significant economical burden. Hospital stay and pharmaceutical expenses accounted for the most part of the associated costs. The differences in costs obtained with both methods were small. Since not all selected cases were matched, there may be an error in the appreciation of the difference between cases and controls.

Research Priorities Project, year 2000: establishing a direction for infection control and hospital epidemiology

BACKGROUND

The field called "infection control" has expanded beyond hospitals to include many health care locations, some aspects of personnel health, elements of noninfectious complications, and occasionally the epidemiology of other problems that occur in care facilities. A research agenda that addresses these newer segments and provides a framework for answering fundamental questions is essential for the field and for the work of The Research Foundation for Prevention of Complications Associated with Health Care (formerly APIC Research Foundation).

METHODS

We used a multiple-round iterative consensus process (Delphi technique) with 50 experts and a validation round among participants at the 4th Decennial Conference.

RESULTS

The expert panel reduced 102 separate items to 21 high-ranked research priorities. The highest-ranked subject areas involved research to improve compliance with excellent practices, to study antibiotic usage and resistance, to measure the financial impact of complications and value of interventions, to perform surveillance of infectious and noninfectious complications across the spectrum of care delivery, and to study effectiveness of interventions to prevent complications at specific sites. There were differences in education and discipline between the expert panel and the 4th Decennial participants and with respect to ranking some of the individual priorities. Among respondents from outside the United States and Canada, occupational health issues were ranked more highly.

CONCLUSIONS

The research priorities provide a blueprint for future progress and will require a collaborative, multicenter, multinational approach.

Preoperative drug dispensing as predictor of surgical site infection

The system used by the National Nosocomial Infection Surveillance (NNIS) program to measure risk of surgical site infection uses a score of 3 on the American Society of Anesthesiologists (ASA)-physical status scale as a measure of underlying illness. The chronic disease score measures health status as a function of age, sex, and 29 chronic diseases, inferred from dispensing of prescription drugs. We studied the relationship between the chronic disease score and surgical site infection and whether the score can supplement the NNIS risk index. In a retrospective comparison of 191 patients with surgical site infection and 378 uninfected controls, the chronic disease score and ASA score were highly correlated. The chronic disease score improved prediction of infection by the NNIS risk index and augmented the ASA score for risk adjustment.

The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs

OBJECTIVE

To determine mortality, morbidity, and costs attributable to surgical-site infections (SSIs) in the 1990s.

DESIGN

A matched follow-up study of a cohort of patients with SSI, matched one-to-one with patients without SSI.

SETTING

A 415-bed community hospital.

STUDY POPULATION

255 pairs of patients with and without SSI were matched on age, procedure, National Nosocomial Infection Surveillance System risk index, date of surgery, and surgeon.

OUTCOME MEASURES

Mortality, excess length of hospitalization, and extra direct costs attributable to SSI; relative risk for intensive care unit (ICU) admission and for readmission to the hospital.

RESULTS

Of the 255 pairs, 20 infected patients (7.8%) and 9 uninfected patients (3.5%) died during the postoperative hospitalization (relative risk [RR], 2.2; 95% confidence interval [CI95], 1.1-4.5). Seventy-four infected patients (29%) and 46 uninfected patients (18%) required ICU admission (RR, 1.6; CI95, 1.3-2.0). The median length of hospitalization was 11 days for infected patients and 6 days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days (CI95, 5-8 days). The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089 (CI95, $2,139-$4,163). Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge (RR, 5.5; CI95, 4.0-7.7). When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively.

CONCLUSIONS

In the 1990s, patients who develop SSI have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital. Programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals.

Quality and cost impacts: prevention of post-operative clean wound infections

This paper report the effectiveness of a nursing quality assurance program over three years, which demonstrates improvement in the incidence and severity of post-operative clean wound infections and the associated extended length of hospital stay and cost. General surgery categories included cardiovascular, orthopaedic, neurosurgery, kidney, abdominal, mammary and other. Cardiovascular categories included coronary artery bypass graft (CABG), heart transplant, and atrial valve replacement. Hip replacement and total knee replacement procedures were included in the orthopaedic category. Additional length of stay and concomitant hospital costs were calculated. Results show that early reporting of observations and implementation of appropriate treatment will decrease the incidence, severity and associated costs of post-operative clean wound infections.

New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage

BACKGROUND

Nosocomial infections cause significant patient morbidity and mortality. The 2.5 million nosocomial infections that occur each year cost the US healthcare system $5 million to $10 million. Staphylococcus aureus has long been recognized as an important pathogen in human disease and is the most common cause of nosocomial infections.

OBJECTIVE

To describe the epidemiology of S. aureus nosocomial infections that are attributable to patients' endogenous colonization.

DATA SOURCES

Review of the English-language literature and a MEDLINE search (as of September 1997).

DATA SYNTHESIS

The ecologic niche of S. aureus is the anterior nares. The prevalence of S. aureus nasal carriage is approximately 20-25%, but varies among different populations, and is influenced by age, underlying illness, race, certain behaviors, and the environment in which the person lives or works. The link between S. aureus nasal carriage and development of subsequent S. aureus infections has been established in patients on hemodialysis, on continuous ambulatory peritoneal dialysis, and those undergoing surgery. S. aureus nasal carriers have a two-to tenfold increased risk of developing S. aureus surgical site or intravenous catheter infections. Thirty percent of 100% of S. aureus infections are due to endogenous flora and infecting strains were genetically identical to nasal strains. Three treatment strategies may eliminate nasal carriage: locally applied antibiotics or disinfectants, systemic antibiotics, and bacterial interference. Among these strategies, locally applied or systemic antibiotics are most commonly used. Nasal ointments or sprays and oral antibiotics have variable efficacy and their use frequently results in antimicrobial resistance among S. aureus strains. Of the commonly used agents, mupirocin (pseudomonic acid) ointment has been shown to be 97% effective in reducing S. aureus nasal carriage. However, resistance occurs when the ointment has been applied for a prolonged period over large surface areas.

CONCLUSIONS

Given the importance of S. aureus nosocomial infections and the increased risk of S. aureus nasal carriage in patients with nosocomial infections, investigators need to study cost-effective strategies to prevent certain types of nosocomial infections or nosocomial infections that occur in specific settings. One potential strategy is to decrease S. aureus nasal carriage among certain patient populations.

Ventilator-associated pneumonia: clinical significance and implications for nursing

Pneumonia is the second most common nosocomial infection in the United States and the leading cause of death from nosocomial infections. Intubation and mechanical ventilation greatly increase the risk of bacterial pneumonia. Ventilator-associated pneumonia (VAP) occurs in a patient treated with mechanical ventilation, and it is neither present nor developing at the time of intubation; it is a serious problem--with significant morbidity and mortality rates. Aspiration of bacteria from the oropharynx, leakage of contaminated secretions around the endotracheal tube, patient position, and cross-contamination from respiratory equipment and health care providers are important factors in the development of VAP. Nurses caring for patients treated with mechanical ventilation must recognize risk factors and include strategies for reducing these factors as part of their nursing care. This article summarizes the literature related to VAP: its incidence, associated factors, diagnosis, and current therapies, with an emphasis on nursing implications in the care of these patients.

Nosocomial infections in patients having cardiovascular operations: a multivariate analysis of risk factors

A total of 970 adult patients undergoing cardiovascular operations during a 1-year period were eligible for a case-control study on the risk factors for nosocomial infection. Cases were defined as patients in whom a postoperative infection developed. Every case was paired with one uninfected subject. Nosocomial infection occurred in 89 (9.2%) patients. A total of 120 episodes of infection were diagnosed (1.3 episodes per patient). The infection ratio was 12.4%. Surgical site infection was the most common (5.6%), followed by pneumonia (3.2%), urinary tract infection requiring the use of intravenous antibiotics (1.8%), deep surgical site (0.9%), and bacteremia (0.7%). Advanced age, urgent intervention, duration of surgical procedure, blood transfusion, and use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage) were significantly associated with infection in the bivariate analysis. Nosocomial infection resulted in a significant increase in the length of hospital stay. Cases showed an almost fivefold greater risk of death than controls (odds ratio, 4.73; 95% confidence interval, 1.11 to 6.83; p = 0.009). Age older than 65 years, female sex, and mode of surgical intervention were selected in the multivariate analysis for patients undergoing cardiac operations, whereas general anesthesia or assisted ventilation, central venous catheter, and blood transfusion were the variables selected for patients undergoing operation for vascular disorders. In summary, the recognition of risk factors for postoperative infection in patients undergoing cardiovascular surgical procedures may contribute to improve their prognosis and to more organized surveillance and control activities in the hospital environment.

Device-day infection rates - a surveillance component system for intensive care units at Security Forces Hospital, Riyadh, Saudi Arabia

A surveillance component system for Intensive Care Units (ICUs) designed to account for major extrinsic risk factors for nosocomial infections using device days as the denominator has been advocated. A study of the surveillance component system in ICUs was conducted in Security Forces Hospital (SFH), Riyadh, Saudi Arabia, from February 1993 to January 1994 to verify the validity and compare the device-related infection rates with the infection rates based on patient admission and patient days. The standard recommended method was used in data collection. Device-associated infection rates vary by ICU types and device exposure. The surgical ICU (SICU) had the highest pneumonia rate while the pediatric ICU (PICU) had the lowest, being 22.0 and 6.4 per 1000 ventilator days respectively. Bacteremia was highest in the PICU with 20.7/1000 intravascular catheter days. The urinary tract infection rate of 11.4/1000 urinary catheter days was the highest in the medical ICU (MICU). These were statistically significant (P>0.001). The conclusion from the demonstration of these variables is that the use of the surveillance component system gives specific information on the effect of invasive devices in the occurrence of infection related to their use in the various ICUs. It permits the calculation of risk-specific infection rates, being a marker for the unit's invasive practices. Improved handwashing and the wearing of sterile gloves reduced the central intravascular catheter bacteremia rate in PICU from 20.7 to 10.0/1000 catheter days.

A comparison of two skin preps used in cardiac surgical procedures

Postoperative surgical site infections contribute significantly to increased patient morbidity and mortality rates and unnecessary hospital costs. Effective and efficient preoperative patient skin preparation is an important perioperative nursing intervention that decreases the number of wound contaminants and reduces the risks for postoperative surgical site infections. This study examined the effectiveness and time and material costs of two preoperative patient skin prep methods (ie, isopropyl alcohol prep/iodophor-impregnated adhesive drape method, iodophor scrub and paint prep/plain adhesive drape method). The isopropyl alcohol prep/iodophor-impregnated adhesive drape method clinically was as effective as the iodophor scrub and paint prep/plain adhesive drape method, more cost-effective when time and materials were compared, and less cost-effective when materials alone were compared. To make appropriate decisions about the use of preoperative patient skin prep methods, perioperative nurse managers and staff members need to examine and determine whether costs in time or materials have the greater impact on their surgical settings.

Underestimation of surgical site infection rates in obstetrics and gynecology

BACKGROUND

With the increasing volume of same-day operations and shortened hospital stays, it becomes more likely that a significant percentage of surgical site infections will occur after these patients' discharges.

METHODS

To document the true incidence of postdischarge surgical site infection, surveillance was undertaken in a group of obstetric and gynecologic patients. The study consisted of two parts. (1) A questionnaire was mailed to each surgeon, inquiring about clinical evidence of infection. The infection control service continued to do surveillance of wound infection in the usual manner, and the results of the two methods were compared. (2) A questionnaire was provided to patients undergoing operation, inquiring about signs and symptoms of wound infection.

RESULTS

A total of 469 surgical procedures were included, with a total of 24 infections detected (5.2%). Of these, 14 infections (58.3%) were detected by the usual surveillance method. An additional 10 infections (41.7%) were detected after patient discharge by the physician questionnaire. Only two of the 24 infections were detected by the patient questionnaire.

CONCLUSIONS

Failure to include postdischarge surgical site surveillance results in a substantial underestimation of the true surgical site infection rate. Physician input and strong support have prompted a regular biannual postdischarge surgical site surveillance program in this patient population.

Hand washing frequency in an emergency department

STUDY OBJECTIVE

Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one ED and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience.

DESIGN

Observational.

SETTING

ED of an 1,100-bed tertiary referral, central city, private teaching hospital.

PARTICIPANTS

Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study.

INTERVENTIONS

An observer recorded the number of patient contacts and activities for each participant during three-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity.

RESULTS

Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (P < .0001) or resident physicians (P < .0001). Hand washes occurred after 28.4% of 272 clean contacts (SD, 2.34%), which was significantly less (P < .0001) than 50.0% of 46 dirty contacts (SD, 7.4%) and 64.8% of 91 gloved contacts (SD, 5.0%). The number of years of clinical experience was not significantly related to hand-washing frequency (P = .82). Soap and water were used in 126 of the hand washes, and an alcohol preparation was used in the remaining six. The average duration of soap-and-water hand washes was 9.5 seconds.

CONCLUSION

Compliance with hand washing recommendations was low in this ED. Nurses washed their hands significantly more often than either staff physicians or resident physicians, but the average hand-washing duration was less than recommended for all groups. Poor compliance in the ED may be due to the large number of patient contacts, simultaneous management of multiple patients, high illness acuity, and severe time constraints. Strategies for improving compliance with this fundamental method of infection control need to be explored because simple educational interventions have been unsuccessful in other health care settings.

Recent developments in our understanding of sepsis: evaluation of anti-endotoxin antibodies and biological response modifiers

Sepsis and septic shock are among the most frequent life-threatening infectious disease problems encountered in emergency medicine practice. This review summarizes the extensive research into the pathophysiology of sepsis, with emphasis on Gram-negative infection. Particular reference is given to the exogenous and endogenous mediators involved in the sepsis cascade. It also critically evaluates new preparations developed to blunt the actions of the exogenous and endogenous mediators responsible for the clinical manifestations comprising this syndrome. Clinical signs likely to be associated with Gram-negative infection are also reviewed, and guidelines are considered for the potential use of newly developed anti-endotoxin antibodies and other biological response modifiers in the treatment of patients with Gram-negative sepsis.

Postoperative wound infection after total abdominal hysterectomy: a controlled study of the increased duration of hospital stay and trends in postoperative wound infection

BACKGROUND

Total abdominal hysterectomy, a common operative procedure, is infrequently accompanied by incisional wound infection. No recent study has examined the excess hospital stay attributable to such infections.

METHODS

This historical cohort study of cases and matched controls was performed in a tertiary care university hospital.

RESULTS

During the 5-year study period (1985 to 1989), the infection rate was 10.5 per 100 procedures; patients with infection remained hospitalized 3.55 days longer than did matched control patients (p = 0.0025).

CONCLUSION

In this era after the introduction of the diagnosis-related groups for reimbursement, incisional wound infection after total abdominal hysterectomy leads to a significant period of extra hospital stay.

Intraperitoneal administration of leukotriene B4 (LTB4) and omega-guanidino caproic acid methane sulfonate (GCA) increased the survival of mice challenged with methicillin-resistant Staphylococcus aureus (MRSA)

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) very often complicate management of immunocompromised patients. We studied the effect of leukotriene B4 (LTB4) and epsilon-guanidino caproic acid methane sulfonate (GCA), on MRSA infection. Mice fed a 20% casein diet were intraperitoneally administered LTB4, GCA, or saline (control) daily for 30 days. On the 10th day of this treatment, mice were challenged with MRSA. The survival rate in the control group (20%) was significantly lower than the rates in the GCA (60%) and LTB4 (50%) groups, respectively (p < 0.05). There was a significant reduction of MRSA in the spleen and kidney of the survived mice in GCA group as against mice in the LTB4 and saline groups, indicating a better recovery in GCA group than the other groups. The results suggest that intraperitoneal administration of GCA and LTB4 may play a role in host defense mechanism during MRSA infections.

The effects of oral RNA and intraperitoneal nucleoside-nucleotide administration on methicillin-resistant Staphylococcus aureus infection in mice

The effects of oral RNA and intraperitoneal nucleoside-nucleotide mixture administration on methicillin-resistant Staphylococcus aureus (MRSA) strain 8985N infection were studied in mice. BALB/c mice were fed a nucleic acid-free diet or nucleic acid-free diet supplemented with 0.5% or 2.5% ribonucleic acid (RNA) for 30 days. Nucleoside-nucleotide mixture or saline (control) was intraperitoneally administered daily to these rats except for the 2.5% RNA group, which received saline only. On the 10th day of this treatment, the mice were inoculated intravenously with the viable MRSA organisms. Susceptibility to the MRSA was determined by animal survival and recovery of the MRSA from the organs. The survival rates in the three groups that were administered saline were 29%, 35%, and 40% for nucleic acid-free diet, 0.5% RNA, and 2.5% RNA groups, respectively, whereas in the two groups that received the nucleoside-nucleotide mixture the rates were 69% for the nucleic acid-free diet group and 55% for 0.5% RNA group. The susceptibility of the mice to the MRSA challenge was not affected by dietary RNA, which indicates the ineffectiveness of oral RNA. The combined survival rate in the two nucleoside-nucleotide groups (64%) was statistically different (p < .01) from that in the three saline groups (34%). There was a greater reduction in viable organism recovery in the kidney and spleen of the surviving mice that had been administered the nucleoside-nucleotide mixture than in those administered saline.(ABSTRACT TRUNCATED AT 250 WORDS)

Postdischarge surveillance for nosocomial wound infection: a brief review and commentary

Escalating medical care costs during the last decade have resulted in shorter hospital stays and higher volumes of outpatients surgical procedures. As a result, the proportion of nosocomial surgical wound infections manifesting after discharge will increase. We performed a literature review to assess the current state of the art of postdischarge surveillance for nosocomial wound infection. From 20% to 70% of postoperative surgical site infections do not become apparent until after the patient's discharge, resulting in serious underreporting of true rates. Infections in outpatients are not being identified efficiently. Institutions using self-reporting methods report a low validity for these methods. The Centers for Disease Control and the Joint Commission for the Accreditation of Healthcare Organizations currently have no strong guidelines on the subject. Since valid postdischarge surveillance may become a necessity for a quality infection control program, new national recommendations are needed.

Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units

BACKGROUND

Effective hand-washing can prevent nosocomial infections, particularly in high-risk areas of the hospital. There are few clinical studies of the efficacy of specific hand-cleansing agents in preventing the transmission of pathogens from health care workers to patients.

METHODS

For eight months, we conducted a prospective multiple-crossover trial involving 1894 adult patients in three intensive care units (ICUs). In a given month, the ICU used a hand-washing system involving either chlorhexidine, a broad-spectrum antimicrobial agent, or 60 percent isopropyl alcohol with the optional use of a nonmedicated soap; in alternate months the other system was used. Rates of nosocomial infection and hand-washing compliance were monitored prospectively.

RESULTS

When chlorhexidine was used, there were 152 nosocomial infections, as compared with 202 when the combination of alcohol and soap was used (adjusted incidence-density ratio [IDR], 0.73; 95 percent confidence interval, 0.59 to 0.90). The largest reduction with chlorhexidine was in gastrointestinal infections (IDR, 0.19; 95 percent confidence interval, 0.05 to 0.64). When chlorhexidine was available, the rates of nosocomial infection declined in each of the ICUs, and health care workers washed their hands more often than when alcohol and soap were used (relative risk, 1.28; 95 percent confidence interval, 1.02 to 1.60). The total volume of alcohol and soap used was 46 percent that of chlorhexidine (P less than 0.001).

CONCLUSIONS

A hand-disinfection system using an antimicrobial agent (chlorhexidine) reduces the rate of nosocomial infections more effectively than one using alcohol and soap. The improvement may be explained at least in part by better compliance with hand-washing instructions when chlorhexidine was used.

Prolongation of hospital stay and extra costs due to ventilator-associated pneumonia in an intensive care unit

A prospective cohort study was performed to determine the prolongation of stay and the extra costs incurred due to the occurrence of ventilator-associated pneumonia in intensive care unit patients. Over a 16-month period a sample of 270 consecutive adult patients from a large university anesthesiological intensive care unit requiring ventilation therapy for more than 24 hours was analyzed. A matching procedure using multiple control patients without pneumonia per infected patient (= case) was employed. Of 78 cases 21 (26.9%) died and were excluded from the matching procedure as well as 23 (29.5%) for whom suitable controls could not be found. The maximum number of controls per case was five. The mean added stay was calculated to be 10.13 days and the extra costs attributable to the prolongation of stay were 14,253 German Marks (US$8,800) per patient, demonstrating considerable added stay and costs due to ventilator-associated pneumonia acquired during intensive care. However, it should be taken into account that the calculations for excess stay and costs are based on a subset of rather ill patients and thus cannot generally apply to all ventilated patients and that cases were excluded which could not be matched.

National nosocomial infections surveillance system (NNIS): description of surveillance methods

The National Nosocomial Infections Surveillance System (NNIS) is an ongoing collaborative surveillance system sponsored by the Centers for Disease Control (CDC) to obtain national data on nosocomial infections. The CDC uses the data that are reported voluntarily by participating hospitals to estimate the magnitude of the nosocomial infection problem in the United States and to monitor trends in infections and risk factors. Hospitals collect data by prospectively monitoring specific groups of patients for infections with the use of protocols called surveillance components. The surveillance components used by the NNIS are hospitalwide, intensive care unit, high-risk nursery, and surgical patient. Detailed information including demographic characteristics, infections and related risk factors, pathogens and their antimicrobial susceptibilities, and outcome, is collected on each infected patient. Data on risk factors in the population of patients being monitored are also collected; these permit the calculation of risk-specific rates. An infection risk index, which includes the traditional wound class, is being evaluated as a predictor of the likelihood that an infection will develop after an operation. A major goal of the NNIS is to use surveillance data to develop and evaluate strategies to prevent and control nosocomial infections. The data collected with the use of the surveillance components permit the calculation of risk-specific infection rates, which can be used by individual hospitals as well as national health-care planners to set priorities for their infection control programs and to evaluate the effectiveness of their efforts. The NNIS will continue to evolve in finding more effective and efficient ways to assess the influence of patient risk and changes in the financing of health care on the infection rate.

Nosocomial infection surveillance in a vascular surgery unit

An epidemiological nosocomial infection surveillance program was conducted in the Vascular Surgery Unit of Purpan University Hospital, Toulouse, France, involving 389 patients hospitalized between June 1 and November 30, 1988. The methodology and inclusion criteria used were those of the Centers for Disease Control of Atlanta. Twenty-six patients had 30 nosocomial infections according to these criteria, a prevalence of 6.7% and an incidence of 5.6%. These patients were hospitalized for 485 of a total of 4317 days; bed occupation due to infection was 11.23%. Of the 30 infections, the most common were 13 (43.5%) urinary tract infections and six (20%) operative wound infections. E. coli (8 isolates) and Staphylococcus aureus (7 isolates) were the most frequently encountered offending microorganisms. A case-control study showed that mean hospitalization time was increased by 11 days (p less than 0.001) in infected patients and that antibiotics were used four times as often in these patients (p less than 0.001). Urinary tract infection represented 50% of nosocomial infections in our study. The prevalence and incidence of wound infection was 20% and 8%, respectively. Nosocomial infection always occurred in patients already infected or who were debilitated. Nosocomial infections prolonged hospitalization by 57%.

Quality assessment. An emerging component of hospital epidemiology

Amid the national preoccupation for monitoring health care and health care providers, it is argued that quality assurance is basically an epidemiological pursuit. The study of the distribution and determinants of desirable health care--quality assurance--is best illustrated by the efforts of those who have worked to prevent and control the untoward outcomes associated with hospital-acquired infections. As such, infection control is the paradigm for quality assurance, and hospital epidemiology is the discipline best suited to deal with continual need for providing information for health care decisionmakers.

The infection control practitioner: an action plan for the 1990s

Some articles have suggested that to survive in the 1990s an infection control practitioner (ICP) will have to be "smarter, brighter, or gone"--they assume that new initiatives for hospital peer review (utilization review, risk management, antibiotic use review, and quality assurance) soon will swallow up the ICP and the infection control program. This article questions that assumption. It reviews data supporting the continuing need for hospital infection control programs and presents information suggesting that the need for the ICP will increase rather than decline during the 1990s. Four essential characteristics for infection control programs are listed, and skills that make the ICP a valuable resource for other peer review programs are described. Several ways that the ICP can (and must) bring this information to the attention of other hospital personnel are suggested. Such actions help assure recognition of the continuing important role of the ICP and the hospital infection control program in each U.S. hospital and long-term care institution.

Infection prevention and control in the era of the AIDS/HIV epidemic

The chronology of important events in the AIDS/HIV epidemic is presented in Table 2. Nurses are the largest group of health care workers and persons who provide direct care and handle sharp objects regularly. As the number of persons infected with HIV increases and as more infected persons become ill enough to require care, the opportunity for an individual nurse to have contact with an infected person will increase. Because many persons with HIV infection also have Kaposi's sarcoma and other malignancies, some oncology nurses may have more contact with HIV-infected individuals than nurses in general. However, it is well established that the major risk for HIV infection is from puncture injuries, and a number of strategies are available and are being developed to make needle and sharps handling safer. Nurses must take personal responsibility for knowing how to reduce their own risks for exposure to HIV and other infectious agents while keeping in mind the need not to increase risks of nosocomial infections in patients. Thus, all nurses need a comprehensive understanding of the purposes of barriers (eg, gloves, gowns, masks, handwashing, room assignment) and when and how to use them correctly. In addition, all nurses who have contact with blood and body fluids should take responsibility for their own immunity to hepatitis B by obtaining hepatitis B vaccination. By using all of these strategies in combination, many infection risks to nurses and patients will be minimized.

Nosocomial gram-negative bloodstream isolates: a comparison of in vitro antibiotic potency

Nosocomial bloodstream infections add to the morbidity, mortality and length of hospitalization that is attributed to the underlying diseases alone. We have compared the in vitro potency of fifteen antibiotics against 136 isolates from clinically significant nosocomial gram-negative bacteraemias. Ciprofloxacin was the most potent antibiotic and had the broadest spectrum of activity (98% of isolates susceptible, MIC90 range: 0.06-0.5 micrograms ml-1). We subjected all isolates to beta-lactamase induction but antibiotic susceptibility was unaffected by this procedure.

APIC and the 1985 position paper: "Listen to the music"

The Association for Practitioners in Infection Control (APIC), in existence now for 16 years, is still considered to be a relatively young professional organization. During that time its many accomplishments include membership growth to more than 7500 persons, establishment of a national office, annual revenues of more than $700,000, publications of a bimonthly scientific journal, publication of the standard reference work for infection control practice, establishment of the process leading to a certifying examination in infection control, an annual educational conference attended by more than 1000 persons, and increasing recognition by other professional groups, state and federal agencies, and the scientific community as a leading voice that represents professionals involved in infection control practice in the United States. These accomplishments have been due in large part to the dedication and hard work of its members, especially the hundreds of persons who have filled local and national positions of leadership. However, APIC now finds itself at a crossroads; changes in the current health care climate and publication of the results of a national study on the efficacy of infection control practice have contributed to a reassessment of infection control programs and the role and scope of persons involved in the field. The purpose of this editorial is to review the background of our two position papers, to comment on an expanded role of hospital epidemiology, and to examine the response of APIC to our membership in terms of commitments identified in the two papers.