Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates

Hospital-acquired bloodstream infections in patients with cancer: current knowledge and future directions

Patients with cancer experience higher rates of preventable harm from hospital-acquired bloodstream infections (haBSIs) and central-line-associated bloodstream infections (CLABSIs) compared with the general hospital population. The prevention of haBSIs and CLABSIs in patients with cancer is an urgent priority, and requires standardized surveillance and reporting efforts. The application of haBSI and CLABSI definitions, classification systems and surveillance strategies for patients with cancer is complex, and there is wide variation in clinical practice. Existing systems were not designed explicitly for patients with cancer, and have different strengths and weaknesses in the cancer setting. For these reasons, epidemiological estimates of haBSIs and CLABSIs in patients with cancer also require careful interpretation. This complexity can be a barrier to identifying appropriate targets for intervention and reducing preventable harm. This review provides an overview of key concepts and challenges in haBSI surveillance and prevention specific to patients with cancer. In addition, this review summarizes the strengths and weaknesses of commonly used surveillance definitions and denominators in the setting of cancer care; existing surveillance practice; epidemiology of haBSIs and CLABSIs; prevention strategies; and current knowledge gaps. A global collaborative effort to harmonize the surveillance of hospital-acquired infections in patients with cancer would be invaluable to improve the accuracy and utility of existing data, advance efforts to prevent hospital-acquired infections, and improve patient safety.

Reducing the rate of central line-associated bloodstream infections; a quality improvement project

BACKGROUND

The burden of central line-associated bloodstream infections is significant and has negative implications for healthcare, increasing morbidity and mortality risks, increasing inpatient hospital stays, and increasing the cost of hospitalization. Efforts to reduce the incidence of central line-associated bloodstream infections have utilized quality improvement projects that implement, measure, and monitor outcomes. However, variations in location, healthcare organization, patient risks, and practice gaps are key to the success of interventions and approaches. This study aims to evaluate interventions of a quality improvement project on the reduction of central line-associated bloodstream infection rates at a university teaching hospital.

METHODS

This was a retrospective review of a quality improvement project that was implemented using the Plan-Do-Study-Act quality improvement cycle. Active surveillance of processes and outcomes was performed in the critical care areas; compliance to central line care bundles, and central line-associated bloodstream infections. Interrupted time series was used to analyze trends pre and post-intervention and regression modeling to estimate data segments preceding and succeeding the interventions.

RESULTS

There were 350 central line insertions, 3912 catheter days, and 20 central line-associated bloodstream infection events during the intervention period. Compliance with central line care bundles was at 94%. There was a trend in the reduction of central line-associated bloodstream infections by 18% that did not reach statistical significance (p = 0.252).

CONCLUSIONS

Improvement projects to reduce central line-associated bloodstream infections face challenges and complexities associated with implementing interventions in real-world healthcare settings. There is a great need to continuously monitor, evaluate, readjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for non-adherence as keys to achieving desired outcomes.

Systematic review finds risk of bias and applicability concerns for models predicting central line-associated bloodstream infection

OBJECTIVES

To systematically review the risk of bias and applicability of published prediction models for risk of central line-associated bloodstream infection (CLA-BSI) in hospitalized patients.

STUDY DESIGN AND SETTING

Systematic review of literature in PubMed, Embase, Web of Science Core Collection, and Scopus up to July 10, 2023. Two authors independently appraised risk models using CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and assessed their risk of bias and applicability using Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

Sixteen studies were included, describing 37 models. When studies presented multiple algorithms, we focused on the model that was selected as the best by the study authors. Eventually we appraised 19 models, among which 15 were regression models and four machine learning models. All models were at a high risk of bias, primarily due to inappropriate proxy outcomes, predictors that are unavailable at prediction time in clinical practice, inadequate sample size, negligence of missing data, lack of model validation, and absence of calibration assessment. 18 out of 19 models had a high concern for applicability, one model had unclear concern for applicability due to incomplete reporting.

CONCLUSION

We did not identify a prediction model of potential clinical use. There is a pressing need to develop an applicable model for CLA-BSI.

Random variation drives a critical bias in the comparison of healthcare-associated infections

OBJECTIVE

To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals.

DESIGN

A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections.

METHODS

Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS).

RESULTS

Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score.

CONCLUSIONS

SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.

Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia

OBJECTIVE

To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.

DESIGN

HOB preventability rating guide was compared against a reference standard expert panel.

PARTICIPANTS

A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.

METHODS

The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.

RESULTS

Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (κ, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus.

CONCLUSIONS

Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.

Computer Informatics for Infection Control

Computer informatics have the potential to improve infection control outcomes in surveillance, prevention, and public health. Surveillance activities include surveillance of infections, device use, and facility/ward outbreak detection and investigation. Prevention activities include awareness of multidrug-resistant organism carriage on admission, identification of high-risk individuals or populations, reducing device use, and antimicrobial stewardship. Enhanced communication with public health and other health care facilities across networks includes automated electronic communicable disease reporting, syndromic surveillance, and regional outbreak detection. Computerized public health networks may represent the next major evolution in infection control. This article reviews the use of informatics for infection control.

PRAISE: providing a roadmap for automated infection surveillance in Europe

INTRODUCTION

Healthcare-associated infections (HAI) are among the most common adverse events of medical care. Surveillance of HAI is a key component of successful infection prevention programmes. Conventional surveillance - manual chart review - is resource intensive and limited by concerns regarding interrater reliability. This has led to the development and use of automated surveillance (AS). Many AS systems are the product of in-house development efforts and heterogeneous in their design and methods. With this roadmap, the PRAISE network aims to provide guidance on how to move AS from the research setting to large-scale implementation, and how to ensure the delivery of surveillance data that are uniform and useful for improvement of quality of care.

METHODS

The PRAISE network brings together 30 experts from ten European countries. This roadmap is based on the outcome of two workshops, teleconference meetings and review by an independent panel of international experts.

RESULTS

This roadmap focuses on the surveillance of HAI within networks of healthcare facilities for the purpose of comparison, prevention and quality improvement initiatives. The roadmap does the following: discusses the selection of surveillance targets, different organizational and methodologic approaches and their advantages, disadvantages and risks; defines key performance requirements of AS systems and suggestions for their design; provides guidance on successful implementation and maintenance; and discusses areas of future research and training requirements for the infection prevention and related disciplines. The roadmap is supported by accompanying documents regarding the governance and information technology aspects of implementing AS.

CONCLUSIONS

Large-scale implementation of AS requires guidance and coordination within and across surveillance networks. Transitions to large-scale AS entail redevelopment of surveillance methods and their interpretation, intensive dialogue with stakeholders and the investment of considerable resources. This roadmap can be used to guide future steps towards implementation, including designing solutions for AS and practical guidance checklists.

Electronic Measurement of a Clinical Quality Measure for Inpatient Hypoglycemic Events: A Multicenter Validation Study

BACKGROUND

Hypoglycemia related to antidiabetic drugs (ADDs) is important iatrogenic harm in hospitalized patients. Electronic identification of ADD-related hypoglycemia may be an efficient, reliable method to inform quality improvement.

OBJECTIVE

Develop electronic queries of electronic health records for facility-wide and unit-specific inpatient hypoglycemia event rates and validate query findings with manual chart review.

METHODS

Electronic queries were created to associate blood glucose (BG) values with ADD administration and inpatient location in 3 tertiary care hospitals with Patient-Centered Outcomes Research Network (PCORnet) databases. Queries were based on National Quality Forum criteria with hypoglycemia thresholds <40 and <54 mg/dL, and validated using a stratified random sample of 321 BG events. Sensitivity and specificity were calculated with manual chart review as the reference standard.

RESULTS

The sensitivity and specificity of queries for hypoglycemia events were 97.3% [95% confidence interval (CI), 90.5%-99.7%] and 100.0% (95% CI, 92.6%-100.0%), respectively for BG <40 mg/dL, and 97.7% (95% CI, 93.3%-99.5%) and 100.0% (95% CI, 95.3%-100.0%), respectively for <54 mg/dL. The sensitivity and specificity of the query for identifying ADD days were 91.8% (95% CI, 89.2%-94.0%) and 99.0% (95% CI, 97.5%-99.7%). Of 48 events missed by the queries, 37 (77.1%) were due to incomplete identification of insulin administered by infusion. Facility-wide hypoglycemia rates were 0.4%-0.8% (BG <40 mg/dL) and 1.9%-3.0% (BG <54 mg/dL); rates varied by patient care unit.

CONCLUSIONS

Electronic queries can accurately identify inpatient hypoglycemia. Implementation in non-PCORnet-participating facilities should be assessed, with particular attention to patient location and insulin infusions.

Healthcare Associated Infections: An Interoperable Infrastructure for Multidrug Resistant Organism Surveillance

Prevention and surveillance of healthcare associated infections caused by multidrug resistant organisms (MDROs) has been given increasing attention in recent years and is nowadays a major priority for health care systems. The creation of automated regional, national and international surveillance networks plays a key role in this respect. A surveillance system has been designed for the Abruzzo region in Italy, focusing on the monitoring of the MDROs prevalence in patients, on the appropriateness of antibiotic prescription in hospitalized patients and on foreseeable interactions with other networks at national and international level. The system has been designed according to the Service Oriented Architecture (SOA) principles, and Healthcare Service Specification (HSSP) standards and Clinical Document Architecture Release 2 (CDAR2) have been adopted. A description is given with special reference to implementation state, specific design and implementation choices and next foreseeable steps. The first release will be delivered at the Complex Operating Unit of Infectious Diseases of the Local Health Authority of Pescara (Italy).

Designing Surveillance of Healthcare-Associated Infections in the Era of Automation and Reporting Mandates

Surveillance and feedback of infection rates to clinicians and other stakeholders is a cornerstone of healthcare-associated infection (HAI) prevention programs. In addition, HAIs are increasingly included in public reporting and payment mandates. Conventional manual surveillance methods are resource intensive and lack standardization. Developments in information technology have propelled a movement toward the use of standardized and semiautomated methods.When developing automated surveillance systems, several strategies can be chosen with regard to the degree of automation and standardization and the definitions used. Yet, the advantages of highly standardized surveillance may come at the price of decreased clinical relevance and limited preventability. The choice among (automated) surveillance approaches, therefore, should be guided by the intended aim and scale of surveillance (eg, research, in-hospital quality improvement, national surveillance, or pay-for-performance mandates), as this choice dictates subsequent methods, important performance characteristics, and suitability of the data generated for the different applications.

A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error

OBJECTIVE

To establish the reliability of the application of National Health and Safety Network (NHSN) central-line-associated bloodstream infection (CLABSI) criteria within established reporting systems internationally.

DESIGN

Diagnostic-test accuracy systematic review.

METHODS

We conducted a search of Medline, SCOPUS, the Cochrane Library, CINAHL (EbscoHost), and PubMed (NCBI). Cohort studies were eligible for inclusion if they compared publicly reported CLABSI rates and were conducted by independent and expertly trained reviewers using NHSN/Centers for Disease Control (or equivalent) criteria. Two independent reviewers screened, extracted data, and assessed risk of bias using the QUADAS 2 tool. Sensitivity, specificity, negative and positive predictive values were analyzed.

RESULTS

A systematic search identified 1,259 publications; 9 studies were eligible for inclusion (n = 7,160 central lines). Publicly reported CLABSI rates were more likely to be underestimated (7 studies) than overestimated (2 studies). Specificity ranged from 0.70 (95% confidence interval [CI], 0.58-0.81) to 0.99 (95% CI, 0.99-1.00) and sensitivity ranged from 0.42 (95% CI, 0.15-0.72) to 0.88 (95% CI, 0.77-0.95). Four studies, which included a consecutive series of patients (whole cohort), reported CLABSI incidence between 9.8% and 20.9%, and absolute CLABSI rates were underestimated by 3.3%-4.4%. The risk of bias was low to moderate in most included studies.

CONCLUSIONS

Our findings suggest consistent underestimation of true CLABSI incidence within publicly reported rates, weakening the validity and reliability of surveillance measures. Auditing, education, and adequate resource allocation is necessary to ensure that surveillance data are accurate and suitable for benchmarking and quality improvement measures over time.

REGISTRATION

Prospectively registered with International prospective register of systematic reviews (PROSPERO ID CRD42015021989; June 7, 2015). https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID%3dCRD42015021989.

A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.

A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events

The scientific literature indicates that blood culture contamination often leads to inappropriate antimicrobial treatment, adverse patient occurrences, and potential reporting of false-positive central line-associated bloodstream infections. The findings of a national infection prevention survey of blood culture practices and related interventions in hospitals support the need for infection preventionists to expand their participation in the review of topics related to the ordering and collection of blood for culture.

Electronic Surveillance For Catheter-Associated Urinary Tract Infection Using Natural Language Processing

Catheter-associated urinary tract infection (CAUTI) is a common and costly healthcare-associated infection, yet measuring it accurately is challenging and resource-intensive. Electronic surveillance promises to make this task more objective and efficient in an era of new financial and regulatory imperatives, but previous surveillance approaches have used a simplified version of the definition. We applied a complete definition, including subjective elements identified through natural language processing of clinical notes. Through examination of documentation practices, we defined a set of rules that identified positively and negatively asserted symptoms of CAUTI. Our algorithm was developed on a training set of 1421 catheterizedpatients and prospectively validated on 1567 catheterizedpatients. Compared to gold standard chart review, our tool had a sensitivity of 97.1%, specificity of 94.5% PPV of 66.7% and NPV of 99.6% for identifying CAUTI. We discuss sources of error and suggestions for more computable future definitions.

Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review

Surveillance bias may threaten the accuracy of inpatient complication measures. A systematic literature review was conducted to examine whether surveillance bias influences the validity of selected Patient Safety Indicator- and health care associated infection-related measures. Ten venous thromboembolism (VTE) articles were identified: 7 trauma related, 3 postoperative, and 1 central line-associated bloodstream infection (CLABSI) article. Nine VTE articles found positive associations between deep vein thrombosis imaging and VTE diagnoses. Because imaging also may be symptom driven, most studies performed additional analyses to corroborate findings. Six trauma-related and 2 postoperative VTE studies concluded that surveillance bias was present, the latter based on circumstantial evidence. The non-VTE study found a significant positive correlation between surveillance aggressiveness and intensive care unit CLABSI rates. Even considering VTE, relatively little is known about the impact of surveillance bias on inpatient complication measures. Given the implications of misclassifying hospitals on quality, this issue requires further investigation using more direct measurement methods.

Bacterial distributions and prognosis of bloodstream infections in patients with liver cirrhosis

Bloodstream infections (BSIs) are a frequently observed complication in liver cirrhosis patients. This study aimed to investigate the microbiological characteristics and outcomes of BSIs in patients with liver cirrhosis. We retrospectively studied 852 patients with liver cirrhosis who developed a BSI. Patient outcome was evaluated using 30-day mortality and assessed using multivariate stepwise logistic regression analysis. Antibiotic sensitivity of the pathogens was tested. Gram-negative bacteria were responsible for 59.6% of BSIs, and Gram-positive bacteria caused 40.4% of the episodes among liver cirrhosis patients. The bacterial distribution significantly differed between hospital-acquired and community-acquired infections, especially in cases caused by Gram-negative pathogens. The results of the drug sensitivity test suggested that amikacin, cefoperazone/sulbactam, and piperacillin/tazobactam highly suppressed Gram-negative infections, while vancomycin and teicoplanin strongly inhibited Gram-positive BSIs. Liver failure, liver cancer, complications, Child-Pugh grade, septic shock, administration of appropriate antibiotics within 24 h, ICU admission, nosocomial infection, and Gram nature of the bacteria were independent risk factors for 30-day mortality (P < 0.05). The choice of initial empirical antibiotics should be based on the type, severity and origin of infection and on the local epidemiological data on antibiotic resistance. Accurate evaluation of risk factors for mortality may improve appropriate therapeutic choice.

Prevention of Vascular Catheter-Related Bloodstream Infections

Catheter-related bloodstream infections (CRBSI) are responsible for significant morbidity, mortality, and excess health care costs. It is increasingly evident that many CRBSI can be prevented with current knowledge and techniques. Preventive measures can be broadly grouped into clinical practice-based interventions and technologic innovations. Clinical practice-based interventions require changes in human behavior and can be subdivided into interventions before and at the time of insertion and postinsertion. Despite recent successes with prevention of CRBSI, pertinent questions regarding pathogenesis and prevention remain unanswered and work on improved surveillance, devices less prone to infection, and more effective prevention techniques are needed.

Assessment of the accuracy and consistency in the application of standardized surveillance definitions: A summary of the American Journal of Infection Control and National Healthcare Safety Network case studies, 2010-2016

BACKGROUND

The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance definitions are the most widely used criteria for health care-associated infection (HAI) surveillance. NHSN participants agree to conduct surveillance in accordance with the NHSN protocol and criteria. To assess the application of these standardized surveillance specifications and offer infection preventionists (IPs) opportunities for ongoing education, a series of case studies, with questions related to NHSN definitions and criteria were published.

METHODS

Beginning in 2010, case studies with multiple-choice questions based on standard surveillance criteria and protocols were written and published in the American Journal of Infection Control with a link to an online survey. Participants anonymously submitted their responses before receiving the correct answers.

RESULTS

The 22 case studies had 7,950 respondents who provided 27,790 responses to 75 questions during the first 6 years. Correct responses were selected 62.5% of the time (17,376 out of 27,290), but ranged widely (16%-87%). In a subset analysis, 93% of participants self-identified as IPs (3,387 out of 3,640), 4.5% were public health professionals (163 out of 3,640), and 2.5% were physicians (90 out of 3,640). IPs responded correctly (62%) more often than physicians (55%) (P = .006).

CONCLUSIONS

Among a cohort of voluntary participants, accurate application of surveillance criteria to case studies was suboptimal, highlighting the need for continuing education, competency development, and auditing.

National Automated Surveillance of Hospital-Acquired Bacteremia in Denmark Using a Computer Algorithm

BACKGROUND In 2015, Denmark launched an automated surveillance system for hospital-acquired infections, the Hospital-Acquired Infections Database (HAIBA). OBJECTIVE To describe the algorithm used in HAIBA, to determine its concordance with point prevalence surveys (PPSs), and to present trends for hospital-acquired bacteremia SETTING Private and public hospitals in Denmark METHODS A hospital-acquired bacteremia case was defined as at least 1 positive blood culture with at least 1 pathogen (bacterium or fungus) taken between 48 hours after admission and 48 hours after discharge, using the Danish Microbiology Database and the Danish National Patient Registry. PPSs performed in 2012 and 2013 were used for comparison. RESULTS National trends showed an increase in HA bacteremia cases between 2010 and 2014. Incidence was higher for men than women (9.6 vs 5.4 per 10,000 risk days) and was highest for those aged 61-80 years (9.5 per 10,000 risk days). The median daily prevalence was 3.1% (range, 2.1%-4.7%). Regional incidence varied from 6.1 to 8.1 per 10,000 risk days. The microorganisms identified were typical for HA bacteremia. Comparison of HAIBA with PPS showed a sensitivity of 36% and a specificity of 99%. HAIBA was less sensitive for patients in hematology departments and intensive care units. Excluding these departments improved the sensitivity of HAIBA to 44%. CONCLUSIONS Although the estimated sensitivity of HAIBA compared with PPS is low, a PPS is not a gold standard. Given the many advantages of automated surveillance, HAIBA allows monitoring of HA bacteremia across the healthcare system, supports prioritizing preventive measures, and holds promise for evaluating interventions. Infect Control Hosp Epidemiol 2017;38:559-566.

Quantifying Antimicrobial Exposure: Hazards in Populations With End-Stage Renal Disease

Using a rigorously collected data set of antimicrobial use among patients receiving chronic hemodialysis, antimicrobial use was calculated using 3 different methodologies: daily defined dose, days of therapy, and start-stop days. Estimates of antimicrobial use varied by as much as 10-fold, depending on the type of antimicrobial. Infect Control Hosp Epidemiol 2017;38:360-363.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Performance characteristics and associated outcomes for an automated surveillance tool for bloodstream infection

BACKGROUND

The objective of this study was to evaluate performance metrics and associated patient outcomes of an automated surveillance system, the blood Nosocomial Infection Marker (NIM).

METHODS

We reviewed records of 237 patients with and 36,927 patients without blood NIM using the National Healthcare Safety Network (NHSN) definition for laboratory-confirmed bloodstream infection (BSI) as the gold standard. We matched cases with noncases by propensity score and estimated attributable mortality and cost of NHSN-reportable central line-associated bloodstream infections (CLABSIs) and non-NHSN-reportable BSIs.

RESULTS

For patients with central lines (CL), the blood NIM had 73.2% positive predictive value (PPV), 99.9% negative predictive value (NPV), 89.2% sensitivity, and 99.7% specificity. For all patients regardless of CL status, the blood NIM had 53.6% PPV, 99.9% NPV, 84.0% sensitivity, and 99.9% specificity. For CLABSI cases compared with noncases, mortality was 17.5% versus 9.4% (P = .098), and median charge was $143,935 (interquartile range [IQR], $89,794-$257,447) versus $115,267 (IQR, $74,937-$173,053) (P < .01). For non-NHSN-reportable BSI cases compared with noncases, mortality was 23.6% versus 6.7% (P < .0001), and median charge was $86,927 (IQR, $54,728-$156,669) versus $62,929 (IQR, $36,743-$115,693) (P < .0001).

CONCLUSIONS

The NIM is an effective screening tool for BSI. Both NHSN-reportable and nonreportable BSI cases were associated with increased mortality and cost.

Magnet® Hospital Recognition Linked to Lower Central Line-Associated Bloodstream Infection Rates

Central-line-associated bloodstream infections (CLABSI) are among the deadliest heathcare-associated infections, with an estimated 12-25% mortality rate. In 2014, the Centers for Medicare and Medicaid Services (CMS) began to penalize hospitals for poor performance with respect to selected hospital-acquired conditions, including CLABSI. A structural factor associated with high-quality nursing care and better patient outcomes is The Magnet Recognition Program®. The purpose of this study was to explore the relationship between Magnet status and hospital CLABSI rates. We used propensity score matching to match Magnet and non-Magnet hospitals with similar hospital characteristics. In a matched sample of 291 Magnet hospitals and 291 non-Magnet hospitals, logistic regression models were used to examine whether there was a link between Magnet status and CLABSI rates. Both before and after matching, Magnet hospital status was associated with better (lower than the national average) CLABSI rates (OR = 1.60, 95%CI: 1.10, 2.33 after matching). While established programs such as Magnet recognition are consistently correlated with high-quality nursing work environments and positive patient outcomes, additional research is needed to determine whether Magnet designation produces positive patient outcomes or rewards existing excellence.

Necessary Infrastructure of Infection Prevention and Healthcare Epidemiology Programs: A Review

The scope of a healthcare institution's infection prevention and control/healthcare epidemiology program (IPC/HE) should be driven by the size and complexity of the patient population served, that population's risk for healthcare-associated infection (HAI), and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following: ∙ Surveillance.∙ Performance improvement to reduce HAI ∙ Acute event response, including outbreak investigation ∙ Education and training of both healthcare personnel and patients ∙ Reporting of HAI to the Centers for Disease Control and Prevention's National Healthcare Safety Network as well as entities required by law.

A national Infection in Critical Care Quality Improvement Programme for England: A survey of stakeholder priorities and preferences

INTRODUCTION

Severe infection is one of the most common causes of critical illness. Healthcare-associated infections complicating critical illness bring the additional challenge of multidrug resistance. However, England lacks a national surveillance system for infections in intensive care units. Prior experience with surveillance systems suggests that they are most effective when placed within a collaborative quality improvement framework.

METHOD

A national survey of adult, paediatric and neonatal intensive care doctors, nurses, microbiologists and infection control practitioners was undertaken throughout the UK to determine stakeholder engagement.

RESULTS

Of 763 respondents (80% ICU physicians; 8% nurses) from 158 hospital Trusts across the UK, 721 (94.4%) supported establishing a surveillance system; 63.5% preferred that data collection be mandatory; 47.5% considered that the work should be undertaken within existing resources. Respondents prioritised catheter-associated and multidrug resistant infections. Free-text responses demonstrated strong support for using the data for epidemiological information and benchmarking for quality improvement.

DISCUSSION

The survey provides a satisfactory foundation for establishing a national surveillance system for infection prevention and control in critical care in England.

A Multicenter Longitudinal Study of Hospital-Onset Bacteremia: Time for a New Quality Outcome Measure?

BACKGROUND

Central-line-associated bloodstream infection (CLABSI) rate is an important quality measure, but it suffers from subjectivity and interrater variability, and decreasing national CLABSI rates may compromise its power to discriminate between hospitals. This study evaluates hospital-onset bacteremia (HOB, ie, any positive blood culture obtained 48 hours post admission) as a healthcare-associated infection-related outcome measure by assessing the association between HOB and CLABSI rates and comparing the power of each to discriminate quality among intensive care units (ICUs).

METHODS

In this multicenter study, ICUs provided monthly CLABSI and HOB rates for 2012 and 2013. A Poisson regression model was used to assess the association between these 2 rates. We compared the power of each measure to discriminate between ICUs using standardized infection ratios (SIRs) with 95% confidence intervals (CIs). A measure was defined as having greater power to discriminate if more of the SIRs (with surrounding CIs) were different from 1.

RESULTS

In 80 ICUs from 16 hospitals in the United States and Canada, a total of 663 CLABSIs, 475,420 central line days, 11,280 HOBs, and 966,757 patient days were reported. An absolute change in HOB of 1 per 1,000 patient days was associated with a 2.5% change in CLABSI rate (P<.001). Among the 80 ICUs, 20 (25%) had a CLABSI SIR and 60 (75%) had an HOB SIR that was different from 1 (P<.001).

CONCLUSION

Change in HOB rate is strongly associated with change in CLABSI rate and has greater power to discriminate between ICU performances. Consideration should be given to using HOB to replace CLABSI as an outcome measure in infection prevention quality assessments.

Data requirements for electronic surveillance of healthcare-associated infections

Electronic surveillance for healthcare-associated infections (HAIs) is increasingly widespread. This is driven by multiple factors: a greater burden on hospitals to provide surveillance data to state and national agencies, financial pressures to be more efficient with HAI surveillance, the desire for more objective comparisons between healthcare facilities, and the increasing amount of patient data available electronically. Optimal implementation of electronic surveillance requires that specific information be available to the surveillance systems. This white paper reviews different approaches to electronic surveillance, discusses the specific data elements required for performing surveillance, and considers important issues of data validation.

Probabilistic Measurement of Central Line–Associated Bloodstream Infections

OBJECTIVE

To develop a probabilistic method for measuring central line–associated bloodstream infection (CLABSI) rates that reduces the variability associated with traditional, manual methods of applying CLABSI surveillance definitions.

DESIGN

Multicenter retrospective cohort study of bacteremia episodes among patients hospitalized in adult patient-care units; the study evaluated presence of CLABSI.

SETTING

Hospitals that used SafetySurveillor software system (Premier) and who also reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN).

PATIENTS

Patients were identified from a stratified sample from all eligible blood culture isolates from all eligible hospital units to generate a final set with an equal distribution (ie, 20%) from each unit type. Units were divided a priori into 5 major groups: medical intensive care unit, surgical intensive care unit, medical-surgical intensive care unit, hematology unit, or general medical wards.

INTERVENTIONS

Episodes were reviewed by 2 experts, and a selection of discordant reviews were re-reviewed. Data were joined with NHSN data for hospitals for in-plan months. A predictive model was created; model performance was assessed using the c statistic in a validation set and comparison with NHSN reported rates for in-plan months.

RESULTS

A final model was created with predictors of CLABSI. The c statistic for the final model was 0.75 (0.68–0.80). Rates from regression modeling correlated better with expert review than NHSN-reported rates.

CONCLUSIONS

The use of a regression model based on the clinical characteristics of the bacteremia outperformed traditional infection preventionist surveillance compared with an expert-derived reference standard.

Infect. Control Hosp. Epidemiol. 2016;37(2):149–155

Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections

BACKGROUND

A literature search was conducted using keywords for articles published in English from January 1990 to March 2015. Using criteria related to blood culture collection and handling, the search yielded 101 articles. References used also included Microbiology Laboratory standards, guidelines, and textbook information.

RESULTS

The literature identified diverse and complex issues surrounding blood culture practices, including the impact of false-positive results, laboratory definition of contamination, effect on central line-associated bloodstream infection (CLABSI) reporting, indications for collecting blood cultures, drawing from venipuncture sites versus intravascular catheters, selection of antiseptics, use of needleless connectors, inoculation of blood culture bottles, and optimizing program management in emergency departments, education, and implementation of bundled practice initiatives.

CONCLUSION

Hospitals should optimize best practice in the collection, handling, and management of blood culture specimens, an often overlooked but essential component in providing optimal care of patients in all settings and populations, reducing financial burdens, and increasing the accuracy of reportable CLABSI. Although universal concepts exist in blood culture practices, some issues require further research to determine benefit. Institutions undertaking a review of their blood culture programs are encouraged to use a checklist that addresses elements that encompass the research contained in this review.

Validation of an automated surveillance approach for drain-related meningitis: a multicenter study

OBJECTIVE Manual surveillance of healthcare-associated infections is cumbersome and vulnerable to subjective interpretation. Automated systems are under development to improve efficiency and reliability of surveillance, for example by selecting high-risk patients requiring manual chart review. In this study, we aimed to validate a previously developed multivariable prediction modeling approach for detecting drain-related meningitis (DRM) in neurosurgical patients and to assess its merits compared to conventional methods of automated surveillance. METHODS Prospective cohort study in 3 hospitals assessing the accuracy and efficiency of 2 automated surveillance methods for detecting DRM, the multivariable prediction model and a classification algorithm, using manual chart review as the reference standard. All 3 methods of surveillance were performed independently. Patients receiving cerebrospinal fluid drains were included (2012-2013), except children, and patients deceased within 24 hours or with pre-existing meningitis. Data required by automated surveillance methods were extracted from routine care clinical data warehouses. RESULTS In total, DRM occurred in 37 of 366 external cerebrospinal fluid drainage episodes (12.3/1000 drain days at risk). The multivariable prediction model had good discriminatory power (area under the ROC curve 0.91-1.00 by hospital), had adequate overall calibration, and could identify high-risk patients requiring manual confirmation with 97.3% sensitivity and 52.2% positive predictive value, decreasing the workload for manual surveillance by 81%. The multivariable approach was more efficient than classification algorithms in 2 of 3 hospitals. CONCLUSIONS Automated surveillance of DRM using a multivariable prediction model in multiple hospitals considerably reduced the burden for manual chart review at near-perfect sensitivity.

Data elements and validation methods used for electronic surveillance of health care-associated infections: a systematic review

BACKGROUND

We describe the primary data sources, data elements, and validation methods currently used in electronic surveillance systems (ESS) for identification and surveillance of health care-associated infections (HAIs), and compares these data elements and validation methods with recommended standards.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed and manual search was conducted to identify research articles describing ESS for identification and surveillance of HAIs published January 1, 2009-August 31, 2014. Selected articles were evaluated to determine what data elements and validation methods were included.

RESULTS

Among the 509 articles identified in the original literature search, 30 met the inclusion criteria. Whereas the majority of studies (83%) used recommended data sources and validated the numerator (80%), only 10% of studies performed external and internal validation. In addition, there was variation in the ESS data formats used.

CONCLUSIONS

Our findings suggest that the majority of ESS for HAI surveillance use standard definitions, but the lack of widespread internal data, denominator, and external validation in these systems reduces the reliability of their findings. Additionally, advanced programming skills are required to create, implement, and maintain these systems and to reduce the variability in data formats.

Slow adoption of automated infection prevention surveillance: are human factors contributing?

Although automated surveillance technology has been evolving for decades, adoption of these technologies is in a nascent state. The current trajectory of public reporting, continued emergence of multidrug-resistant organisms, and mandated antimicrobial stewardship initiatives will result in an increased surveillance workload for ICPs. The use of traditional surveillance methods will be inefficient in meeting the demands for more data and are potentially flawed by subjective interpretation. An examination is offered of the slow adoption of automated surveillance technology from a system perspective with the inherent ambiguities that may operate within the ICP work structure. Formal qualitative research is needed to assess the human factors associated with lack of acceptance of automated surveillance systems. Identification of these factors will allow the National Healthcare Safety Network and professional organizations to offer educational programs and mentoring to the ICP community that target knowledge deficits and the embedded culture that embraces the status quo. With the current focus on fully electronic surveillance systems that perform surveillance in its entirety without case review, effective use of the data will be dependent on ICP skills and their understanding of the strengths and limitations of output from algorithmic detection models.

An electronic surveillance tool for catheter-associated urinary tract infection in intensive care units

BACKGROUND

Traditional methods of surveillance of catheter-associated urinary tract infections (CAUTIs) are error-prone and resource-intensive. To resolve these issues, we developed a highly sensitive electronic surveillance tool.

OBJECTIVE

To develop an electronic surveillance tool for CAUTIs and assess its performance.

METHODS

The study was conducted at a 947-bed tertiary care center. Patients included adults aged ≥18 years admitted to an intensive care unit between January 10 and June 30, 2012, with an indwelling urinary catheter during their admission. We identified CAUTIs using 4 methods: traditional surveillance (TS) (ie, manual chart review by ICPs), an electronic surveillance (ES) tool, augmented electronic surveillance (AES) (ie, ES with chart review on a subset of cases), and reference standard (RS) (ie, a subset of CAUTIs originally ascertained by TS or ES, confirmed by review). We assessed performance characteristics to RS for reviewed cases.

RESULTS

We identified 417 candidate CAUTIs in 308 patients; 175 (42.0%) of these candidate CAUTIs were selected for review, yielding 32 confirmed CAUTIs in 22 patients (RS). Compared with RS, the sensitivities of TS, ES, and AES were 43.8% (95% confidence interval [CI], 26.4%-62.3%), 100.0% (95% CI, 89.1%-100.0%), and 100.0% (95% CI, 89.1%-100.0%). Specificities were 82.5% (95% CI, 75.3%-88.4%), 2.8% (95% CI, 0.8%-7.0%), and 100.0% (95% CI, 97.5%-100.0%).

CONCLUSIONS

Electronic CAUTI surveillance offers a streamlined approach to improve reliability and resource burden of surveillance.

Introduction of software tools for epidemiological surveillance in infection control in Colombia

INTRODUCTION

Healthcare-Associated Infections (HAI) are a challenge for patient safety in the hospitals. Infection control committees (ICC) should follow CDC definitions when monitoring HAI. The handmade method of epidemiological surveillance (ES) may affect the sensitivity and specificity of the monitoring system, while electronic surveillance can improve the performance, quality and traceability of recorded information.

OBJECTIVE

To assess the implementation of a strategy for electronic surveillance of HAI, Bacterial Resistance and Antimicrobial Consumption by the ICC of 23 high-complexity clinics and hospitals in Colombia, during the period 2012-2013.

METHODS

An observational study evaluating the introduction of electronic tools in the ICC was performed; we evaluated the structure and operation of the ICC, the degree of incorporation of the software HAI Solutions and the adherence to record the required information.

RESULTS

Thirty-eight percent of hospitals (8/23) had active surveillance strategies with standard criteria of the CDC, and 87% of institutions adhered to the module of identification of cases using the HAI Solutions software. In contrast, compliance with the diligence of the risk factors for device-associated HAIs was 33%.

CONCLUSIONS

The introduction of ES could achieve greater adherence to a model of active surveillance, standardized and prospective, helping to improve the validity and quality of the recorded information.

Accuracy of using automated methods for detecting adverse events from electronic health record data: a research protocol

Background

Adverse events are associated with significant morbidity, mortality and cost in hospitalized patients. Measuring adverse events is necessary for quality improvement, but current detection methods are inaccurate, untimely and expensive. The advent of electronic health records and the development of automated methods for encoding and classifying electronic narrative data, such as natural language processing, offer an opportunity to identify potentially better methods. The objective of this study is to determine the accuracy of using automated methods for detecting three highly prevalent adverse events: a) hospital-acquired pneumonia, b) catheter-associated bloodstream infections, and c) in-hospital falls.

Methods/design

This validation study will be conducted at two large Canadian academic health centres: the McGill University Health Centre (MUHC) and The Ottawa Hospital (TOH). The study population consists of all medical, surgical and intensive care unit patients admitted to these centres between 2008 and 2014. An automated detection algorithm will be developed and validated for each of the three adverse events using electronic data extracted from multiple clinical databases. A random sample of MUHC patients will be used to develop the automated detection algorithms (cohort 1, development set). The accuracy of these algorithms will be assessed using chart review as the reference standard. Then, receiver operating characteristic curves will be used to identify optimal cut points for each of the data sources. Multivariate logistic regression and the areas under curve (AUC) will be used to identify the optimal combination of data sources that maximize the accuracy of adverse event detection. The most accurate algorithms will then be validated on a second random sample of MUHC patients (cohort 1, validation set), and accuracy will be measured using chart review as the reference standard. The most accurate algorithms validated at the MUHC will then be applied to TOH data (cohort 2), and their accuracy will be assessed using a reference standard assessment of the medical chart.

Discussion

There is a need for more accurate, timely and efficient measures of adverse events in acute care hospitals. This is a critical requirement for evaluating the effectiveness of preventive interventions and for tracking progress in patient safety through time.

Primary bacteraemia is associated with a higher mortality risk compared with pulmonary and intra-abdominal infections in patients with sepsis: a prospective observational cohort study

OBJECTIVE

To investigate whether common infection foci (pulmonary, intra-abdominal and primary bacteraemia) are associated with variations in mortality risk in patients with sepsis.

DESIGN

Prospective, observational cohort study.

SETTING

Three surgical intensive care units (ICUs) at a university medical centre.

PARTICIPANTS

A total of 327 adult Caucasian patients with sepsis originating from pulmonary, intra-abdominal and primary bacteraemia participated in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The patients were followed for 90 days and mortality risk was recorded as the primary outcome variable. To monitor organ failure, sepsis-related organ failure assessment (Sequential Organ Failure Assessment, SOFA) scores were evaluated at the onset of sepsis and throughout the observational period as secondary outcome variables.

RESULTS

A total of 327 critically ill patients with sepsis were enrolled in this study. Kaplan-Meier survival analysis showed that the 90-day mortality risk was significantly higher among patients with primary bacteraemia than among those with pulmonary and intra-abdominal foci (58%, 35% and 32%, respectively; p=0.0208). To exclude the effects of several baseline variables, we performed multivariate Cox regression analysis. Primary bacteraemia remained a significant covariate for mortality in the multivariate analysis (HR 2.10; 95% CI 1.14 to 3.86; p=0.0166). During their stay in the ICU, the patients with primary bacteraemia presented significantly higher SOFA scores than those of the patients with pulmonary and intra-abdominal infection foci (8.5±4.7, 7.3±3.4 and 5.8±3.5, respectively). Patients with primary bacteraemia presented higher SOFA-renal score compared with the patients with other infection foci (1.6±1.4, 0.8±1.1 and 0.7±1.0, respectively); the patients with primary bacteraemia required significantly more renal replacement therapy than the patients in the other groups (29%, 11% and 12%, respectively).

CONCLUSIONS

These results indicate that patients with sepsis with primary bacteraemia present a higher mortality risk compared with patients with sepsis of pulmonary or intra-abdominal origins. These results should be assessed in patients with sepsis in larger, independent cohorts.

The Efficacy of Daily Bathing with Chlorhexidine for Reducing Healthcare-Associated Bloodstream Infections: A Meta-analysis

Design.

Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies to assess the efficacy of daily bathing with chlorhexidine (CHG) for prevention of healthcare-associated bloodstream infections (BSIs).

Setting.

Medical, surgical, trauma, and combined medical-surgical intensive care units (ICUs) and long-term acute care hospitals.

Participants.

Inpatients.

Methods.

Data on patient population, diagnostic criteria for BSIs, form and concentration of topical CHG, incidence of BSIs, and study design were extracted.

Results.

One randomized controlled trial and 11 nonrandomized controlled trials reporting a total of 137,392 patient-days met the inclusion criteria; 291 patients in the CHG arm developed a BSI over 67,775 patient-days, compared with 557 patients in the control arm over 69,617 catheter-days. CHG bathing resulted in a reduced incidence of BSIs: the pooled odds ratio using a random-effects model was 0.44 (95% confidence interval, 0.33–0.59; P< .00001). Statistical heterogeneity was moderate, with an I2 of 58%. For the subgroup of studies that examined central line–associated BSIs, the odds ratio was 0.40 (95% confidence interval, 0.27–0.59).

Conclusions.

Daily bathing with CHG reduced the incidence of BSIs, including central line-associated BSIs, among patients in the medical ICU. Further studies are recommended to determine the optimal frequency, method of application, and concentration of CHG as well as the comparative effectiveness of this strategy relative to other preventive measures available for reducing BSIs. Future studies should also examine the efficacy of daily CHG bathing in non-ICU populations at risk for BSI.

Infect Control Hosp Epidemiol 2012;33(3):257-267

Diagnosing and Reporting of Central Line–Associated Bloodstream Infections

Background.

The diagnosis of central line-associated bloodstream infections (CLABSIs) is often controversial, and existing guidelines differ in important ways.

Objective.

To determine both the range of practices involved in obtaining blood culture samples and how central line-associated infections are diagnosed and to obtain members' opinions regarding the process of designating bloodstream infections as publicly reportable CLABSIs.

Design.

Electronic and paper 11-question survey of infectious-diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).

Participants.

All 1,364 IDSA EIN members were invited to participate.

Results.

692 (51%) members responded; 52% of respondents with adult practices reported that more than half of the blood culture samples for intensive care unit (ICU) patients with central lines were drawn through existing lines. A sizable majority of respondents used time to positivity, differential time to positivity when paired blood cultures are used, and quantitative culture of catheter tips when diagnosing CLABSI or determining the source of that bacteremia. When determining whether a bacteremia met the reportable CLABSI definition, a majority used a decision method that involved clinical judgment.

Conclusions.

Our survey documents a strong preference for drawing 1 set of blood culture samples from a peripheral line and 1 from the central line when evaluating fever in an ICU patient, as recommended by IDSA guidelines and in contrast to current Centers for Disease Control and Prevention recommendations. Our data show substantial variability when infectious-diseases physicians were asked to determine whether bloodstream infections were primary bacteremias, and therefore subject to public reporting by National Healthcare Safety Network guidelines, or secondary bacteremias, which are not reportable.