Hospital-Acquired Infections Under Pay-for-Performance Systems: an Administrative Perspective on Management and Change

Determinants of Healthcare-Associated Infections in King Abdulaziz Specialized Hospital in Taif, Saudi Arabia

BACKGROUND

Healthcare-associated infections (HAIs) represent a significant challenge in hospital settings, contributing to increased morbidity, mortality, and healthcare costs. This study aimed to estimate the prevalence and socio-demographic and clinical determinants of HAIs at the King Abdulaziz Specialized Hospital (KAASH) in Taif, Saudi Arabia.

METHODOLOGY

A hospital-based cross-sectional study was conducted from March 2023 to January 2024 targeting inpatients aged 18 and above in all units and wards. Data were collected using the National Healthcare Safety Network (NHSN) criteria for definitions of surveillance. A structured questionnaire gathered socio-demographic and clinical data from patients or next of kin if the patient was not fully oriented. Descriptive statistics were performed, and analytical methods used included Pearson chi-square test, Pearson correlation, independent t-test, and one-way analysis of variance.

RESULTS

Among 318 participants included in this study, the mean age of participants was 56.44 years, with a slight female predominance (n=164, 51.6%). Hypertension (n=162, 50.9%) and diabetes (n=126, 39.6%) were the most prevalent comorbidities. Pneumonia (n=60, 26.8%) and trauma (n=55, 17.4%) were the leading causes of admission. The two most common HAIs included catheter-associated urinary tract infections (CAUTI) (n=124, 39%) and central line-associated bloodstream infections (CLABSI) (n=74, 23.3%). The primary causative organisms were Klebsiella pneumoniae (n=96, 30.2%) and Acinetobacter baumannii (n=32, 10.1%). The most significant predictors of HAIs were as follows: For CLABSI, risk factors include having three or more comorbidities, fever above 37.8°C, chills or rigors, hypotension, and positive blood culture. For CAUTI, key predictors were urinary tract infection (UTI), positive urine culture, acute pain or swelling of the testes, suprapubic tenderness, visible hematuria, and leukocytosis. Significant predictors of bloodstream infections (BSI) include having a BSI, positive blood culture, chills or rigors, and hypotension. Fever and hypotension increased CLABSI and BSI risk but reduced the CAUTI risk.

CONCLUSION

The study highlights a significant burden of HAIs at the KAASH, with multiple predictors. The findings underscore the need for robust infection control measures and targeted interventions to reduce HAI incidence and improve patient outcomes.

UV Disinfection Robots: A Review

The novel coronavirus (COVID-19) pandemic has completely changed our lives and how we interact with the world. The pandemic has brought about a pressing need to have effective disinfection practices that can be incorporated into daily life. They are needed to limit the spread of infections through surfaces and air, particularly in public settings. Most of the current methods utilize chemical disinfectants, which can be laborious and time-consuming. Ultraviolet (UV) irradiation is a proven and powerful means of disinfection. There has been a rising interest in the implementation of UV disinfection robots by various public institutions, such as hospitals, long-term care homes, airports, and shopping malls. The use of UV-based disinfection robots could make the disinfection process faster and more efficient. The objective of this review is to equip readers with the necessary background on UV disinfection and provide relevant discussion on various aspects of UV robots.

Empiric Usage of “Anti-Pseudomonal” Agents for Hospital-Acquired Urinary Tract Infections

Hospital-acquired urinary tract infection (HAUTI) is one of the most common hospital-acquired infections, and over 80% of HAUTI are catheter-associated (CAUTI). Pseudomonas aeruginosa, as well as other non-glucose fermenting Gram negative organisms (NGFGN, e.g., Acinetobacter baumannii), are frequently covered empirically with “anti-Pseudomonals” being administered for every HAUTI (and CAUTI). However, this common practice was never trialed in controlled settings in order to quantify its efficacy and its potential impacts on hospitalization outcomes. There were 413 patients with HAUTI that were included in this retrospective cohort study (2017–2018), 239 (57.9%) had CAUTI. There were 75 NGFGN infections (18.2% of HAUTI, 22.3% of CAUTI). P. aeruginosa was the most common NGFGN (82%). Despite multiple associations per univariable analysis, recent (3 months) exposure to antibiotics was the only independent predictor for NGFGN HAUTI (OR = 2.4, CI-95% = 1.2–4.8). Patients who received empiric anti-Pseudomonals suffered from worse outcomes, but in multivariable models (one for each outcome), none were independently associated with the empiric administration of anti-Pseudomonals. To conclude, approximately one of every five HAUTI (and CAUTI) are due to NGFGN, which justifies the practice of empiric anti-Pseudomonals for patients with HAUTI (and CAUTI), particularly patients who recently received antibiotics. The practice is not associated with independent deleterious impacts on outcomes.

Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.

Early prediction of central line associated bloodstream infection using machine learning

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are associated with significant morbidity, mortality, and increased healthcare costs. Despite the high prevalence of CLABSIs in the U.S., there are currently no tools to stratify a patient's risk of developing an infection as the result of central line placement. To this end, we have developed and validated a machine learning algorithm (MLA) that can predict a patient's likelihood of developing CLABSI using only electronic health record data in order to provide clinical decision support.

METHODS

We created three machine learning models to retrospectively analyze electronic health record data from 27,619 patient encounters. The models were trained and validated using an 80:20 split for the train and test data. Patients designated as having a central line procedure based on International Statistical Classification of Diseases and Related Health Problems 10 codes were included.

RESULTS

XGBoost was the highest performing MLA out of the three models, obtaining an AUROC of 0.762 for CLABSI risk prediction at 48 hours after the recorded time for central line placement.

CONCLUSIONS

Our results demonstrate that MLAs may be effective clinical decision support tools for assessment of CLABSI risk and should be explored further for this purpose.

Effect of Time of Daily Data Collection on the Calculation of Catheter-associated Urinary Tract Infection Rates

Introduction

According to the National Healthcare Safety Network (NHSN) definitions for Catheter-associated urinary tract infections (CAUTI) rates, determination of the number of urinary catheter days must occur by calculating the number of catheters in place "for each day of the month, at the same time of day" but does not define at what time of day this occurs. The purpose of this review was to determine if a data collection time of 11 am would yield a greater collection of urinary catheter days than that done at midnight.

Methods

During a 20-month period, the number of urinary catheter days was calculated using once-a-day electronic measurements to identify a urinary catheter presence. We used data collected at 11 am and collected at midnight (our historic default) in comparing the calculated urinary catheter days and resultant CAUTI rates.

Results

There were 7,548 patients who had a urinary tract catheter. The number of urinary catheter days captured using the 11 am collection time was 15,425, and using the midnight collection time was 10,234, resulting in a 50.7% increase. The CAUTI rate per 1,000 urinary catheter days calculated using the 11 am collection method was 0.58, and using the midnight collection method was 0.88, a reduced CAUTI rate of 33.6%.

Conclusion

The data collection time can significantly impact the calculation of urinary catheter days and on calculated CAUTI rates. Variations in how healthcare systems define their denominator per current National Healthcare Safety Network policy may result in significant differences in reported rates.

Institutionalizing an interprofessional simulation education program: an organizational case study using a model of strategic change

Initiatives to implement interprofessional simulation education programs (ISEP) often fail due to lack of support, resources from management or proper integration into the organization system. This paper aims to identify factors that ensure the successful implementation of an ISEP. Further, the study explores the potential effects an ISEP can have on organizational processes and culture. The case study describes the implementation process of an ISEP in a non-academic community hospital using interviews, participative observations and archival data over six years. A thematic approach has been used to analyze the data guided by Kotter's 8-step model for organizational change. Strategies for a successful implementation of an ISEP include: 1) make a case for interprofessional simulation-based education (SBE), 2) search for healthcare champions, 3) define where the ISEP will lead the organization, 4) spread the word about interprofessional SBE, 5) ensure that structures, skills and supervisors align with the change effort, 6) win over smaller entities, 7) enable peer feedback and create more change, 8) institutionalize the ISEP. Indicators of how the ISEP impacted hospital culture are presented and discussed. ISEPs - if implemented effectively - provide powerful opportunities to span boundaries between professional groups, foster interprofessional collaboration, and eventually improve patient care.

Virtual infection prevention-The next frontier

The coronavirus disease 2019 (COVID-19) pandemic has resulted in the acceleration of telehealth and remote environments as stakeholders and healthcare systems respond to the threat of this disease. How can infectious diseases and healthcare epidemiology expertise be adapted to support safe care for all?

Evaluation of the National Healthcare Safety Network standardized infection ratio risk adjustment for healthcare-facility-onset Clostridioides difficile infection in intensive care, oncology, and hematopoietic cell transplant units in general acute-care hospitals

OBJECTIVE

To evaluate the National Health Safety Network (NHSN) hospital-onset Clostridioides difficile infection (HO-CDI) standardized infection ratio (SIR) risk adjustment for general acute-care hospitals with large numbers of intensive care unit (ICU), oncology unit, and hematopoietic cell transplant (HCT) patients.

DESIGN

Retrospective cohort study.

SETTING

Eight tertiary-care referral general hospitals in California.

METHODS

We used FY 2016 data and the published 2015 rebaseline NHSN HO-CDI SIR. We compared facility-wide inpatient HO-CDI events and SIRs, with and without ICU data, oncology and/or HCT unit data, and ICU bed adjustment.

RESULTS

For these hospitals, the median unmodified HO-CDI SIR was 1.24 (interquartile range [IQR], 1.15-1.34); 7 hospitals qualified for the highest ICU bed adjustment; 1 hospital received the second highest ICU bed adjustment; and all had oncology-HCT units with no additional adjustment per the NHSN. Removal of ICU data and the ICU bed adjustment decreased HO-CDI events (median, -25%; IQR, -20% to -29%) but increased the SIR at all hospitals (median, 104%; IQR, 90%-105%). Removal of oncology-HCT unit data decreased HO-CDI events (median, -15%; IQR, -14% to -21%) and decreased the SIR at all hospitals (median, -8%; IQR, -4% to -11%).

CONCLUSIONS

For tertiary-care referral hospitals with specialized ICUs and a large number of ICU beds, the ICU bed adjustor functions as a global adjustment in the SIR calculation, accounting for the increased complexity of patients in ICUs and non-ICUs at these facilities. However, the SIR decrease with removal of oncology and HCT unit data, even with the ICU bed adjustment, suggests that an additional adjustment should be considered for oncology and HCT units within general hospitals, perhaps similar to what is done for ICU beds in the current SIR.

The learning hospital: From theory to practice in a hospital infection prevention program

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Impact of a Novel Antimicrobial Surface Coating on Health Care–Associated Infections and Environmental Bioburden at 2 Urban Hospitals

Background

Approximately 1 in 25 people admitted to a hospital in the United States will suffer a health care–associated infection (HAI). Environmental contamination of hospital surfaces contributes to HAI transmission. We investigated the impact of an antimicrobial surface coating on HAIs and environmental bioburdens at 2 urban hospitals.

Methods

A transparent antimicrobial surface coating was applied to patient rooms and common areas in 3 units at each hospital. Longitudinal regression models were used to compare changes in hospital-onset multidrug-resistant organism bloodstream infection (MDRO-BSI) and Clostridium difficile infection (CDI) rates in the 12 months before and after application of the surface coating. Incidence rate ratios (IRRs) were compared for units receiving the surface coating application and for contemporaneous control units. Environmental samples were collected pre- and post-application to identify bacterial colony forming units (CFUs) and the percent of sites positive for select, clinically relevant pathogens.

Results

Across both hospitals, there was a 36% decline in pooled HAIs (combined MDRO-BSIs and CDIs) in units receiving the surface coating application (IRR, 0.64; 95% confidence interval [CI], .44–.91), and no decline in the control units (IRR, 1.20; 95% CI, .92–1.55). Following the surface application, the total bacterial CFUs at Hospitals A and B declined by 79% and 75%, respectively; the percentages of environmental samples positive for clinically relevant pathogens also declined significantly for both hospitals.

Conclusions

Statistically significant reductions in HAIs and environmental bioburdens occurred in the units receiving the antimicrobial surface coating, suggesting the potential for improved patient outcomes and persistent reductions in environmental contamination. Future studies should assess optimal implementation methods and long-term impacts.

Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

PURPOSE OF REVIEW

To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes.

RECENT FINDINGS

HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.