Costs of hospital-acquired infection and transferability of the estimates: a systematic review

Hospital-acquired infection following spinal tumor surgery: A frailty-driven pre-operative risk model

BACKGROUND

Hospital-acquired infection (HAI) after spinal tumor resection surgery contributes to adverse patient outcomes and excess healthcare resource utilization. This study sought to develop a predictive model for HAI occurrence following surgery for spinal tumors.

METHODS

The National Surgical Quality Improvement Program (NSQIP) 2015-2019 database was queried for spinal tumor resections. Baseline demographics and preoperative clinical characteristics, including frailty, were analyzed. Frailty was measured by modified frailty score 5 (mFI-5) and risk analysis index (RAI). Univariate and multivariable analyses were performed to identify independent risk factors for HAI occurrence. A logit-based predictive model for HAI occurrence was designed and discriminative power was assessed via receiver operating characteristic (ROC) analysis.

RESULTS

Of 5883 patients undergoing spinal tumor surgery, HAI occurred in 574 (9.8 %). The HAI (vs. non-HAI) cohort was older and frailer with higher rates of preoperative functional dependence, chronic steroid use, chronic lung disease, coagulopathy, diabetes, hypertension, tobacco smoking, unintentional weight loss, and hypoalbuminemia (all P < 0.05). In multivariable analysis, independent predictors of HAI occurrence included severe frailty (mFI-5, OR: 2.3, 95 % CI: 1.1-5.2, P = 0.035), nonelective surgery (OR: 1.7, 95 % CI: 1.1-2.4, P = 0.007), and hypoalbuminemia (OR: 1.5, 95 % CI: 1.1-2.2, P = 0.027). A logistic regression model with frailty score alongside age, race, BMI, elective vs. non-elective surgery, and pre-operative labs have predicted HAI occurrence with a C-statistic of 0.68 (95 % CI: 0.64-0.72).

CONCLUSIONS

HAI occurrence after spinal tumor surgery can be predicted by standardized frailty metrics, mFI-5 and RAI-rev, alongside routinely measured preoperative characteristics (demographics, comorbidities, pre-operative labs).

Disease-Related Costs Published in The Middle East and North Africa Region: Systematic Review and Analysis of Transferability

BACKGROUND

In the Middle East and North Africa (MENA) the scarcity of local cost data is a key barrier to conducting health economic evaluations. We systematically reviewed reports of disease-related costs from MENA and analysed their transferability within the region.

METHODS

We searched PubMed and included full text English papers that reported disease-related costs from the local populations of Algeria, Bahrain, Egypt, Iraq, Jordan, Saudi Arabia, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Syria, Tunisia, United Arab Emirates and Yemen between 1995 and 2019. Screening, study selection and data extraction were done in duplicate. Study-related variables, costing methods, all costs and their characteristics were extracted and analysed via descriptive methods. From multi-country studies of MENA employing homogenous costing methods, we estimated the ratio (cost transfer coefficient) between the relative differences in direct medical costs and macroeconomic indicators via robust regression. We predicted each cost via the estimated cost transfer formula and evaluated prediction error between true and predicted (transferred) costs.

RESULTS

The search yielded 1646 records, 206 full text papers and 3525 costs from 84 diagnoses. Transferability was analysed involving 144 direct medical costs from eight multi-country studies. Adjusting the average of available foreign costs by 0.28 times the relative difference in GDP per capita provided the most accurate estimates. The correlation between true and predicted costs was 0.96; 68% of predicted costs fell in the true ± 50% range. Predictions were more accurate for costs from studies that involved the largest number of countries, for countries outside the Gulf region and for drug costs versus unit or disease costs.

CONCLUSION

The estimated cost transfer formula allows the prediction of missing costs in MENA if only GDP per capita is available for adjustment to the local setting. Input costs for the formula should be collected from multiple sources and match the decision situation.

Medical Resource Use and Medical Costs for Radiotherapy-Related Adverse Effects: A Systematic Review

Simple Summary

Cancer patients who receive radiotherapy often suffer from adverse effects that require healthcare resources to manage. This study summarized evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and provided recommendations for including this evidence in economic evaluations. Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was overestimated or underestimated.

Abstract

Background: Despite the need for a proper economic evaluation of new radiotherapies, the economic burden of radiotherapy-induced adverse effects remains unclear. A systematic review has been conducted to identify the existing evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and also to provide recommendations for including this evidence in economic evaluations. Methods: This systematic review of healthcare resource use and/or medical costs related to radiotherapy-induced adverse effects was performed up until 2020, focusing on patients with head and neck cancer, brain cancer, prostate cancer, eye cancer and breast cancer. Results: Resource use for treating the same adverse effects varied considerably across studies; for instance, the cost for mucositis ranged from USD 2949 to USD 17,244. This broad range could be related to differences in (1) severity of adverse effects in the study population, (2) study design, (3) cost estimation approach and (4) country and clinical practice. Conclusions: Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was being overestimated or underestimated in economic evaluation for radiotherapy.

Indirectness (transferability) is critical when considering existing economic evaluations for GRADE Clinical Practice Guidelines: A systematic review

OBJECTIVE

GRADE practice guideline developers often perform systematic reviews of potential economic evaluations to inform recommendation decision-making. We aimed to identify indirectness characteristics of economic evaluations, related to GRADE evidence-to-decision (EtD) theoretical frameworks, that influence selection of these articles.

STUDY DESIGN AND SETTING

MEDLINE, EMBASE, CINAHL and EconLit were systematically searched to May 2020 to identify indirectness characteristics relevant for economic evaluation transferability to GRADE evidence-to-decision (EtD) theoretical frameworks. Four reviewers screened citations to identify articles of any type that explored study characteristics most important or relevant to economic evaluation transferability, restricted to English language We generated frequencies of article features, used thematic analysis to summarize study characteristics and assessed certainty in the evidence using GRADE-CERQual.

RESULTS

We included 57 articles, with a dearth of empirical literature - some may have been missed. We identified 8 general themes and 28 sub-themes most important to transferability from 41% of articles. Moderate-to-high confidence evidence suggested that GRADE EtD domains of population, intervention and comparison research question elements, resource use estimation and methodology, and provider and decision-maker acceptability are most important indirectness study characteristics that economists consider when choosing economic evaluation outcomes for use in recommendation decision-making.

CONCLUSION

We have identified factors important for guideline developers to consider when selecting economic evaluations as research evidence. An economic competency on the development team facilitates these endeavors. This supports the GRADE Working Group's tenant of transparent reporting or availability of sufficient information elsewhere to assess indirectness.

Evaluation of the costing methodology of published studies estimating costs of surgical site infections: A systematic review

OBJECTIVES

Surgical site infections (SSIs) are associated with increased length of hospitalization and costs. Epidemiologists and infection control practitioners, who are in charge of implementing infection control measures, have to assess the quality and relevance of the published SSI cost estimates before using them to support their decisions. In this review, we aimed to determine the distribution and trend of analytical methodologies used to estimate cost of SSIs, to evaluate the quality of costing methods and the transparency of cost estimates, and to assess whether researchers were more inclined to use transferable studies.

METHODS

We searched MEDLINE to identify published studies that estimated costs of SSIs from 2007 to March 2021, determined the analytical methodologies, and evaluated transferability of studies based on 2 evaluation axes. We compared the number of citations by transferability axes.

RESULTS

We included 70 studies in our review. Matching and regression analysis represented 83% of analytical methodologies used without change over time. Most studies adopted a hospital perspective, included inpatient costs, and excluded postdischarge costs (borne by patients, caregivers, and community health services). Few studies had high transferability. Studies with high transferability levels were more likely to be cited.

CONCLUSIONS

Most of the studies used methodologies that control for confounding factors to minimize bias. After the article by Fukuda et al, there was no significant improvement in the transferability of published studies; however, transferable studies became more likely to be cited, indicating increased awareness about fundamentals in costing methodologies.

Cost transferability problems in economic evaluation as a framework for an European health care and social costs database

This article presents part of the work within Work Package 3 (WP3) of Impact HTA (Improved methods and actionable tools for enhancing HTA), a H2020 EU-funded research project, intended to enhance and promote collaboration in HTA across EU MS. Amongst other objectives, and in close collaboration with WP4, WP3 addressed setting up a multi-country unit-cost database: the European health care and social costs database (EU HCSCD). The purpose of the database is to facilitate the transference of healthcare economic evaluation analyses across countries, jurisdictions and settings. WP3 concentrates on healthcare costs; WP4 on social costs. This paper discusses the state of the art on this topic, building an appropriate conceptual and theoretical framework for Database development. We conducted a broad, but not systematic, literature and gray-literature review (LR), identifying existing practices and problems, and their implications, described in the Results section. We discuss practical implications and draw important conclusions behind the construction, and future evolution, of this database.

The cost-effectiveness of temporary single-patient rooms to reduce risks of healthcare-associated infection

BACKGROUND

The use of single rooms for patient isolation often forms part of a wider bundle to prevent certain healthcare-associated infections (HAIs) in hospitals. Demand for single rooms often exceeds what is available and the use of temporary isolation rooms may help resolve this. Changes to infection prevention practice should be supported by evidence showing that cost-effectiveness is plausible and likely.

AIM

To perform a cost-effectiveness evaluation of adopting temporary single rooms into UK National Health Service (NHS) hospitals.

METHODS

The cost-effectiveness of a decision to adopt a temporary, single-patient, isolation room to the current infection prevention efforts of an NHS hospital was modelled. Primary outcomes are the expected change to total costs and life-years from an NHS perspective.

FINDINGS

The mean expected incremental cost per life-year gained (LYG) is £5,829. The probability that adoption is cost-effective against a £20,000 threshold per additional LYG is 93%, and for a £13,000 threshold the probability is 87%. The conclusions are robust to scenarios for key model parameters. If a temporary single-patient isolation room reduces risks of HAI by 16.5% then an adoption decision is more likely to be cost-effective than not. Our estimate of the effectiveness reflects guidelines and reasonable assumptions and the theoretical rationale is strong.

CONCLUSION

Despite uncertainties about the effectiveness of temporary isolation rooms for reducing risks of HAI, there is some evidence that an adoption decision is likely to be cost-effective for the NHS setting. Prospective studies will be useful to reduce this source of uncertainty.

Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan

BACKGROUND

Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan.

METHODS

This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases.

RESULTS

VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD.

DISCUSSION

VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy.

CONCLUSIONS

VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.

A critical evaluation of current protocols for self-sterilizing surfaces designed to reduce viral nosocomial infections

BACKGROUND

Biocidal high-touch surfaces contact surfaces can be used to help reduce healthcare-acquired infections (HAIs). While the bactericidal protocols are well developed, there remains high variability in the methods used to evaluate the virucidal properties of such surfaces. This paper seeks to identify the most commonly used methods and critically evaluate the strengths of each method by comparing tests from standard testing organisations and related bactericidal protocols.

METHODS

Three databases and grey literature were queried using a key-word search for relevant articles. Articles were selected if they met the criteria of virucidal properties of self-sterilizing surfaces designed to prevent HAIs. Of the resulting 177 articles, 38 met the inclusion criteria.

RESULTS

The resulting papers varied greatly in their testing methods and recommendations. Further, no standard test adequately meets the needs for specifically testing virucidal properties of self-sterilizing surfaces.

CONCLUSIONS

Studies have shown that temperature and humidity can affect the performance of virucidal touch-surfaces, but no standard protocols were found to test these factors.

Urgent need for standardised guidelines for reporting healthcare costs in ICUs - Results of an integrative review of costing methodologies

OBJECTIVES

Diverse costing methodologies in critical care have produced discrepant results. We aimed to critically review studies addressing critical care patients' costs, to estimate total costs and cost categories and to delineate methodologies used and relevant limitations.

METHODS

Integrative review based on key-word searches of electronic databases targeting primary studies that report estimates of patient cost, in the last 21 years. We assessed the level transparency of reporting and the quality of the studies, by the SIGN tool.

RESULTS

Overall, 12 research articles were included, of which eight studies mentioned the specific approach used to identify the elements of cost. Most studies employed a micro-costing and one study a macro-costing approach. With regard to approaches to valuation of cost components, only one study identified the bottom-up approach. The total patient cost ranged from US$ 487 to US$ 39,300 and human resources was identified as the cost category mostly driving total costs.

CONCLUSIONS

Although valid methodologies to evaluate critical care patients' costs, such as micro-costing, are employed more frequently, a variety of non-standardized methods are still used. There is a pressing need to develop standardised guidelines for reporting of observational studies of cost in healthcare, with particular considerations for critical care.

Cost-Effectiveness of Docetaxel and Paclitaxel for Adjuvant Treatment of Early Breast Cancer: Adaptation of a Model-Based Economic Evaluation From the United Kingdom to South Africa

OBJECTIVES

Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments.

METHODS

A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses.

RESULTS

The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as -R578 and -R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses.

CONCLUSIONS

Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa.

The Attributable Direct Medical Cost of Healthcare Associated Infection Caused by Multidrug Resistance Organisms in 68 Hospitals of China

Healthcare associated infection (HAI) is known to increase the economic burden of patients while the medical cost due to MDRO HAI is even higher. Three hundred eighty-one multidrug resistance organisms (MDROs) healthcare associated infection (HAI) case-patients and three hundred eighty-one matched control-patients were identified between January and December in 2015. The average total hospitalization medical cost of the case group was $6127.65 and that of the control group was $2274.02. The difference between the case group and the control group was statistically significant (t = 21.07; P < 0.01). The attributable cost of MDRO HAI was $3853.63. The direct medical costs due to different MDRO infections were different. The increased medical costs of CR-AB, CR-KP, and CR-PA were significantly higher than that of MRSA, MRSE, ESBL E. coli, and ESBL Kp (P < 0. 05). Among the subitem expenses, the drug cost increased the most (the average cost was $1457.72), followed by the treatment fee and test fee; the differences were statistically significant (P < 0.01).

Heterogeneity of cost estimates in health economic evaluation research. A systematic review of stress urinary incontinence studies

Introduction and hypothesis

There is increased demand for an international overview of cost estimates and insight into the variation affecting these estimates. Understanding of these costs is useful for cost-effectiveness analysis (CEA) research into new treatment modalities and for clinical guideline development.

Methods

A systematic search was conducted in Ovid MEDLINE & other non-indexed materials and Ovid Embase for articles published between 1995 and 2017. The National Health Service Economic Evaluation Database (NHS-EED) filter and the McMaster sensitive therapy filter were combined with a bespoke search strategy for stress urinary incontinence (SUI). We extracted unit cost estimates, assessed variability and methodology, and determined transferability.

Results

We included 37 studies in this review. Four hundred and eighty-two cost estimates from 13 countries worldwide were extracted. Descriptive analysis shows that hospital stay in gynecology ranged between €82 and €1,292 per day. Costs of gynecological consultation range from €30 in France to €158 in Sweden. In the UK, costs are estimated at €228 per hour. Costs of a tension-free vaginal tape (TVT) device range from €431 in Finland to €994 in Canada. TVT surgery per minute costs €25 in France and €82 in Sweden. Total costs of TVT range from €1,224 in Ireland to €5,809 for inpatient care in France. Variation was explored.

Conclusions

Heterogeneity was observed in cost estimates for all units at all levels of health care. CEAs of SUI interventions cannot be interpreted without bias when the base of these analyses—namely costs—cannot be compared and generalized.

Evaluation of economic burden of colonic surgical site infection at a Japanese hospital

BACKGROUND

Several reports have been published regarding cost increases attributable to surgical site infections (SSIs) in Europe and the USA. However, such studies have been limited in Japan.

AIM

To evaluate the economic burden of colorectal SSIs on hospitals in Japan.

METHODS

This study was undertaken at a Japanese university hospital. Amongst 265 patients who had undergone colorectal surgery in the Department of Coloproctological Surgery between November 2014 and March 2016, 16 patients who developed SSIs and could be allocated a diagnosis procedure combination code were selected as SSI cases. Individual SSI cases were matched to non-SSI cases based on a combination of surgical category, age band, sex, wound class, presence of stoma and risk index. Median length of stay (LOS) and piecework reference cost were compared between SSI episodes and non-SSI episodes.

FINDINGS

The median LOS for patients with SSI and without SSI was 25.5 [interquartile range (IQR) 21.5-39.3] and 16.5 (IQR 12.5-18.5) days, respectively (P<0.01). The median piecework reference cost for patients with SSI and without SSI was ¥842,155 (IQR ¥716,423-1,388,968) and ¥575,795 (IQR ¥529,638-680,105), respectively (P<0.01).

CONCLUSION

SSIs led to a significant increase in LOS and economic burden. Although the SSI episodes appear to be more profitable than the non-SSI episodes, the economic profit for SSI episodes was less than that for non-SSI episodes in the observation period, when opportunity costs were taken into account.

Building a Successful Infection Prevention Program: Key Components, Processes, and Economics

Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

Peripheral venous catheter-related bloodstream infection is associated with severe complications and potential death: a retrospective observational study

BACKGROUND

The purpose of this study was to identify the clinical characteristics and outcomes of peripheral vascular catheter-related bloodstream infections (PVC-BSIs) and determine the risk of severe complications or death.

METHODS

We performed a retrospective observational study from June 2010 to April 2015 at two regional university-affiliated hospitals in Tokyo. We studied the clinical manifestations, underlying diseases, laboratory results, treatment methods, recurrence rates, and complications in 62 hospitalized patients diagnosed with PVC-BSIs by positive blood cultures.

RESULTS

The median time from admission to bacteremia was 17 days (range, 3-142 days) and that from catheter insertion to bacteremia diagnosis was 6 days (range, 2-15 days). Catheter insertion sites were in the arm in 48 (77.4%) patients, in the foot in 3 (4.8%) patients, and in an unrecorded location in 11 (17.7%) patients. Additionally, the causative pathogens were Gram-positive microorganisms in 58.0% of cases, Gram-negative microorganisms in 35.8% of cases, Candida spp. in 6.2% of cases, and polymicrobials in 25.8% of cases. Eight (12.9%) patients died within 30 days of their blood culture becoming positive. Patients who died of PVC-BSIs had a higher proportion of Staphylococcus aureus infection than patients who survived (odds ratio, 8.33; p = 0.004).

CONCLUSIONS

PVC-BSIs are a significant cause of health care-associated infection. We observed cases of severe PVC-BSI requiring intensive and long-term care along with lengthy durations of antibiotic treatment due to hematogenous complications, and some patients died. For patients with PVC-BSIs, S. aureus bacteremia remains a major problem that may influence the prognosis.

Review: Antimicrobial efficacy validation using in vitro and in vivo testing methods

Pre-clinical antimicrobial validation testing for single and combination products, and parameters that should be considered when testing the antimicrobial performance of a medical device, are discussed. Guidance is provided on key elements required for in vitro and in vivo antimicrobial validation, including validation of microbial growth, microbial recovery, neutralization, and antimicrobial activity. An important consideration, both in terms of practicality and economics, is designing in vitro studies that bridge to in vivo testing: A representative in vitro model is used to generate data on many clinically relevant microorganisms, and then one microorganism is selected for use in in vivo testing. If the in vivo results correlate to the in vitro results, it can reasonably be extrapolated that the same would be true for the remaining microorganisms tested in vitro. Thus, the selection of relevant in vitro models for testing is critical for successful antimicrobial validation testing.

The additional costs of catheter-related bloodstream infections in intensive care units

PURPOSE

The additional costs of health care-associated infections vary depending on the reimbursement systems of different countries. We estimated the additional costs of central venous catheter-related bloodstream infections (CVC-CRBSI) in Japan, which has a universal health insurance system covering all citizens.

METHODS

We conducted a retrospective matched case-control study. Twenty-two patients with CVC-CRBSI were identified among 2,148 patients treated between October 2011 and May 2014 in the intensive care unit of Tokyo Medical University Hospital (1,015 beds). Twenty-two matched controls were selected on the basis of 5 criteria. The drug and medical material costs and technical fees incurred from the date of catheter insertion until hospital discharge were examined using a fee-for-service system. The additional costs of CVC-CRBSI were calculated as the difference between the costs of cases and controls. The contribution of antimicrobial drugs and the causative microorganism to the additional drug costs were also assessed.

RESULTS

The additional costs of CVC-CRBSI were estimated at $57,090 per case. Antimicrobial agents comprised only about 10% of the additional drug costs. The additional costs of Candida infection were almost twice those of CVC-CRBSI caused by other microorganisms.

CONCLUSIONS

The additional costs of CVC-CRBSI in Japan were estimated at $57,090 per case.

Management of nurse shortage and its impact on pathogen dissemination in the intensive care unit

INTRODUCTION

Studies provide evidence that reduced nurse staffing resources are associated to an increase in health care-associated infections in intensive care units, but tools to assess the contribution of the mechanisms driving these relations are still lacking. We present an agent-based model of pathogen spread that can be used to evaluate the impact on nosocomial risk of alternative management decisions adopted to deal with transitory nurse shortage.

MATERIALS AND METHODS

We constructed a model simulating contact-mediated dissemination of pathogens in an intensive-care unit with explicit staffing where nurse availability could be temporarily reduced while maintaining requisites of patient care. We used the model to explore the impact of alternative management decisions adopted to deal with transitory nurse shortage under different pathogen- and institution-specific scenarios. Three alternative strategies could be adopted: increasing the workload of working nurses, hiring substitute nurses, or transferring patients to other intensive-care units. The impact of these decisions on pathogen spread was examined while varying pathogen transmissibility and severity of nurse shortage.

RESULTS

The model-predicted changes in pathogen prevalence among patients were impacted by management decisions. Simulations showed that increasing nurse workload led to an increase in pathogen spread and that patient transfer could reduce prevalence of pathogens among patients in the intensive-care unit. The outcome of nurse substitution depended on the assumed skills of substitute nurses. Differences between predicted outcomes of each strategy became more evident with increasing transmissibility of the pathogen and with higher rates of nurse shortage.

CONCLUSIONS

Agent-based models with explicit staff management such as the model presented may prove useful to design staff management policies that mitigate the risk of healthcare-associated infections under episodes of increased nurse shortage.

Healthcare-associated infections in gynecology and obstetrics at a university hospital in the Czech Republic

OBJECTIVE

To determine the spectrum of etiology and the incidence of healthcare-associated infections (HAIs) among gynecologic and obstetric patients.

METHODS

In a descriptive survey, data were analyzed from in-patients at the Department of Gynecology and Obstetrics, University Hospital and Faculty of Medicine in Hradec Králové, Czech Republic, between January 2007 and December 2011.

RESULTS

Among 21 937 patients treated during the study period, there were 189 (0.86%) cases of HAI. Gynecologic patients had a higher incidence of HAIs (1.31%) compared with pregnant women (0.60%). The incidence of HAI was 0.13% after laparoscopic surgery, 0.63% after a minor gynecologic intervention, and 3.73% after major surgery. Vaginal delivery (0.36%) represented a low risk of HAI. Compared with vaginal delivery, the incidence of HAI increased twofold for planned cesarean delivery (0.64%), and tenfold for emergency cesarean delivery (3.63%). The majority of causative microorganisms (72.7%) were susceptible to penicillin antibiotics. None of the patients died as a result of HAI.

CONCLUSION

The incidence of HAIs at a university hospital in the Czech Republic was very low. Antibiotic resistance was only a minor problem, and the incidence of multiresistant strains was rare.

Impact of surgical site infections after open and laparoscopic colon and rectal surgeries on postoperative resource consumption

PURPOSE

To estimate the impact of surgical site infection (SSI) on postoperative resource consumption for colon and rectal open and laparoscopic surgeries after accounting for infection depth and patient characteristics, and to compare these estimates among institutions.

METHODS

We collected administrative and SSI-related data from eight Japanese hospitals, and used generalized linear models to estimate excess postoperative length of stay (LOS) and charges attributable to SSI. Covariates included wound class, American Society of Anesthesiologists (ASA) score, operation time, emergency, colostomy, trauma, implant, and comorbidities.

RESULTS

We examined 1,108 colon surgery (CS) and 477 rectal surgery (RS) patients. For open surgery, the postoperative LOS in non-SSI patients was 13.5 (CS) and 15.9 days (RS). Compared with non-SSI patients, the postoperative LOS increased by 4.5 (CS) and 2.8 days (RS) for superficial SSI, 6.8 (CS) and 8.5 days (RS) for deep SSI, and 7.8 and 9.5 days for space/organ SSI. For laparoscopic surgery, the postoperative LOS was 9.8 (CS) and 14.6 days (RS). SSI was significantly associated with increased postoperative LOS for superficial SSI [by 4.8 (CS) and 3.6 days (RS)], deep SSI [by 10.3 (CS) and 23.9 days (RS)], and space/organ SSI [by 8.9 days (RS)]. The postoperative LOS among hospitals was 3.8-10.4 days (CS) and 1.3-12.2 days (RS). Postoperative SSI-attributable charges ranged from $386 to $2,873, depending on organ, procedure, and infection depth.

CONCLUSION

This study quantified the impact of SSIs on resource consumption and confirmed significant cost variations among hospitals. These variations could not be explained by patient characteristics or infection type.