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Rosa R, Jimenez A, Andrews D, Dinh H, Parra K, Martinez O, Abbo LM. Impact of In-house Candida auris Polymerase Chain Reaction Screening on Admission on the Incidence Rates of Surveillance and Blood Cultures With C. auris and Associated Cost Savings. Open Forum Infect Dis 2023; 10:ofad567. [PMID: 38023537 PMCID: PMC10665036 DOI: 10.1093/ofid/ofad567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background The impact of strategies for rapid diagnostic screening of Candida auris on hospital operations has not been previously characterized. We describe the implementation of in-house polymerase chain reaction (PCR) testing on admission for screening of colonization with C. auris, associated process improvements, and financial impact. Methods This study was conducted across an integrated health system. Patients were tested based on risk factors for C. auris carriage. Pre-intervention, the PCR was sent out to a reference laboratory, and postintervention was performed in-house. Changes in the incidence rates (IRs) of C. auris present on admission (CA-POA) and C. auris hospital-onset fungemia (CA-HOF) were assessed using interrupted time series analysis. The economic impact on isolation and testing costs was calculated. Results Postintervention, the IR of CA-POA doubled (IRR, 2.57; 95% CI, 1.16-5.69; P = .02) compared with the pre-intervention period. The baseline rate of CA-HOF was increasing monthly by 14% (95% CI, 1.05-1.24; P = .002) pre-intervention, while during the postintervention period there was a change in slope with a monthly decrease in IR of 13% (95% CI, 0.80-0.99; P = .02). The median turnaround time (TAT) of the results (interquartile range) was reduced from 11 (8-14) days to 2 (1-3) days. Savings were estimated to be between $772 513.10 and $3 730 480.26. Conclusions By performing in-house PCR for screening of C. auris colonization on admission, we found a doubling of CA-POA rates, a subsequent decrease in CA-HOF rates, reduced TAT for PCR results, and more efficient use of infection control measures. In-house testing was cost-effective in a setting of relatively high prevalence among individuals with known risk factors.
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Affiliation(s)
- Rossana Rosa
- Department of Infection Prevention, Jackson Health System, Miami, Florida, USA
| | - Adriana Jimenez
- Department of Infection Prevention, Jackson Health System, Miami, Florida, USA
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
| | - David Andrews
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Huy Dinh
- Microbiology section, Department of Pathology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Katiuska Parra
- Microbiology section, Department of Pathology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Octavio Martinez
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Microbiology section, Department of Pathology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Lilian M Abbo
- Department of Infection Prevention, Jackson Health System, Miami, Florida, USA
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Unnewehr M, Meyer-Oschatz F, Friederichs H, Windisch W, Schaaf B. Clinical and imaging factors that can predict contagiousness of pulmonary tuberculosis. BMC Pulm Med 2023; 23:328. [PMID: 37674138 PMCID: PMC10481505 DOI: 10.1186/s12890-023-02617-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Knowledge on predicting pulmonary tuberculosis (PTB) contagiosity in the hospital admission setting is limited. The objective was to assess clinical and radiological criteria to predict PTB contagiosity. METHODS Retrospective analysis of 7 clinical, 4 chest X-ray (CXR) and 5 computed tomography (CT) signs in 299 PTB patients admitted to an urban tertiary hospital from 2008 to 2016. If the acid fact bacilli stain was positive (AFB+) on admission, the case was considered high contagiosity. RESULTS Best predictors for high PTB contagiosity (AFB+) were haemoptysis (OR 4.33), cough (3.00), weight loss (2.96), cavitation in CT (2.75), cavitation in CXR (2.55), tree-in-bud-sign in CT (2.12), German residency of the patient (1.89), and abnormal auscultation findings (1.83). A previous TB infection reduced the risk of contagiosity statistically (0.40). Radiographic infiltrates, miliary picture, and pleural effusion were not helpful in predicting high or low contagiosity. 34% of all patients were clinically asymptomatic (20% of the highly contagious group, 50% of the low contagious group). CONCLUSION Haemoptysis, cough and weight loss as well as cavitation and tree-in-bud sign in CXR/CT can be helpful to predict PTB contagiosity and to improve PTB management.
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Affiliation(s)
- Markus Unnewehr
- Faculty of Health, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
- Department of Respiratory Medicine, Infectious Diseases, Sleep Medicine, St. Barbara-Klinik, Am Heessener Wald 1, 59073, Hamm, Germany.
- Department of Respiratory Medicine, Infectious Diseases, Intensive Care Medicine, Klinikum Dortmund, Münsterstraße 240, 44145, Dortmund, Germany.
| | - Florian Meyer-Oschatz
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine, Bundeswehrzentralkrankenhaus Koblenz, Rübenacher Straße 170, 56072, Koblenz, Germany
- Faculty of Medicine, Universität Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Hendrik Friederichs
- Medical Education Research Group, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Wolfram Windisch
- Faculty of Health, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Ostmerheimer Str. 200, 51109, Köln, Germany
| | - Bernhard Schaaf
- Faculty of Health, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
- Department of Respiratory Medicine, Infectious Diseases, Intensive Care Medicine, Klinikum Dortmund, Münsterstraße 240, 44145, Dortmund, Germany
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Hagiya H, Otsuka F. Increased evidence for no benefit of contact precautions in preventing extended-spectrum β-lactamases-producing Enterobacteriaceae: Systematic scoping review. Am J Infect Control 2023; 51:1056-1062. [PMID: 36736903 DOI: 10.1016/j.ajic.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Extended-spectrum β-lactamases-producing Enterobacteriaceae (ESBL-E) is a critical antimicrobial resistance pathogen, to which we need to pay the greatest attention. This study was aimed at uncovering the present evidence for the preventive effectiveness of contact precautions for patients colonized or infected with ESBL-E. METHODS According to the Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews, we searched MEDLINE for articles with relevant keywords from the beginning of 2010 to October 18, 2022. RESULTS Of the 355 articles found, 9, including 8 observational studies and 1 randomized controlled trial, were selected. Safety of discontinuing contact precautions was evaluated mainly in acute-care and long-term care hospitals. Consistently, all authors concluded that contact precautions can be safely discontinued in patients colonized or infected with ESBL-E. CONCLUSION The clinical impact of discontinuing contact precautions for patients with ESBL-E is minimal and can be safely withdrawn at acute, noncritical, adult care wards. Relevant data from pediatric and geriatric wards, as well as intensive care units, were insufficient and should be investigated in future research.
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Affiliation(s)
- Hideharu Hagiya
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan.
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan
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Doolan CP, Sahragard B, Leal J, Sharma A, Kim J, Spackman E, Hollis A, Pillai DR. Clostridioides difficile Near-Patient Testing Versus Centralized Testing: A Pragmatic Cluster Randomized Crossover Trial. Clin Infect Dis 2023; 76:1911-1918. [PMID: 36718646 PMCID: PMC10249988 DOI: 10.1093/cid/ciad046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Management of suspected Clostridioides difficile infection (CDI) in the hospital setting typically results in patient isolation, laboratory testing, infection control, and presumptive treatment. We investigated whether implementation of rapid near-patient testing (NPT) reduced patient isolation time, hospital length of stay (LOS), antibiotic usage, and cost. METHODS A 2-period pragmatic cluster randomized crossover trial was conducted. Thirty-nine wards were randomized into 2 study arms. The primary outcome measure was effect of NPT on patient isolation time using a mixed-effects generalized linear regression model. Secondary outcomes examined were hospital LOS and antibiotic therapy based on a negative binomial regression model. Natural experiment (NE), intention-to-treat (ITT), and per-protocol (PP) analyses were conducted. RESULTS During the entire study period, a total of 656 patients received NPT for CDI and 1667 received standard-of-care testing. For the primary outcome, a significant decrease of patient isolation time with NPT was observed (NE, 9.4 hours [P < .01]; ITT, 2.3 hours [P < .05]; PP, 6.7 hours [P < .1]). A significant reduction in hospital LOS was observed with NPT for short stay (NE, 47.4% [P < .01]; ITT, 18.4% [P < .01]; PP, 34.2% [P < .01]). Each additional hour delay for a negative result increased metronidazole use (24 defined daily doses per 1000 patients; P < .05) and non-CDI-treating antibiotics by 70.13 mg (P < .01). NPT was found to save 25.48 US dollars per patient when including test cost to the laboratory and patient isolation in the hospital. CONCLUSIONS This pragmatic cluster randomized crossover trial demonstrated that implementation of CDI NPT can contribute to significant reductions in isolation time, hospital LOS, antibiotic usage, and healthcare cost. Clinical Trials Registration. NCT03857464.
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Affiliation(s)
- Cody P Doolan
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Alberta, Canada
| | - Babak Sahragard
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jenine Leal
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Anuj Sharma
- Ephicacy Canada Inc., Toronto, Ontario, Canada
| | - Joseph Kim
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eldon Spackman
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Aidan Hollis
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Dylan R Pillai
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Calgary, Alberta, Canada
- Department Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada
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Vuichard-Gysin D, Nueesch R, Fuerer RL, Dangel M, Widmer A. Measuring perception of mental well-being in patients under isolation precautions: a prospective comparative study. BMJ Open 2022; 12:e044639. [PMID: 35314467 PMCID: PMC8938694 DOI: 10.1136/bmjopen-2020-044639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Isolation precautions (IP) are applied to prevent transmission of pathogens in healthcare settings. Potential negative health outcomes experienced by patients have been previously described but results remain conflicting. We aimed at evaluating the psychological impact of IP in adult patients in isolation using a novel psychological assessment tool. STUDY DESIGN Prospective matched cohort study. SETTING Tertiary care centre in Switzerland. PARTICIPANTS Hospitalised patients under IP and non-isolated patients were matched by ward, age and illness severity. OUTCOME MEASURES We measured surrogates of mental and social well-being by using the Pictorial Representation of Illness and Self Measure (PRISM) instrument once during hospitalisation. PRISM is a visual psychometric instrument that has been validated as a quantitative measure of suffering. Smaller distance in self-to-illness separation (SIS) signifies higher importance for a patient. RESULTS 156 patients agreed to participate of which 63 were under IP and 93 were matched controls. Median (IQR) duration of isolation was 5 days (2-10). The median SIS (IQR) for perceived inferior nurses' care was 22.8 (18.5-24.3) and 23.8 (23.3-25.5) for isolated and non-isolated patients, respectively (p<0.001). Similarly, median SIS (IQR) was significantly smaller in isolated than non-isolated patients for avoidance by visitors with 17.5 (7.7-22.0) and 22.2 (21.8-22.6), for loneliness with 7.5 (3.6-16.0) and 18 (10.2-21.6) and for feeling impure with 19 (17.0-21.5) and 21.5 (18.9-22.1), respectively (all p values<0.05). CONCLUSIONS IP to prevent transmission of pathogens may negatively impact mental and social well-being. Measures to alleviate adverse effects of IP should be taken routinely.
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Affiliation(s)
- Danielle Vuichard-Gysin
- Internal Medicine, Spital Thurgau AG, Muensterlingen, Switzerland
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Reto Nueesch
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
- Internal Medicine, Schwyz Hospital, Schwyz, Switzerland
| | | | - Marc Dangel
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Andreas Widmer
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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O’Driscoll V, Georgescu I, Koo I, Arthur R, Chuang R, Dempsey JA, De Franco G, Jones CA. Reducing day 3 baseline monitoring bloodwork and ultrasound for patients undergoing timed intercourse and intrauterine insemination treatment cycles. FERTILITY RESEARCH AND PRACTICE 2021; 7:11. [PMID: 33931123 PMCID: PMC8085474 DOI: 10.1186/s40738-021-00102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the current context of a global pandemic it is imperative for fertility clinics to consider the necessity of individual tests and eliminate those that have limited utility and may impose unnecessary risk of exposure. The purpose of this study was to implement and evaluate a multi-modal quality improvement (QI) strategy to promote resource stewardship by reducing routine day 3 (d3) bloodwork and transvaginal ultrasound (TVUS) for patients undergoing intrauterine insemination (IUI) and timed intercourse (IC) treatment cycles. METHODS After literature review, clinic stakeholders at an academic fertility centre met to discuss d3 testing utility and factors contributing to d3 bloodwork/TVUS in IC/IUI treatment cycles. Consensus was reached that it was unnecessary in patients taking oral/no medications. The primary intervention changed the default setting on the electronic order set to exclude d3 testing for IC/IUI cycles with oral/no medications. Exceptions required active test selection. Protocols were updated and education sessions were held. The main outcome measure was the proportion of cycles receiving d3 bloodwork/TVUS during the 8-week post-intervention period compared with the 8-week pre-intervention period. Balancing measures included provider satisfaction, pregnancy rates, and incidence of cycle cancellation. RESULTS A significant reduction in the proportion of cycles receiving d3 TVUS (57.2% vs 20.8%, p < 0.001) and ≥ 1 blood test (58.6% vs 22.8%, p < 0.001) was observed post-intervention. There was no significant difference in cycle cancellation or pregnancy rates pre- and post-intervention (p = 0.86). Treatment with medications, cyst history, prescribing physician, and treatment centre were associated with receiving d3 bloodwork/TVUS. 74% of providers were satisfied with the intervention. CONCLUSION A significant reduction in IC/IUI treatment cycles that received d3 bloodwork/TVUS was achieved without measured negative treatment impacts. During a pandemic, eliminating routine d3 bloodwork/TVUS represents a safe way to reduce monitoring appointments and exposure.
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Affiliation(s)
- Victoria O’Driscoll
- University of Toronto, Undergraduate Medical Education, 1 King’s College Circle, Room 3157, Toronto, ON M5S 1A8 Canada
- University of Toronto, Institute of Health Policy, Management, and Evaluation, 155 College Street, 4th floor, Toronto, ON M5T 3M6 Canada
| | - Ilinca Georgescu
- Schulich School of Medicine & Dentistry, Western University, 1151 Richmond Street, London, ON N6A 5C1 Canada
| | - Irene Koo
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward Street, Suite 1200, Toronto, ON M5G 1E2 Canada
- Mount Sinai Fertility, Sinai Health System, 250 Dundas Street West, Suite 700, Toronto, ON M5T 2Z5 Canada
| | - Rebecca Arthur
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward Street, Suite 1200, Toronto, ON M5G 1E2 Canada
- Mount Sinai Fertility, Sinai Health System, 250 Dundas Street West, Suite 700, Toronto, ON M5T 2Z5 Canada
| | - Rita Chuang
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward Street, Suite 1200, Toronto, ON M5G 1E2 Canada
| | - Jillian Ann Dempsey
- Mount Sinai Fertility, Sinai Health System, 250 Dundas Street West, Suite 700, Toronto, ON M5T 2Z5 Canada
| | - Giulia De Franco
- Mount Sinai Fertility, Sinai Health System, 250 Dundas Street West, Suite 700, Toronto, ON M5T 2Z5 Canada
| | - Claire Ann Jones
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward Street, Suite 1200, Toronto, ON M5G 1E2 Canada
- Mount Sinai Fertility, Sinai Health System, 250 Dundas Street West, Suite 700, Toronto, ON M5T 2Z5 Canada
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Kaul K, Singh K, Sabatini L, Konchak C, McElvania E, Larkin P, Lindgren R, Sutherland C, Granchalek G, Herrada A, Murray B, Charles EM, Dugad P, Livschiz E. The Value and Institutional Impact of an In-System Laboratory Testing During the COVID-19 Pandemic. Acad Pathol 2021; 8:23742895211010253. [PMID: 33997276 PMCID: PMC8107259 DOI: 10.1177/23742895211010253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 01/21/2023] Open
Abstract
In-system clinical laboratories have proven themselves to be a fundamentally important resource to their institutions during the COVID-19 pandemic of the past year. The ability to provide SARS-CoV-2 molecular testing to our hospital system allowed us to offer the best possible care to our patients, and to support neighboring hospitals and nursing homes. In-house testing led to significant revenue enhancement to the laboratory and institution, and attracted new patients to the system. Timely testing of inpatients allowed the majority who did not have COVID-19 infection to be removed from respiratory and contact isolation, conserving valuable personal protective equipment and staff resources at a time that both were in short supply. As 2020 evolved and our institution restarted delivery of routine care, the availability of in-system laboratory testing to deliver both accurate and timely results was absolutely critical. In this article, we attempt to demonstrate the value and impact of an in-system laboratory during the COVID-19 pandemic. A strong in-house laboratory service was absolutely critical to institutional operational and financial success during 2020, and will ensure resiliency in the future as well.
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Affiliation(s)
- Karen Kaul
- NorthShore University Health System, Evanston, IL, USA
| | | | | | - Chad Konchak
- NorthShore University Health System, Evanston, IL, USA
| | | | - Paige Larkin
- NorthShore University Health System, Evanston, IL, USA
| | | | | | | | | | - Brian Murray
- NorthShore University Health System, Evanston, IL, USA
| | | | - Priya Dugad
- NorthShore University Health System, Evanston, IL, USA
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Ben-David D, Masarwa S, Fallach N, Temkin E, Solter E, Carmeli Y, Schwaber MJ. National Policy for Carbapenem-Resistant Enterobacteriaceae (CRE) Clearance and Discontinuation of Contact Precautions for CRE Carriers in Post-Acute Care Hospitals in Israel: Impact on Isolation-Days and New Acquisitions. Clin Infect Dis 2021; 72:829-835. [PMID: 32034414 DOI: 10.1093/cid/ciaa123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2009, the Israeli Ministry of Health implemented in post-acute care hospitals (PACHs) a process of discontinuing carbapenem-resistant Enterobacteriaceae (CRE) carrier status. We evaluated the policy's impact on isolation-days, CRE prevalence among known carriers who had completed clearance testing, and CRE acquisition among noncarriers. METHODS This retrospective study summarized findings from all 15 PACHs in 2009-2017. CRE carriers were considered cleared and removed from contact isolation after 2 rectal cultures negative for CRE and polymerase chain reaction negative for carbapenemases. Data sources included routine surveillance and 4 point prevalence surveys conducted from 2011 to 2017. RESULTS During the study period, 887 of 6101 CRE carriers (14.5%) completed clearance testing. From 2013 to 2016, the percentage of patient-days in CRE isolation decreased from 9.4% to 3.9% (P = .008). In all surveys combined, there were 819 known CRE carriers; 411 (50%) had completed clearance testing. Of these, 11.4% (47/411) were CRE positive in the survey. At the ward level, the median percentage of patients with no CRE history who were positive on survey decreased from 11.3% in 2011 to 0% in 2017 (P < .001). We found no ward-level correlation between the proportion of carriers who completed clearance and new acquisitions (ρ = 0.02, P = .86). CONCLUSIONS A process for discontinuing CRE carrier status in PACHs led to a significant reduction in the percentage of patient-days in contact isolation without increasing CRE acquisitions among noncarriers.
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Affiliation(s)
- Debby Ben-David
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Samira Masarwa
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Noga Fallach
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Elizabeth Temkin
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Ester Solter
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mitchell J Schwaber
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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van Dijk MD, Voor In 't Holt AF, Polinder S, Severin JA, Vos MC. The daily direct costs of isolating patients identified with highly resistant micro-organisms in a non-outbreak setting. J Hosp Infect 2020; 109:88-95. [PMID: 33359899 DOI: 10.1016/j.jhin.2020.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Isolation precautions are recommended when caring for patients identified with highly resistant micro-organisms (HRMOs). However, the direct costs of patients in isolation are largely unknown. AIM To obtain detailed information on the daily direct costs associated with isolating patients identified with HRMOs. METHODS This study was performed from November until December 2017 on a 12-bed surgical ward. This ward contained solely isolation rooms with anterooms. The daily direct costs of isolation were based on three cost items: (1) additional personal protective equipment (PPE), measured by counting the consumption of empty packaging materials; (2) cleaning and disinfection of the isolation room, based on the costs of an outsourced cleaning company; and (3) additional workload for healthcare workers, based on literature and multiplied by the average gross hourly salary of nurses. A distinction was made between the costs for strict isolation, contact-plus isolation, and contact isolation. FINDINGS During the study period, 26 patients were nursed in isolation because of HRMO carriage. Time for donning and doffing of PPE was 31 min per day. The average daily direct costs of isolation were the least expensive for contact isolation (gown, gloves), €28/$31, and the most expensive for strict isolation (surgical mask, gloves, gown, cap), €41/$47. CONCLUSION Using a novel, easy method to estimate consumption of PPE, we conclude that the daily direct costs of isolating a patient differ per type of isolation. Insight into the direct costs of isolation is of utmost importance when developing or updating infection prevention policies.
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Affiliation(s)
- M D van Dijk
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | - A F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | - S Polinder
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | - J A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, The Netherlands.
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Impact of on-site compared to off-site testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) on duration of isolation and resource utilization. Infect Control Hosp Epidemiol 2020; 42:1004-1006. [PMID: 32829737 PMCID: PMC8245332 DOI: 10.1017/ice.2020.433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Rapid detection and isolation of coronavirus disease 2019 (COVID-19) patients is the only means of reducing hospital transmission. We describe the impact of implementation of on-site severe acute respiratory coronavirus virus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) testing on reducing turnaround time, isolation duration, pathology test ordering, and antibiotic use in patients who do not have COVID-19.
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11
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Christie J, Wright D, Liebowitz J, Stefanacci P. Can a nasal and skin decolonization protocol safely replace contact precautions for MRSA-colonized patients? Am J Infect Control 2020; 48:922-924. [PMID: 31937456 DOI: 10.1016/j.ajic.2019.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 01/27/2023]
Abstract
Contact precautions (CP) are employed in United States hospitals in order to prevent transmission of pathogens via supplies, equipment, and health care worker hands. CP is required in many hospitals for both colonized and infected methicillin-resistant Staphylococcus aureus (MRSA) patients. The isolation of colonized patients often results in a high rate of CP, leading some hospitals to abandon CP for MRSA-colonized patients without adding any safety measure to address transmission risk. Understanding this risk, 7 network hospitals in a US health care system made the decision to replace CP for high-risk MRSA-colonized patients with targeted nasal and body decolonization, leading to significant cost savings and staff satisfaction without any increase in MRSA transmission.
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Affiliation(s)
- Jacqueline Christie
- Departments of Quality and Nursing, Universal Health Services, Inc., King of Prussia, PA.
| | - Don Wright
- Departments of Quality and Nursing, Universal Health Services, Inc., King of Prussia, PA
| | - Jacalyn Liebowitz
- Departments of Quality and Nursing, Universal Health Services, Inc., King of Prussia, PA
| | - Paul Stefanacci
- Departments of Quality and Nursing, Universal Health Services, Inc., King of Prussia, PA
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Brown L, Munro J, Rogers S. Use of personal protective equipment in nursing practice. Nurs Stand 2020; 34:59-66. [PMID: 31468815 DOI: 10.7748/ns.2019.e11260] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2018] [Indexed: 02/02/2023]
Abstract
A comprehensive understanding of infection prevention and control is essential for nurses when seeking to protect themselves, patients, colleagues and the general public from the transmission of infection. Personal protective equipment (PPE) - such as gloves, aprons and/or gowns, and eye protection - is an important aspect of infection prevention and control for all healthcare staff, including nurses. Its use requires effective assessment, an understanding of the suitability of various types of PPE in various clinical scenarios, and appropriate application. Understanding the role of PPE will enable nurses to use it appropriately and reduce unnecessary cost, while ensuring that the nurse-patient relationship remains central to care. This article defines PPE and its components, outlines when it should be used and details its optimal application.
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Affiliation(s)
| | - Julianne Munro
- Christchurch Women's Hospital, Christchurch, New Zealand
| | - Suzy Rogers
- Christchurch Hospital, Christchurch, New Zealand
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13
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Use of airborne infection isolation in potential cases of pulmonary tuberculosis. Infect Control Hosp Epidemiol 2020; 41:505-509. [PMID: 32172696 DOI: 10.1017/ice.2020.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To identify risk factors of patients placed in airborne infection isolation (AII) for possible pulmonary tuberculosis (TB) to better predict TB diagnosis and allow more judicious use of AII. METHODS Case-control, retrospective study at a single tertiary-care academic medical center. The study included all adult patients admitted from October 1, 2014, through October 31, 2017, who were placed in AII for possible pulmonary TB. Cases were defined as those ultimately diagnosed with pulmonary TB. Controls were defined as those not diagnosed with pulmonary TB. Those with TB diagnosed prior to admission were excluded. In total, 662 admissions (558 patients) were included. RESULTS Overall, 15 cases of pulmonary TB were identified (2.7%); of these, 2 were people living with human immunodeficiency virus (HIV; PLWH). Statistical analysis was limited by low case number. Those diagnosed with pulmonary TB were more likely to have been born outside the United States (53% vs 13%; P < .001) and to have had prior positive TB testing, regardless of prior treatment (50% vs 19%; P = .015). A multivariate analysis using non-US birth and prior positive TB testing predicted an 18.2% probability of pulmonary TB diagnosis when present, compared with 1.0% if both factors were not present. CONCLUSIONS The low number of pulmonary TB cases indicated AII overuse, especially in PLWH, and more judicious use of AII is warranted. High-risk groups, including those born outside the United States and those with prior positive TB testing, should be considered for AII in the appropriate clinical setting.
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Carey D, Price K, Neal S, Compton C, Ash C, Bryan N, Kaplan P, McMullen K. The impact of discontinuing contact precautions for multidrug resistant organisms at a less than 400-bed level II teaching hospital and a community hospital: A 3-month pilot study. Am J Infect Control 2020; 48:333-336. [PMID: 31519476 DOI: 10.1016/j.ajic.2019.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The impact of discontinuing contact precautions (CPs) for patients with select multidrug-resistant organisms on bacteremia infection rates was evaluated in this quality improvement project. METHODS The removal of use of CPs, with increased focus on standard precautions, for all patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization/infection was piloted via a quality improvement project over a 3-month period. RESULTS CP was discontinued in December 2018. Comparing 3 months pre- and postchange, the overall incidence density rate decreased for hospital-onset (HO) laboratory-identified (LabID) MRSA bacteremia (0.07 vs 0.02; P = .52), whereas HO LabID VRE bacteremia rates remained the same (0.00 vs 0.00). Overall estimated financial savings, including personal protective equipment ($15,375) and staff time ($17,165), was $32,540 for the project period, with annualized estimated savings of $130,160. CONCLUSIONS In this pilot study evaluating the discontinuance of CPs, there was no evidence of an increase in HO MRSA or VRE LabID bacteremia incidence density rates. This practice change may be safely implemented at similar health care facilities.
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Affiliation(s)
- Darlene Carey
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA.
| | - Kaleb Price
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Shylanda Neal
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Cinnamon Compton
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Charles Ash
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Nicole Bryan
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Peter Kaplan
- Infection Prevention and Control, Gwinnett Medical Center, Lawrenceville, GA
| | - Kathleen McMullen
- Infection Prevention, Occupational Health and Wound Care, Christian Hospital and Northwest Healthcare, St. Louis, MO
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Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial. THE LANCET. INFECTIOUS DISEASES 2020; 20:575-584. [PMID: 32087113 DOI: 10.1016/s1473-3099(19)30626-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/02/2019] [Accepted: 10/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme. METHODS We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070. FINDINGS We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions. INTERPRETATION Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening. FUNDING European Commission.
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16
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Sharma A, Pillai DR, Lu M, Doolan C, Leal J, Kim J, Hollis A. Impact of isolation precautions on quality of life: a meta-analysis. J Hosp Infect 2020; 105:35-42. [PMID: 32059996 DOI: 10.1016/j.jhin.2020.02.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/07/2020] [Indexed: 02/01/2023]
Abstract
Impact of isolation precautions on psychological wellbeing of patients has yet to be fully quantified. To assess the impact of isolation precautions on patients' health-related quality of life and depression or anxiety scales and estimate per day cost of anxiety and depression. Literature pertaining to impact of isolation precautions was searched on EMBASE and PubMed databases and Google Scholar. A two-step independent screening of the articles was performed. Articles that compared isolated and non-isolated patients using different quality of life and psychological burden scales were included. A meta-analysis was conducted using the Hospital Anxiety and Depression Scales (HADS-A and HADS-D). Psychological burden measures from selected literature were presented in a graph as effect sizes. Per day cost of anxiety and depression was estimated using pooled mean difference from meta-analysis. Out of 106 articles, 94 were excluded due to inclusion criteria, leaving 12 for full text review. After review of full text of the articles, seven articles were shortlisted for empirical analysis and four out of these seven for meta-analysis. The pooled mean difference estimates for HADS-A was -1.4 (P=0.15) and that for HADS-D was -1.85 (P=0.09). In the empirical analysis of psychological burden scales, the effect in all studies except one was negative. Results from meta-analysis and empirical analysis of psychological burden implied that isolated patients are worse off in general. The implied estimated per day cost of anxiety and depression in terms of quality-adjusted life years (QALYs) is approximately US$10.
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Affiliation(s)
- A Sharma
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - D R Pillai
- Departments of Pathology & Laboratory Medicine, Medicine, and Microbiology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - M Lu
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - C Doolan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - J Leal
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada; Departments of Community Health Sciences and Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - J Kim
- Infection Prevention and Control, Alberta Health Services, Calgary, Alberta, Canada
| | - A Hollis
- Department of Economics, University of Calgary, Calgary, Alberta, Canada.
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Implementing a Clostridium difficile testing algorithm and its effect on isolation duration and treatment initiation: a pre- and post-implementation study. Eur J Clin Microbiol Infect Dis 2020; 39:1071-1076. [PMID: 31970532 PMCID: PMC7225191 DOI: 10.1007/s10096-020-03823-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/19/2020] [Indexed: 02/08/2023]
Abstract
A proportion of patients suspected of Clostridium difficile infection are unnecessarily placed in contact isolation. By introducing a random-access glutamate dehydrogenase (GDH) test for C. difficile, we aimed to reduce isolation time. In addition, we investigated whether the result of the toxin A&B enzyme immunoassay (EIA) was associated with the decision to initiate antibiotic treatment against C. difficile. This retrospective pre- and post-implementation study was from June 3, 2016, to June 4, 2018. Pre-implementation, only a NAAT was performed. In the post-implementation period, a GDH test was performed; if positive, a toxin A&B EIA followed the same day and subsequently a NAAT. Contact isolation for CDI was discontinued when the GDH test was negative. Median time in isolation was 50.8 h pre-implementation (n = 189) versus 28.0 h post-implementation (n = 119), p < 0.001. The GDH test had a negative predictive value of 98.8% (95% CI 97.9–99.4). In 7/31 (22.6%) patients with a positive NAAT and GDH test and a negative toxin A&B EIA, no antibiotics against C. difficile were initiated versus 4/28 (14.3%) patients who were NAAT, GDH and toxin A&B EIA positive. Introducing a random-access screening test resulted in a significant decrease in patient isolation time. The GDH test had a high negative predictive value making it suitable to determine whether contact isolation can be discontinued. Furthermore, the result of a toxin A&B EIA had limited added value on the percentage of patients in whom antibiotic treatment against C. difficile was initiated.
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18
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Schrank GM, Snyder GM, Davis RB, Branch-Elliman W, Wright SB. The discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: Impact upon patient adverse events and hospital operations. BMJ Qual Saf 2019; 29:1-2. [PMID: 31320496 DOI: 10.1136/bmjqs-2018-008926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 06/11/2019] [Accepted: 06/29/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are a resource-intensive intervention to reduce healthcare-associated infections, potentially impeding patient throughput and limiting bed availability to isolate other contagious pathogens. We investigated the impact of the discontinuation of contact precautions (DcCP) for endemic MRSA and VRE on patient outcomes and operations metrics in an acute care setting. METHODS This is a retrospective, quasi-experimental analysis of the 12 months before and after DcCP for MRSA and VRE at an academic medical centre. The frequency for bed closures due to contact isolation was measured, and personal protective equipment (PPE) expenditures and patient satisfaction survey results were compared using the Wilcoxon signed-rank test. Using an interrupted time series design, emergency department (ED) admission wait times and rates of patient falls, pressure ulcers and nosocomial MRSA and VRE clinical isolates were compared using GEEs. RESULTS Prior to DcCP, bed closures for MRSA and/or VRE isolation were associated with estimated lost hospital charges of $9383 per 100 bed days (95% CI: 8447 to 10 318). No change in ED wait times or change in trend was observed following DcCP. There were significant reductions in monthly expenditures on gowns (-61.0%) and gloves (-16.3%). Patient satisfaction survey results remained stable. No significant changes in rates or trends were observed for patient falls or pressure ulcers. Incidence rates of nosocomial MRSA (1.58 (95% CI: 0.82 to 3.04)) and VRE (1.02 (95% CI: 0.82 to 1.27)) did not significantly change. CONCLUSIONS DcCP was associated with an increase in bed availability and revenue recovery, and a reduction in PPE expenditures. Benefits for other hospital operations metrics and patient outcomes were not identified.
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Affiliation(s)
- Gregory M Schrank
- Department of Medicine, Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Graham M Snyder
- Department of Infection Prevention and Control, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Roger B Davis
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Westyn Branch-Elliman
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, West Roxbury, Massachusetts, United States.,VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States
| | - Sharon B Wright
- Harvard Medical School, Boston, Massachusetts, United States.,Division of Infection Control/Hospital Epidemiology, Silverman Institute of Health Care Quality & Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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19
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Direct Costs of a Contact Isolation Day: A Prospective Cost Analysis at a Swiss University Hospital. Infect Control Hosp Epidemiol 2017; 39:101-103. [PMID: 29249218 DOI: 10.1017/ice.2017.258] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We prospectively evaluated direct costs of contact precautions using on-site observation. Additional mean costs per patient day were calculated for extra materials used, increased workload, and one-off isolation activities. The cost of contact precautions was $158.90 (95% confidence interval, $124.90‒$192.80) per patient day. Infect Control Hosp Epidemiol 2018;39:101-103.
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20
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Dhar S, Cook E, Oden M, Kaye KS. Building a Successful Infection Prevention Program: Key Components, Processes, and Economics. Infect Dis Clin North Am 2017; 30:567-89. [PMID: 27515138 DOI: 10.1016/j.idc.2016.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Sorabh Dhar
- Department of Hospital Epidemiology and Infection Prevention, Detroit Medical Center, Detroit, MI, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Department of Hospital Epidemiology and Infection Prevention, John D Dingell VA Medical Center, Detroit, MI, USA; Harper University Hospital, 5 Hudson, 3990 John R, Detroit, MI 48201, USA.
| | - Evelyn Cook
- Duke Infection Control Outreach Network, Duke University Medical Center, 1610 Sycamore Street, Durham, NC 27707, USA
| | - Mary Oden
- Infection Prevention, Clinical Operations, Tenet Health, 1443 Ross Avenue Suite 1400, Dallas, TX 75202, USA
| | - Keith S Kaye
- Department of Hospital Epidemiology and Infection Prevention, Detroit Medical Center, Detroit, MI, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; University Health Center, 4201 Saint Antoine, Suite 2B, Box 331, Detroit, MI 48201, USA
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Lapointe-Shaw L, Voruganti T, Kohler P, Thein HH, Sander B, McGeer A. Cost-effectiveness analysis of universal screening for carbapenemase-producing Enterobacteriaceae in hospital inpatients. Eur J Clin Microbiol Infect Dis 2017; 36:1047-1055. [PMID: 28078557 DOI: 10.1007/s10096-016-2890-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/22/2016] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to assess the cost-effectiveness of screening all hospital inpatients for carbapenemase-producing Enterobacteriaceae (CPE) at the time of hospital admission, compared to not screening, from a US hospital perspective. We used a linked transmission/Markov model to compare outcomes for a typical hospitalized medical patient, from a community with a colonization prevalence of 0.05%. Outcomes were number of colonized patients, CPE-related clinical infections and deaths, expected quality-adjusted life years (QALYs), cost, and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to assess the effect of parameter uncertainty, using a willingness-to-pay threshold of $100,000 per QALY gained. Screening prevented six CPE colonization cases per 1000 patients (1/1000 colonized with screening, 7/1000 without screening), over half of all symptomatic CPE infections (2/10,000 symptomatic with screening, 5/10,000 symptomatic without screening), and nearly half of all CPE-related deaths (8/100,000 deaths with screening, 15/100,000 deaths without screening). Screening accrued 0.0009 additional QALYs and cost an additional $24.68, compared to not screening, and was cost-effective (ICER $26,283 per QALY gained). Our results were sensitive to uncertainty in prevalence and the number of secondary colonizations per colonized patient. Screening was not cost-effective at a prevalence below 0.015% or if transmission to fewer than 0.9 new patients occurred for each colonized patient. At prevalence levels above 0.3%, screening was cost-saving compared to not screening. Screening inpatients for CPE carriage is likely cost-effective, and may be cost-saving, depending on the local prevalence of carriage.
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Affiliation(s)
- L Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Canada.
- Toronto General Hospital, 14 EN room 213, 200 Elizabeth St., Toronto, ON, M5G 2C4, Canada.
| | - T Voruganti
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - P Kohler
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - H-H Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - B Sander
- Public Health Ontario, Toronto, Canada
| | - A McGeer
- Sinai Health System, Toronto, Canada
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Subramony A, Zachariah P, Krones A, Whittier S, Saiman L. Impact of Multiplex Polymerase Chain Reaction Testing for Respiratory Pathogens on Healthcare Resource Utilization for Pediatric Inpatients. J Pediatr 2016; 173:196-201.e2. [PMID: 27039227 PMCID: PMC5452417 DOI: 10.1016/j.jpeds.2016.02.050] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/15/2016] [Accepted: 02/18/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether multiplex polymerase chain reaction (mPCR) vs non-mPCR testing impacts the use of antibiotics, chest radiographs, and isolation precautions. STUDY DESIGN We retrospectively compared use of antibiotics, chest radiographs, and isolation precautions for patients <18 years old (excluding neonates) hospitalized at a tertiary referral center tested for respiratory pathogens in the emergency department or during the first 2 hospital days, during 2 periods: June 2010-June 2012 (non-mPCR group) vs October 2012-May 2014 (mPCR group). RESULTS Subjects (n = 2430) in the mPCR group were older, had more complex chronic conditions, and were admitted to the pediatric intensive care unit more often compared with the non-mPCR (n = 2349) group. Subjects in the mPCR group had more positive tests (42.4% vs 14.4%, P < .01), received fewer days of antibiotics (4 vs 5 median antibiotic days, P < .01), fewer chest radiographs performed, (59% vs 78%, P < .01), and were placed in isolation longer (20 vs 0 median isolation-hours, P < .01) compared with the non-mPCR group. In multivariable regression, patients tested with mPCR were less likely to receive antibiotics for ≥2 days (OR 0.5, 95% CI 0.5-0.6), chest radiographs at admission (OR 0.4, 95% CI 0.3-0.4), and more likely to be in isolation for ≥2 days (OR 2.4, 95% CI 2.1-2.8) compared with the non-mPCR group. CONCLUSIONS Use of mPCR testing for respiratory viruses among hospitalized patients was significantly associated with decreased healthcare resource utilization, including decreased use of antibiotics and chest radiographs, and increased use of isolation precautions.
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Affiliation(s)
- Anupama Subramony
- Department of Pediatrics, Cohen Children's Medical Center, Hofstra-Northwell School of Medicine, New Hyde Park, NY.
| | - Philip Zachariah
- Department of Pediatrics, Columbia University Medical Center, New York, NY,NewYork-Presbyterian Hospital, New York, NY
| | - Ariella Krones
- Department of Medicine, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Susan Whittier
- Department of Pediatrics, Columbia University Medical Center, New York, NY,NewYork-Presbyterian Hospital, New York, NY
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY,NewYork-Presbyterian Hospital, New York, NY
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Quan KA, Cousins SM, Porter DD, Puppo RA, Huang SS. Automated tracking and ordering of precautions for multidrug-resistant organisms. Am J Infect Control 2015; 43:577-80. [PMID: 25681303 DOI: 10.1016/j.ajic.2014.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The transmission and infection risk associated with multidrug-resistant organism (MDRO) carriers necessitates surveillance and tracking to provide proper contact precautions. As MDROs increase in scope, automated electronic health record (EHR) systems may help with surveillance demands. METHODS We created a system for MDROs and Clostridium difficile tracking that automated the following 3 main surveillance and tracking activities: monitoring of microbiology results and initiation of chart-based flags, ordering of contact precautions on admission, and ensuring appropriate removal of precautions. RESULTS Automation saved 43 infection preventionist hours per 1,000 admissions, in addition to previously unquantified hours spent reviewing MDRO history for every admission. Automatic retiring of certain MDRO flags ensured removal of contact precautions after a specified time. A point-prevalence assessment for eligibility for discontinuation found that all precautions were appropriate, with none eligible for removal. By integrating microbiology data, EHR tracking flags, and automated orders, this system assured rapid and comprehensive placement of patients into contact precautions without requiring oversight by infection prevention personnel. CONCLUSION We show that automated systems embedded within EHRs can ensure tracking and application of appropriate contact precautions while simultaneously producing tremendous time savings for infection prevention programs.
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25
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The Impact of Discontinuing Contact Precautions for VRE and MRSA on Device-Associated Infections. Infect Control Hosp Epidemiol 2015; 36:978-80. [DOI: 10.1017/ice.2015.99] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The impact of discontinuing contact precautions for patients with MRSA and VRE colonization/infection on device-associated hospital-acquired infection rates at an academic medical center was investigated in this before-and-after study. In the setting of a strong horizontal infection prevention platform, discontinuation of contact precautions had no impact on device-associated hospital-acquired infection rates.Infect. Control Hosp. Epidemiol. 2015;36(8):978–980
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