Improving hospital-acquired infection rates: the CDC experience

ZnO-based antimicrobial coatings for biomedical applications

Rapid transmission of infectious microorganisms such as viruses and bacteria through person-to-person contact has contributed significantly to global health issues. The high survivability of these microorganisms on the material surface enumerates their transmissibility to the susceptible patient. The antimicrobial coating has emerged as one of the most interesting technologies to prevent growth and subsequently kill disease-causing microorganisms. It offers an effective solution a non-invasive, low-cost, easy-in-use, side-effect-free, and environmentally friendly method to prevent nosocomial infection. Among antimicrobial coating, zinc oxide (ZnO) stands as one of the excellent materials owing to zero toxicity, high biocompatibility to human organs, good stability, high abundancy, affordability, and high photocatalytic performance to kill various infectious pathogens. Therefore, this review provides the latest research progress on advanced applications of ZnO nanostructure-based antibacterial coatings for medical devices, biomedical applications, and health care facilities. Finally, future challenges and clinical practices of ZnO-based antibacterial coating are addressed.

Early recognition and response to increases in surgical site infections using optimized statistical process control charts-the Early 2RIS Trial: a multicenter cluster randomized controlled trial with stepped wedge design

Background

Surgical site infections (SSIs) cause significant patient suffering. Surveillance and feedback of SSI rates is an evidence-based strategy to reduce SSIs, but traditional surveillance methods are slow and prone to bias. The objective of this cluster randomized controlled trial (RCT) is to determine if using optimized statistical process control (SPC) charts for SSI surveillance and feedback lead to a reduction in SSI rates compared to traditional surveillance.

Methods

The Early 2RIS Trial is a prospective, multicenter cluster RCT using a stepped wedge design. The trial will be performed in 29 hospitals in the Duke Infection Control Outreach Network (DICON) and 105 clusters over 4 years, from March 2016 through February 2020; year one represents a baseline period; thereafter, 8–9 clusters will be randomized to intervention every 3 months over a 3-year period using a stepped wedge randomization design. All patients who undergo one of 13 targeted procedures at study hospitals will be included in the analysis; these procedures will be included in one of six clusters: cardiac, orthopedic, gastrointestinal, OB-GYN, vascular, and spinal. All clusters will undergo traditional surveillance for SSIs; once randomized to intervention, clusters will also undergo surveillance and feedback using optimized SPC charts. Feedback on surveillance data will be provided to all clusters, regardless of allocation or type of surveillance. The primary endpoint is the difference in rates of SSI between the SPC intervention compared to traditional surveillance and feedback alone.

Discussion

The traditional approach for SSI surveillance and feedback has several major deficiencies because SSIs are rare events. First, traditional statistical methods require aggregation of measurements over time, which delays analysis until enough data accumulate. Second, traditional statistical tests and resulting p values are difficult to interpret. Third, analyses based on average SSI rates during predefined time periods have limited ability to rapidly identify important, real-time trends. Thus, standard analytic methods that compare average SSI rates between arbitrarily designated time intervals may not identify an important SSI rate increase on time unless the “signal” is very strong. Therefore, novel strategies for early identification and investigation of SSI rate increases are needed to decrease SSI rates. While SPC charts are used throughout industry and healthcare to improve and optimize processes, including other types of healthcare-associated infections, they have not been evaluated as a tool for SSI surveillance and feedback in a randomized trial.

Trial registration

ClinicalTrials.govNCT03075813, Registered March 9, 2017.

Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA.

MATERIALS AND METHODS

We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis.

RESULTS

Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies.

CONCLUSIONS

These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required.

TRIAL REGISTRATION

PROSPERO CRD42019123776.

Sampling for Collection of Central Line–Day Denominators in Surveillance of Healthcare-Associated Bloodstream Infections

Objective.

To determine the feasibility of estimating the number of central line-days at a hospital from a sample of months or individual days in a year, for surveillance of healthcare-associated bloodstream infections.

Design.

We used data reported to the National Nosocomial Infections Surveillance system in the adult and pediatric intensive care unit component for 1995-2003 and data from a sample of hospitals' daily counts of device use for 12 consecutive months. We calculated the percentile error as the central line-associated bloodstream infection percentile based on rates per line-days minus the percentile based on rates per estimated line-days.

Setting and Participants.

A total of 247 hospitals were used for sampling whole months and 12 hospitals were used for sampling individual days.

Results.

For a 1-month sample of central line–days data, the median percentile error was 3.3 (75th percentile, 7.9; 90th percentile, 15.4). The percentile error decreased with an increase in the number of months sampled. For a 3-month sample, the median percentile error was 1.4 (75th percentile, 4.3; 95th percentile, 8.3). Sampling individual days throughout the year yielded lower percentile errors than sampling an equivalent fraction of whole months. With 1 weekday sampled per week, the median percentile error ranged from 0.65 to 1.40, and the 90th percentile ranged from 2.8 to 5.0. Thus, for 90% of units, collecting data on line-days once a week provides an estimate within ± 5 percentile points of the true line-day rate.

Conclusion.

Sample-based estimates of central line-days can yield results that are acceptable for surveillance of healthcare-associated bloodstream infections.

Integrating intensive care unit (ICU) surveillance into an ICU clinical care electronic system

The intensive care unit (ICU) is the specialty with the highest prevalence of healthcare-associated infection (HCAI) in European hospitals and therefore a priority for surveillance of HCAI. Whereas surveillance is an essential part of an effective infection prevention and control (IPC) programme, all too often it consumes too much clinician and IPC team time, limiting the time available for quality improvement. The case for electronic surveillance is made in the literature from several countries on this basis. These studies indicate that electronic surveillance can improve validity, reduce time spent on surveillance, and provide opportunities for improvement in clinical decision-making and IPC action arising from surveillance. The Scottish ICU HAI surveillance system was established as part of an integrated audit and clinical care system. Investment in this technology infrastructure reduced the burden of data collection and has resulted in a focus on driving improvement in all Scottish ICUs. The experience in Scotland indicates that several critical components are necessary to optimize ICU HCAI surveillance, including: nationally agreed definitions and methods; national investment in information technology infrastructure to make it easier to follow clinical care pathways; leadership of surveillance by intensivists; piloting and validation to ensure confidence in the system; and strategic integration of national and local programmes. These elements have helped improve surveillance data locally, nationally, and at a European level, allowing clinical attention to be focused on the data rather than on the process of data collection.

Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries.

METHODS

This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology.

RESULTS

During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate.

CONCLUSIONS

Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Identification of targets for quality improvement in antimicrobial prescribing: the web-based ESAC Point Prevalence Survey 2009

OBJECTIVES

Since electronic prescribing is limited to few hospitals, point prevalence surveys, such as the standardized European Surveillance of Antimicrobial Consumption point prevalence survey (ESAC PPS), are an alternative tool for monitoring prescribing and helping to identify performance indicators and prescribing trends. The main objective of this study was to identify and assess targets for quality improvement.

METHODS

Each hospital had to carry out the survey within 2 weeks. Each department had to be surveyed in 1 day. Data collected, for all inpatients, included age and gender. For patients on systemic antimicrobial treatment, the antimicrobial/s, infection/prophylaxis site, reason in medical notes and guideline compliance were also collected. A central database using a web-based tool (WebPPS) developed in-house was used for data entry.

RESULTS

Combination of two or more antimicrobials accounted for 30% of use. Surgical prophylaxis was prolonged (>1 day) in 53% of cases. 'Intensive care' had higher proportions of treated patients (53% versus 29%), combination therapy (49% versus 31%), hospital-acquired infections (49% versus 31%) and parenteral administration (91% versus 61%). 'Reason in notes' was documented in 76%, and 'guideline compliance' occurred in 62% of patients.

CONCLUSIONS

The ESAC PPS provided useful information on the quality of prescribing, which identified a number of targets for quality improvement. These could apply to specific departments or whole hospitals. Intensive care, which has different characteristics, should not be compared with general wards with respect to combination therapy, hospital-acquired infections or parenteral proportion. The study confirmed that the ESAC PPS methodology can be used on a large number of hospitals at regional, national, continental or global level.

The impact of health care restructuring on nosocomially acquired blood stream infections

OBJECTIVE

To assess the impact of the health care restructuring, which occurred in Alberta in 1995, on the occurrence of nosocomial blood stream infection and risk factors for these infections at the University of Alberta Hospital.

PATIENTS AND METHODS

Changes in patient population, hospital bed numbers, admissions and hospital days for 1993 and 1994 (1993/94) were compared with those for 1996 and 1997(1996/97). Central venous catheter (CVC) use in intensive care units (ICU), days of total parenteral nutrition (TPN) and hemodialysis were compared for the two time periods. Prospectively collected data obtained by monitoring blood culture results on nosocomial blood stream infections in 1993/94 were compared with those obtained in 1996/97.

RESULTS

Hospital bed number fell by 10% between 1993/94 and 1996/97. Annual admissions fell by 19% and patient days by 17%. Some services markedly increased patient days (neurosurgery 49%, nephrology 30%, orthopedic surgery 24%), and others markedly reduced patient days (obstetrics and gynecology 99%, ophthalmology 100%, adult medicine 41%, general paediatrics 38%). ICU use of CVCs increased by 41%, TPN days increased by 25% and hemodialysis runs increased by 9%. Annual nosocomial blood stream infections increased by 31% and the annual rate per 10,000 patient days increased by 60%. TPN-related blood stream infection rates and ICU CVC infection rates did not change from 1993/94 to 1996/97.

CONCLUSIONS

Hospital restructuring has been associated with a 31% increase in nosocomial blood stream infection number and a 60% increase in rate. The increase has been associated with a change in patient populations and increases in risk factors for blood stream infection.

Trends in nosocomial bloodstream infections following health care restructuring in Alberta between 1999 and 2005

OBJECTIVE

A previous study at the University of Alberta Hospital/Stollery Children's Hospital in Edmonton, Alberta, revealed an increase in hospital-acquired bloodstream infection (BSI) rates associated with an increase in patient acuity during a period of public health care delivery restructuring between 1993 and 1996. The present study assessed trends in BSIs since the end of the restructuring.

DESIGN

Prospective surveillance for BSIs was performed using Centers for Disease Control and Prevention (USA) criteria for infection. BSI cases between January 1, 1999, and December 31, 2005, were reviewed. Available measures of patient volumes, acuity and BSI risk factors between 1999 and 2005 were also reviewed from hospital records.

SETTING

The University of Alberta Hospital/Stollery Children's Hospital (617 adult and 139 pediatric beds, respectively).

PATIENTS

All pediatric and adult patients admitted during the above-specified period with one or more episodes of BSIs.

RESULTS

There was a significant overall decline in the BSI number and rate over the study period between 1999 and 2005. The downward trend was widespread, involving both adult and pediatric populations, as well as primary and secondary BSIs. During this period, the number of hospital-wide and intensive care unit admissions, intensive care unit central venous catheter-days, total parenteral nutrition days and number of solid-organ transplants were either unchanged or increased. Gram-positive bacterial causes of BSIs showed significant downward trends, but Gram-negative bacterial and fungal etiologies were unchanged.

CONCLUSIONS

These data imply that, over time, hospitals can gradually adjust to changing patient care circumstances and, in this example, control infectious complications of health care delivery.

Public health law for the collection and reporting of health care-associated infections

BACKGROUND

State-based laws for reporting of health care-associated infections (HAI) have developed and changed dramatically in recent years, affecting the costs of reporting and impact on infection rates. It is necessary for practitioners of infection control to understand these changing legal frameworks and their application to practice.

METHODS

Employing systematic state-based research, the researchers have documented legislation and administrative regulations for institution-specific HAI reporting, using this information to create a comprehensive resource on state-based laws for mandatory HAI reporting.

RESULTS

As of August 27, 2007, 24 states have adopted laws requiring reporting of HAI rates, with an additional 7 states currently considering legislation that would require HAI reporting and 19 states employing detailed regulation in the absence of any current legislative authorization specific to HAI. This study documents (1) which states require reporting of HAI and, if so, whether this is done by legislation or administrative regulation; (2) whether the specific HAIs to be reported are identified in state law or codified generally as "diseases of public health importance," with reporting specified by administrative regulation; and (3) what reporting policies and procedures are detailed in law.

CONCLUSION

Through analysis of the collected information, the researchers have examined the degree to which states have modernized their respective public health laws to approach mandatory reporting by way of general legislation regarding "matters of public health importance" and subsequent detailed administrative regulation to specify those matters.

Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates

BACKGROUND

The diffusion of national evidence-based practice guidelines and their impact on patient outcomes often go unmeasured.

METHODS

Our objectives were to (1) evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention (CDC) Hand Hygiene Guideline, (2) compare rates of health care-associated infections (HAI) before and after implementation of the Guideline recommendations, and (3) examine the patterns and correlates of changes in rates of HAI. We used pre- and post-Guideline implementation site visits and surveys in the setting of 40 US hospitals--members of the National Nosocomial Infections Surveillance System--and measured HAI rates 1 year before and after publication of the CDC Guideline and used direct observation of hand hygiene compliance and Guideline implementation scores.

RESULTS

All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8% of 1359 staff members surveyed anonymously reported that they were familiar with the Guideline. However, in 44.2% of the hospitals (19/40), there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (mean, 56.6%). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene (P < .001). No impact of Guideline implementation or hand hygiene compliance on other HAI rates was identified. Other factors occurring over time could affect rates of HAI. Observed hand hygiene compliance rates were likely to overestimate rates in actual practice. The study may have been of too short duration to detect the impact of a practice guideline.

CONCLUSION

Wide dissemination of this Guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.

Effectiveness of an Educational Program to Reduce Ventilator-Associated Pneumonia in a Tertiary Care Center in Thailand: A 4-Year Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection-related death and morbidity in intensive care units (ICUs). We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU (MICU).

METHODS

A 4-year controlled, prospective, quasi-experimental study was conducted in an MICU, surgical ICU (SICU), and coronary care unit (CCU) for 1 year before the intervention (period 1), 1 year after the intervention (period 2), and 2 follow-up years (period 3). The SICU and CCU served as control ICUs. The educational program involved respiratory therapists and nurses and included a self-study module with preintervention and postintervention assessments, lectures, fact sheets, and posters.

RESULTS

Before the intervention, there were 45 episodes of VAP (20.6 cases per 1000 ventilator-days) in the MICU, 11 (5.4 cases per 1000 ventilator-days) in the SICU, and 9 (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days; P=.001) and remained stable in the SICU (5.6 cases per 1000 ventilator-days; P=.22) and CCU (4.8 cases per 1000 ventilator-days; P=.48). The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days; P=.07), and rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 (P<.001) and by 8.9 days in period 3 (P<.001). The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50% (P<.001) and 37%-45% (P<.001), respectively.

CONCLUSIONS

A focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.

[Diagnosis and therapy of sepsis]

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Comparisons of health care-associated infections identification using two mechanisms for public reporting

BACKGROUND

Many states have or are in process of legislating hospitals to report health care-associated infections (HAI). The purpose of this article is to compare two methods currently in use by different states: 1) selected infections due to medical care Patient Safety Indicator (PSI-7); and 2) Centers for Disease and Prevention Control (CDC) protocols for central line-associated bloodstream infections (CLA-BSI).

METHODS

Data came from a multihospital study. Site coordinators provided lists of elderly Medicare patients admitted in an enrolled intensive care unit in 2002 cross referenced with patient specific data on CLA-BSI following CDC protocols. PSI-7 was identified using Medicare data and the Agency for Healthcare Research and Quality PSI software version 2.1.

RESULTS

The full sample comprised records from 14,637 patients from 41 intensive care units in 24 hospitals. Patients were excluded if they did not meet the PSI-7 denominator criteria. In a sample of 9,948 patients, both methods identified infections in 89 (0.89%) patients. The methods had little concordance with only 8 patients identified using both methods.

CONCLUSIONS

Inconsistencies that we identified in this study are concerning given the fact that reports of HAI generated by different methods vary widely. Mandatory reporting mechanisms should be standardized and their accuracy confirmed.

Regional Anesthesia Surveillance System: first experiences with a quality assessment tool for regional anesthesia and analgesia

BACKGROUND

The incidence of complications related to regional anesthesia and analgesia is hardly known and estimates are based on extrapolation from controlled trials, insurance registries and retrospective chart reviews and only a few attempts of prospective data collection have been made. We designed a surveillance system for regional anesthesia for easy and reliable data acquisition.

METHODS

A list of definitions of complications and quality indicators of interest was created and introduced in a single institution. Data are collected within the hospital information system and by individual reports of complications from trained reporters in the Acute Pain Service. A data cross-check is performed by the Surveillance coordinator.

RESULTS

We present complications rates for 9790 catheter days and 4547 punctures for continuous neuraxial and peripheral nerve blocks between October 2003 and January 2006. Most complications were related to catheter dislocation and 'wet taps'. Serious complications such as neurologic deficits, bleeding complications and infections were rare. Data quality reached 98% reliability of complication coding.

DISCUSSION

This is the description of a prospective regional anesthesia surveillance system, which currently allows longitudinal analysis of performance parameters at a single institution and will provide data about the incidences of complications related to regional anesthesia and analgesia in the future.

[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Multihospital surveillance of nosocomial methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and Clostridium difficile: analysis of a 4-year data-sharing project, 1999-2002

BACKGROUND

This study sought to establish a benchmark of resistant organism rates among a cohort of regional hospitals.

METHODS

The Centers for Disease Control and Prevention (CDC) definitions were used to standardize the methodology for obtaining rates per 1000 patient days of nosocomial infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), and nosocomial infection with Clostridium difficile (CDIF). Only newly acquired nosocomial cases were counted. Data were reported as individual hospital control charts and as cohorted aggregate data. VHA East Coast Infection Control Professionals from 32 hospitals in New Jersey and Pennsylvania were involved.

RESULTS

Benchmarks were established with pooled mean rates for each cohort. During the observational period, a statistically significant downward trend was observed for VRE and MRSA (P = .02 and .0007, respectively), and an upward trend was observed for CDIF (P = .0256).

CONCLUSION

Benchmarks were established to compare nosocomial MRSA, VRE, and CDIF rates. Although significant changes in rates were observed, no attempt was made to establish a causal relationship between infection control practices and observed rates. However, a secondary gain was achieved through sharing best practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals

BACKGROUND

Hospitalized, critically ill patients have a significant risk of developing nosocomial infection. Most episodes of nosocomial pneumonia occur in patients undergoing mechanical ventilation (MV).

OBJECTIVE

To ascertain the effect of an infection control program on rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Argentina.

METHODS

All adult patients who received MV for at least 24 hours in 4, level III adult ICUs in 2 Argentinean hospitals were included in the study. A before-after study in which rates of VAP were determined during a period of active surveillance without an infection control program (phase 1) were compared with rates of VAP after implementation of an infection control program that included educational and surveillance feedback components (phase 2).

RESULTS

One thousand six hundred thirty-eight MV-days were accumulated in phase 1, and 1520 MV-days were accumulated during phase 2. Rates of VAP were significantly lower in phase 2 than in phase 1 (51.28 vs 35.50 episodes of VAP per 1000 MV-days, respectively, RR = 0.69, 95% CI: 0.49-0.98, P <or= .003).

CONCLUSION

Implementation of a multicomponent infection control program in Argentinean ICUs was associated with significant reductions in rates of VAP.

Prospective surveillance for primary bloodstream infections occurring in Canadian hemodialysis units

OBJECTIVE

Bloodstream infections are a major cause of morbidity and mortality in patients receiving long-term hemodialysis. We wanted to determine the incidence of hemodialysis-related bloodstream infections in Canadian centers participating in the Canadian Nosocomial Infection Surveillance Program.

METHODS

Prospective surveillance for hemodialysis-related bloodstream infections was performed in 11 centers during a 6-month period. Bloodstream infections were defined by published criteria. Hemodialysis denominators included the number of dialysis procedures, the number of patient-days on dialysis, and the frequencies of different types of vascular access.

RESULTS

There were 184 bloodstream infections in 133,158 dialysis procedures (1.4 per 1,000) and 316,953 patient-days (0.6 per 1,000). Hemodialysis access through arteriovenous (AV) fistulae was associated with the lowest risk for bloodstream infection (0.2 per 1,000 dialysis procedures). The relative risk for infection was 2.5 with AV graft access, 15.5 with cuffed and tunneled central venous catheter (CVC) access, and 22.5 with uncuffed CVC access (P < .001). There was marked variation among the 11 centers in the means of vascular access used for hemodialysis. Significant variation in infection rates was observed among the centers when controlling for types of access.

CONCLUSIONS

There was a hierarchy of risk of hemodialysis-related bloodstream infection according to type of vascular access. There was significant variation in the type of vascular access being used among the Canadian hemodialysis centers, and also variation in access-specific infection rates between centers.

A quality management project in 8 selected hospitals to reduce nosocomial infections: a prospective, controlled study

OBJECTIVE

To reduce the number of nosocomial infections (NIs) in surgical patients by a quality management approach.

DESIGN

Prospective, controlled study in 8 medium-sized hospitals during a 26-month period.

SETTING

Four study hospitals and 4 control hospitals.

METHODS

In two 10-month intervention periods, 4 external physicians introduced quality circles and ongoing surveillance in the 4 study hospitals. There were three 8-week observation periods in all 8 hospitals with the same physicians before, during, and after the intervention periods.

RESULTS

During the first observation period, almost identical overall incidence densities were found for the study hospitals and the control hospitals. During the course of the study, the overall incidence density decreased significantly in the study hospitals (risk ratio [RR], 0.74; 95% confidence interval [CI 95], 0.59 to 0.94) and nonsignificantly in the control hospitals (RR, 0.90; CI 95 0.70 to 1.16). With the use of a Cox regression model to evaluate the impact of the intervention periods while taking into account the distribution of risk factors for NI in both groups, a significant risk reduction (RR, 0.75; CI 95, 0.58 to 0.97) was observed after the first intervention period when comparing study and control hospitals. At the end of the study (ie, after the second intervention period), the difference between the study hospitals and the control hospitals was not significant (RR, 0.78; CI 95, 0.60 to 1.01). This was due to no further improvement at the end of the study in the study hospitals and a decrease in the control hospitals.

CONCLUSION

This study demonstrates that NI rates can be significantly reduced by appropriate intervention methods in hospitals that are interested in quality management activities. However, continuous intense efforts are necessary to maintain these improvements.

Promoting quality through measurement of performance and response: prevention success stories

Successful efforts to prevent health-care acquired infections occur daily in U.S. hospitals. However, few of these "success stories" are presented in the medical literature or discussed at professional meetings. Key components of successful prevention efforts include multidisciplinary teams, appropriate educational interventions, and data dissemination to clinical staff.

Epidemiology and risk factors for nosocomial pneumonia. Emphasis on prevention

VAP is a complex nosocomial infection, the disease expression and resulting patient outcome of which is dependent on host factors, the causative organism, the timing and adequacy of treatment, and the presence of intrinsic or inducible antibiotic resistance. Significant improvements have been achieved in our ability to reduce the occurrence of VAP in the hospital setting. Clinicians caring for mechanically ventilated patients should strive to develop focused programs for the prevention of VAP, other nosocomial infections, and the occurrence of antibiotic-resistant infections at their institutions. The benefits of such programs are well demonstrated. The components of a PDSA (Plan-Do-STUDY-Act) model that can be simply employed to develop a VAP prevention program are as follows: Stages Plan: 1. Identify potentially modifiable risk factors for VAP at the institutional level. 2. Develop a strategy to modify or prevent the occurrence of these risk factors. [figure: see text] Do: 1. Carry out the planned intervention strategy. 2. Identify problems in the implementation of the designed intervention. 3. Update the intervention with solutions for the identified problems. 4. Collect basic data (e.g., VAP rates, severity of illness).

STUDY

1. Analyze data. 2. Summarize the results. Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Prepare for next PDSA cycle. Inherent in the development and application of such programs is the concept that they are continuous processes striving to improve clinical performance over time (Fig. 3). At any given institution, the most likely approach to the prevention of NP and VAP will be a multifaceted one, employing interventions aimed at reducing the occurrence of aerodigestive tract colonization with pathogenic bacteria and aspiration. To be successful, such quality improvement programs must be embraced at the institutional level. Only in this way can hospitals hope to successfully reduce their rates of VAP and sustain or improve upon those efforts over time.

Implementation of an interactive computer-assisted infection monitoring program at the bedside

A new computer-assisted infection monitoring (CAI) software program has been developed for use in an intensive-care unit (ICU). By means of an interactive dialogue with physicians at the bedside, infection diagnoses and therapeutic decisions were recorded prospectively during a 3-month test period. By linking epidemiological data with information about therapeutic decisions, CAI could assess the quality of the therapeutic decisions. Antibiotics chosen empirically before the availability of any culture results, matched the antibiotic susceptibility patterns of the subsequently identified pathogens in 74% of the cases. Therapy chosen in collaboration with the computer after the pathogen was known, but before sensitivity results were available, corresponded with the eventual antibiograms of the microorganisms in 90% of the cases. Data analysis by CAI allowed us to assess critically the diagnostic and therapeutic habits in our ICU. Using the query-by-example method, CAI automatically calculated device-associated infection rates.

Reduced mortality in association with the acute respiratory distress syndrome (ARDS)

BACKGROUND

A study was undertaken to investigate possible reductions in mortality and/or changes in outcome predictive factors in patients with the acute respiratory distress syndrome (ARDS) managed in a single centre.

METHODS

The study was a prospective observational cohort study of two patient populations with ARDS. Group 1 comprised 41 patients enrolled between May 1990 and April 1993, and group 2 consisted of 78 patients enrolled between June 1993 and March 1997. The end points of the study were mortality and various factors predictive of death.

RESULTS

There was a marked reduction in mortality between groups 1 and 2 (66% versus 34%; relative risk 1.77; CI 1.23 to 2.55). There were no significant differences between the groups in terms of age (40.6 (3.3) versus 45.5 (2.2) years), APACHE score (14.5 (0.72) versus 13.6 (0.1)), lung injury score (2.95 (0.07) versus 2.8 (0.1)), incidence of multi-organ failure (29% versus 32%), incidence of sepsis (31% versus 39%), or PaO2/FIO2 (kPa) ratio (11.8 (0.67) versus 12.0 (0.6)). There was a significantly lower proportion of men in group 1 (51% versus 74%). The case mix of the two groups was closely matched: following elective surgery 48% versus 48%, trauma 17% versus 16%, primary lung injury 12% versus 24%. Patients in group 1 were supported using several ventilatory and other modes (volume preset, non-inverse ratio ventilation, n = 15; pressure controlled inverse ratio ventilation (PC-IRV), n = 11; ultra high frequency jet ventilation (UHFJV), n = 13; an intravascular oxygenation device (IVOX) and extracorporeal gas exchange (ECGE), n = 2). Within group 1 no significant difference in mortality was observed between the patients on volume controlled ventilation and the remainder. In group 2 all patients received PC-IRV (n = 78) but, in addition, some received other support techniques (UHFJV n = 4, ECGE n = 2). In group 1 only sepsis on admission (21% (survivors) versus 56% (non-survivors)) predicted death. In group 2 age of survivors and non-survivors (41.2 (2.6) versus 52.6 (3.5)), APACHE score (12.2 (0.6) versus 15.8 (0.9)), and PaO2/FIO2 (12.8 (0.86) versus 10.5 (0.72)) predicted survival, but not the incidence of sepsis or multi-organ failure.

CONCLUSIONS

In recent years a highly significant reduction in mortality associated with ARDS has been observed between two groups of patients well matched for disease severity and case mix. Changes in ICU organisation rather than specific interventions may account for this reduction, although different ventilatory and other management strategies used in the two groups may also be relevant.

Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Society for Healthcare Epidemiology of America

The scientific basis for claims of efficacy of nosocomial infection surveillance and control programs was established by the Study on the Efficacy of Nosocomial Infection Control project. Subsequent analyses have demonstrated nosocomial infection prevention and control programs to be not only clinically effective but also cost-effective. Although governmental and professional organizations have developed a wide variety of useful recommendations and guidelines for infection control, and apart from general guidance provided by the Joint Commission on Accreditation of Healthcare Organizations, there are surprisingly few recommendations on infrastructure and essential activities for infection control and epidemiology programs. In April 1996, the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The following report represents the consensus panel's best assessment of needs for a healthy and effective hospital-based infection control and epidemiology program. The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and nonpersonnel resources. The consensus panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee.

Hospital-acquired infections in the United States. The importance of interhospital comparisons

To use infection rates as a basis for measuring quality of care, the rates must be meaningful for interhospital comparison. A crude, overall nosocomial infection rate of a hospital provides no means of adjustment for patients' intrinsic or extrinsic risks. Before interhospital comparison, rates should be adjusted for nosocomial infection risk factors. Interhospital comparison of rates requires that a hospital participate in a multicenter surveillance system or aggregated national database. This article outlines a series of questions for hospital administrations to pose before entering such an endeavor.