Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee

Trends in Health Care-Associated Infection Prevention Practices in US Veterans Affairs Hospitals From 2005 to 2017

IMPORTANCE

Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown.

OBJECTIVE

To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership.

DESIGN, SETTINGS, AND PARTICIPANTS

For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019.

MAIN OUTCOMES AND MEASURES

Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership.

RESULTS

Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P < .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse.

CONCLUSIONS AND RELEVANCE

From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Advanced Loss Eventuality Assessment and Technical Estimates: An Integrated Approach for Management of Healthcare-Associated Infections

BACKGROUND

Healthcare Associated Infections (HAIs) represent a crucial issue in health and patient safety management due to the persistent nature, economic impact and possible preventability of the phenomenon. Compensation claims for damages resulting from HAI could provide insights that can improve the understanding of suboptimal steps in the therapeutic process, enable an estimate of costs related to infectious complications, and guide the development of planning tools for implementation of the quality of care.

OBJECTIVE

This paper analyzes all the HAI claims received at the Umberto I General Hospital of Rome across a five-year period with the aim of outlining a methodological approach to the litigation management and of characterizing the economic impact of infections on health facilities resources.

METHODS

All claims received during the study period have been classified according to the International Classification for Patient Safety (ICPS) system. Subsequently, claims related to Healthcare Associated Infections were evaluated through an innovative tool for determination of the risk of loss, the Advanced Loss Eventuality Assessment (ALEA) score.

RESULTS

The results obtained demonstrate the relevance of a correct management of HAI claims in the administration of a health care system. Specifically, the cases examined during the study highlighted the significant impact of infectious diseases of a nosocomial nature in terms of frequency and economic exposure.

CONCLUSION

The proposed methodological approach allows a productive analysis of the internal processes, providing fundamental data for the refinement of the preventive strategies and for the rationalization of the resources through the expenditure forecasts. Article Highlights Box: Healthcare-Associated Infections represent an essential element to consider in the management of health facilities. • Many studies highlight the economic burden of Healthcare-Associated Infections in health policies. • Litigation management represents a useful resource in the prevention of Healthcare Associated Infections. • Appropriate clinical risk management policies in the field of Healthcare-Associated Infections allow the implementation of preventive measures, the reduction of the incidence of the phenomenon and the quality of care. • The costs of Healthcare-Associated Infections can be limited through a systematic methodological approach based on Advanced Loss Eventuality Assessment and technical estimate of the value of each case. • The application of a standardized system would be desirable in any health facility despite the potential methodological, technical, behavioral and financial issues.

Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria

Antibiotics are the pillar of surgery from prophylaxis to treatment; any failure is potentially a leading cause for increased morbidity and mortality. Robust data on the burden of SSI especially those due to antimicrobial resistance (AMR) show variable rates between countries and geographical regions but accurate estimates of the incidence of surgical site infections (SSI) due to AMR and its related global economic impact are yet to be determined. Quantifying the burden of SSI treatment is an incentive to sensitize governments, healthcare systems, and the society to invest in quality improvement and sustainable development. However in the absence of a unified epidemiologically sound infection definition of SSI and a well-designed global surveillance system, the end result is a lack of accurate and reliable data that limits the comparability of estimates between countries and the possibility of tracking changes to inform healthcare professionals about the appropriateness of implemented infection prevention and control strategies. This review aims to highlight the reported gaps in surveillance methods, epidemiologic data, and evidence-based SSI prevention practices and in the methodologies undertaken for the evaluation of the economic burden of SSI associated with AMR bacteria. If efforts to tackle this problem are taken in isolation without a global alliance and data is still lacking generalizability and comparability, we may see the future as a race between the global research efforts for the advancement in surgery and the global alarming reports of the increased incidence of antimicrobial-resistant pathogens threatening to undermine any achievement.

Perceived impact of state-mandated reporting on infection prevention and control departments

BACKGROUND

Currently, most US states have adopted legislation requiring hospitals to submit health care-associated infection (HAI) data. We evaluated the perceived impact of state HAI laws on infection prevention and control (IPC) departments.

METHODS

A web-based survey of a national sample of all non-veteran hospitals enrolled in the National Healthcare Safety Network was conducted in fall 2011. Variations in IPC department resources and characteristics in states with and without laws were compared by use of χ², Mann-Whitney (Wilcoxon), and Student t tests. Multinomial logistic regression was used to identify increases or decreases, versus no change, in perceived resources, time, influence, and visibility of the IPC department in states with and without HAI laws.

RESULTS

Overall, 1,036 IPC departments provided complete data (30% response rate); 755 (73%) were located in states with laws. Respondents in states with reporting laws were more likely to report less time for routine IPC activities (odds ratio, 1.61; 95% confidence interval, 1.12-2.31) and less visibility of the IPC department (odds ratio, 1.70; 95% confidence interval, 1.12-2.58) than respondents in states without laws, after controlling for geographic region, setting, and the presence of a hospital epidemiologist.

CONCLUSIONS

Respondents in states with laws reported negative effects on their IPC department, beyond what was required by federal mandates. Further research should examine resources necessary to comply with state HAI laws and evaluate unintended consequences of state HAI laws.

Centers for Disease Control and Prevention 2017 Guidelines for Prevention of Surgical Site Infections: Review and Relevant Recommendations

PURPOSE OF REVIEW

The associated patient morbidity and resource-intensive nature of managing surgical site infections (SSI) has focused attention toward not only improving treatment protocols but also enhancing preventative measures. The purpose of this review was to summarize the relevant updated CDC guidelines for the prevention of SSI that were released in 2017. The CDC recommends the integration of the guidelines for improvement in quality metrics, reportable outcomes, and patient safety.

RECENT FINDINGS

The updated guidelines include generalized recommendations for parenteral antimicrobial prophylaxis, non-parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, and antiseptic prophylaxis. The arthroplasty section includes recommendations for blood transfusion, systemic immunosuppressive therapy, and antibiotics during drain use. There was low-quality evidence precluding recommendations for preoperative intra-articular corticosteroid injections, orthopedic surgical space suits, and biofilm management. The recommendations provided throughout this review, including more recent guidelines from other organizations such as the AAOS and ACR, should assist clinicians in developing and/or refining surgical site prevention protocols for their patients undergoing total joint arthroplasty procedures.

Surgical Site Infections: Volume-Outcome Relationship and Year-to-Year Stability of Performance Rankings

BACKGROUND

Surgical site infection (SSI) rates are publicly reported as quality metrics and increasingly used to determine financial reimbursement.

OBJECTIVE

To evaluate the volume-outcome relationship as well as the year-to-year stability of performance rankings following coronary artery bypass graft (CABG) surgery and hip arthroplasty.

RESEARCH DESIGN

We performed a retrospective cohort study of Medicare beneficiaries who underwent CABG surgery or hip arthroplasty at US hospitals from 2005 to 2011, with outcomes analyzed through March 2012. Nationally validated claims-based surveillance methods were used to assess for SSI within 90 days of surgery. The relationship between procedure volume and SSI rate was assessed using logistic regression and generalized additive modeling. Year-to-year stability of SSI rates was evaluated using logistic regression to assess hospitals' movement in and out of performance rankings linked to financial penalties.

RESULTS

Case-mix adjusted SSI risk based on claims was highest in hospitals performing <50 CABG/year and <200 hip arthroplasty/year compared with hospitals performing ≥200 procedures/year. At that same time, hospitals in the worst quartile in a given year based on claims had a low probability of remaining in that quartile the following year. This probability increased with volume, and when using 2 years' experience, but the highest probabilities were only 0.59 for CABG (95% confidence interval, 0.52-0.66) and 0.48 for hip arthroplasty (95% confidence interval, 0.42-0.55).

CONCLUSIONS

Aggregate SSI risk is highest in hospitals with low annual procedure volumes, yet these hospitals are currently excluded from quality reporting. Even for higher volume hospitals, year-to-year random variation makes past experience an unreliable estimator of current performance.

Methodology and Background for the World Health Organization Global Guidelines on the Prevention of Surgical Site Infection

Surgical site infections remain an important topic of concern for surgeons in all specialties and are currently the focus of global health agencies for prevention. Because patients have numerous co-morbidities that increase the risks of surgical site infections, and because of the emergence of more resistant pathogens, it is necessary to revise and update guidelines to assist surgeons in the prevention of these infections. This article will summarize the most recent WHO Global Guidelines for the prevention of Surgical Site Infection that will have applicability for surgeons in all countries.

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants

OBJECTIVE

To evaluate the safety and explore the efficacy of recombinant human lactoferrin (talactoferrin [TLf]) to reduce infection.

STUDY DESIGN

We conducted a randomized, double blind, placebo-controlled trial in infants with birth weight of 750-1500 g. Infants received enteral TLf (n = 60) or placebo (n = 60) on days 1 through 28 of life; the TLf dose was 150 mg/kg every 12 hours. Primary outcomes were bacteremia, pneumonia, urinary tract infection, meningitis, and necrotizing enterocolitis (NEC). Secondary outcomes were sepsis syndrome and suspected NEC. We recorded clinical, laboratory, and radiologic findings, along with diseases and adverse events, in a database used for statistical analyses.

RESULTS

Demographic data were similar in the 2 groups of infants. We attributed no enteral or organ-specific adverse events to TLf. There were 2 deaths in the TLf group (1 each due to posterior fossa hemorrhage and postdischarge sudden infant death), and 1 death in the placebo group, due to NEC. The rate of hospital-acquired infections was 50% lower in the TLf group compared with the placebo group (P < .04), including fewer blood or line infections, urinary tract infections, and pneumonia. Fourteen infants in the TLf group weighing <1 kg at birth had no gram-negative infections, compared with only 3 of 14 such infants in the placebo group. Noninfectious outcomes were not statistically significantly different between the 2 groups, and there were no between-group differences in growth or neurodevelopment over a 1-year posthospitalization period.

CONCLUSION

We found no clinical or laboratory toxicity and a trend toward less infectious morbidity in the infants treated with TLf.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00854633.

First Year of Mandatory Reporting of Healthcare-Associated Infections, Pennsylvania An Infection Control—Chart Abstractor Collaboration

Background.

In 2004, the Commonwealth of Pennsylvania mandated hospitals to report healthcare-associated infections (HAIs). The increased workload led our Infection Control staff to collaborate with Atlas, a group of chart abstractors.

Objective.

The objective of this study was to assess our first year of experience with mandatory reporting of HAIs—specifically, to assess Atlas' contribution to surveillance.

Design.

Cases were selected if they had 1 or more of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes designated by Pennsylvania as a possible HAI. After training by the Infection Control staff, Atlas applied National Nosocomial Infection Surveillance (NNIS) system case definitions for catheter-associated urinary tract infections (UTIs) and surgical site infections (SSIs), and they applied NNIS chest imaging criteria to eliminate cases that were not ventilator-associated pneumonia (VAP). To assess Atlas' performance, Infection Control staff conducted a parallel review.

Results.

For discharges from the hospital during the fourth quarter of 2004, a total of 410 UTIs, 59 SSIs, and 56 VAPs were identified on the basis of state-designated ICD-9-CM codes; review by Atlas/Infection Control determined that 15%, 15%, and 16% of cases met case definitions, respectively. Of cases reviewed by both Infection Control and Atlas, 87% of the assessments made by Atlas were correct for UTI, and 96% were correct for SSI. For VAP, Infection Control concluded that 39% of cases could be ruled out on the basis of chest imaging criteria; Atlas correctly dismissed these 12 cases but incorrectly dismissed an additional 6 (error, 19%). Surveillance was not timely: 1-2 months elapsed between the time of HAI onset and the earliest case review.

Conclusions.

With ongoing training by Infection Control, Atlas successfully demonstrated a role in retrospective HAI surveillance. However, despite a major effort to comply with mandates, time lags and other design limitations rendered the data of low utility for Infection Control. States that are planning HAI-reporting programs should standardize an efficient surveillance methodology that yields data capable of guiding interventions to prevent HAI.

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review

BACKGROUND

Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable.

AIMS

This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety.

METHODS

The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included.

RESULTS

Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations.

CONCLUSIONS

Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs.

Strategies to Prevent Catheter-Associated Urinary Tract 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 catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Surgical site infection: comparing surgeon versus patient self-report

BACKGROUND

To compare the rate of surgical site infection (SSI) using surgeon versus patient report.

MATERIALS AND METHODS

A prospective observational study of surgical patients in four hospitals within one private health-care system was performed. Surgeon report consisted of contacting the surgeon or staff 30 d after procedure to identify infections. Patient report consisted of telephone contact with the patient and confirmation of infections by a trained surgical clinical reviewer.

RESULTS

Between February 2011 and June 2012, there were 2853 surgical procedures that met inclusion criteria. Surgeon-reported SSI rate was significantly lower (2.4%, P value < 0.01) compared with patient self-report (4.3%). The rate was lower across most infection subtypes (1.3% versus 3.0% superficial, 0.3% versus 0.5% organ/space) except deep incisional, most procedure types (2.3% versus 4.4% general surgery) except plastics, most patient characteristics (except body mass index < 18.5), and all hospitals. There were disagreements in 3.4% of cases; 74 cases reported by patients but not surgeons and 21 cases vice versa. Disagreements were more likely in superficial infections (59.8% versus 1.0%), C-sections (22.7% versus 17.7%), hospital A (22.7% versus 17.7%), age < 65 y (74.2% versus 68.3%), and body mass index ≥ 30 (54.2% versus 39.9%).

CONCLUSIONS

Patient report is a more sensitive method of detection of SSI compared with surgeon report, resulting in nearly twice the SSI rate. Fair and consistent ways of identifying SSIs are essential for comparing hospitals and surgeons, locally and nationally.

Probabilistic Measurement of Central Line–Associated Bloodstream Infections

OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

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

INTERVENTIONS

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

RESULTS

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

CONCLUSIONS

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

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

A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection

BACKGROUND

Up to 50% of hospital antibiotic use is inappropriate and therefore improvement strategies are urgently needed. We compared the effectiveness of two strategies to improve the quality of antibiotic use in patients with a complicated urinary tract infection (UTI).

METHODS

In a multicentre, cluster-randomized trial 19 Dutch hospitals (departments Internal Medicine and Urology) were allocated to either a multi-faceted strategy including feedback, educational sessions, reminders and additional/optional improvement actions, or a competitive feedback strategy, i.e. providing professionals with non-anonymous comparative feedback on the department's appropriateness of antibiotic use. Retrospective baseline- and post-intervention measurements were performed in 2009 and 2012 in 50 patients per department, resulting in 1,964 and 2,027 patients respectively. Principal outcome measures were nine validated guideline-based quality indicators (QIs) that define appropriate antibiotic use in patients with a complicated UTI, and a QI sumscore that summarizes for each patient the appropriateness of antibiotic use.

RESULTS

Performance scores on several individual QIs showed improvement from baseline to post-intervention measurements, but no significant differences were found between both strategies. The mean patient's QI sum score improved significantly in both strategy groups (multi-faceted: 61.7% to 65.0%, P = 0.04 and competitive feedback: 62.8% to 66.7%, P = 0.01). Compliance with the strategies was suboptimal, but better compliance was associated with more improvement.

CONCLUSION

The effectiveness of both strategies was comparable and better compliance with the strategies was associated with more improvement. To increase effectiveness, improvement activities should be rigorously applied, preferably by a locally initiated multidisciplinary team.

TRIAL REGISTRATION

Nederlands Trial Register 1742.

A Web-Based, Hospital-Wide Health Care-Associated Bloodstream Infection Surveillance and Classification System: Development and Evaluation

Background

Surveillance of health care-associated infections is an essential component of infection prevention programs, but conventional systems are labor intensive and performance dependent.

Objective

To develop an automatic surveillance and classification system for health care-associated bloodstream infection (HABSI), and to evaluate its performance by comparing it with a conventional infection control personnel (ICP)-based surveillance system.

Methods

We developed a Web-based system that was integrated into the medical information system of a 2200-bed teaching hospital in Taiwan. The system automatically detects and classifies HABSIs.

Results

In this study, the number of computer-detected HABSIs correlated closely with the number of HABSIs detected by ICP by department (n=20; r=.999 P<.001) and by time (n=14; r=.941; P<.001). Compared with reference standards, this system performed excellently with regard to sensitivity (98.16%), specificity (99.96%), positive predictive value (95.81%), and negative predictive value (99.98%). The system enabled decreasing the delay in confirmation of HABSI cases, on average, by 29 days.

Conclusions

This system provides reliable and objective HABSI data for quality indicators, improving the delay caused by a conventional surveillance system.

Strategies to prevent Clostridium difficile 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 Clostridium difficile infection (CDI) prevention efforts. This document updates “Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Introduction: Improving Patient Safety Through Infection Control: A New Healthcare Imperative

Many healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups have advanced the prevention of healthcare-associated infections as a national imperative, stimulating the creation of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” in this supplement. In this introduction, we provide background and context and discuss the major issues that shaped the recommendations included in the compendium.

Statewide Validation of Hospital-Reported Central Line–Associated Bloodstream Infections: Oregon, 2009

Background.

Mandatory reporting of healthcare-associated infections is common, but underreporting by hospitals limits meaningful interpretation.

Objective.

To validate mandatory intensive care unit (ICU) central line–associated bloodstream infection (CLABSI) reporting by Oregon hospitals.

Design.

Blinded comparison of ICU CLABSI determination by hospitals and health department–based external reviewers with group adjudication.

Setting.

Forty-four Oregon hospitals required by state law to report ICU CLABSIs.

Participants.

Seventy-six patients with ICU CLABSIs and a systematic sample of 741 other patients with ICU-related bacteremia episodes.

Methods.

External reviewers examined medical records and determined CLABSI status. All cases with CLABSI determinations discordant from hospital reporting were adjudicated through formal discussion with hospital staff, a process novel to validation of CLABSI reporting.

Results.

Hospital representatives and external reviewers agreed on CLABSI status in 782 (96%) of 817 bacteremia episodes (k = 0.77 [95% confidence interval (CI), 0.70-0.84]). Among the 27 episodes identified as CLABSIs by external reviewers but not reported by hospitals, the final status was CLABSI in 16 (59%). The measured sensitivities of hospital ICU CLABSI reporting were 72% (95% CI, 62%-81%) with adjudicated CLABSI determination as the reference standard and 60% (95% CI, 51%-69%) with external review alone as the reference standard (P = .07). Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI, 0.95-1.51) to 1.54 (95% CI, 1.25-1.88) CLABSIs/1,000 central line–days; ICU CLABSI rates increased by more than 1.00 CLABSI/1,000 central line–days in 6 (14%) hospitals.

Conclusions.

Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance. Discussing discordant findings improves the quality of validation.

Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistantStaphylococcus aureus(MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary, Introduction, and accompanying editorial for additional discussion.

1. Burden of HAIs caused by MRSA in acute care facilities

a. In the United States, the proportion of hospital-associatedS. aureusinfections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% ofS. aureusinfections in hospitals.

b. Although the proportion ofS. aureus–associated HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line–associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001. Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission.

c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care.

Leveraging Electronic Medical Records for Surveillance of Surgical Site Infection in a Total Joint Replacement Population

Objective.

TO evaluate whether a hybrid electronic screening algorithm using a total joint replacement (TJR) registry, electronic surgical site infection (SSI) screening, and electronic health record (EHR) review of SSI is sensitive and specific for SSI detection and reduces chart review volume for SSI surveillance.

Design.

Validation study.

Setting.

A large health maintenance organization (HMO) with 8.6 million members.

Methods.

Using codes for infection, wound complications, cellullitis, procedures related to infections, and surgeon-reported complications from the International Classification of Diseases, Ninth Revision, Clinical Modification, we screened each TJR procedure performed in our HMO between January 2006 and December 2008 for possible infections. Flagged charts were reviewed by clinical-content experts to confirm SSIs. SSIs identified by the electronic screening algorithm were compared with SSIs identified by the traditional indirect surveillance methodology currently employed in our HMO. Positive predictive values (PPVs), negative predictive values (NPVs), and specificity and sensitivity values were calculated. Absolute reduction of chart review volume was evaluated.

Results.

The algorithm identified 4,001 possible SSIs (9.5%) for the 42,173 procedures performed for our TJR patient population. A total of 440 case patients (1.04%) had SSIs (PPV, 11.0%; NPV, 100.0%). The sensitivity and specificity of the overall algorithm were 97.8% and 91.5%, respectively.

Conclusion.

An electronic screening algorithm combined with an electronic health record review of flagged cases can be used as a valid source for TJR SSI surveillance. The algorithm successfully reduced the volume of chart review for surveillance by 90.5%.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. 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 catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Burden of CAUTIs

a. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.

b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.

c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ.

2. Outcomes associated with CAUTI

a. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.

b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.

c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Strategies to prevent catheter-associated urinary tract 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 catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA). the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Risk factors for surgical site infection following cesarean section in a Brazilian Women's Hospital: a case-control study

The present study evaluated patients with diagnosis of surgical site infection (SSI) following cesarean section and their controls to determinate risk factors and impact of antibiotic prophylaxis on this condition.

Methods

All cesareans performed from January 2009 to December 2012 were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were determined after inclusion of case patients. Medical records of case and control patients were reviewed and compared regarding sociodemographic and clinical characteristics.

Results

Our study demonstrated an association following univariate analysis between post-cesarean SSI and number of internal vaginal examinations, time of membrane rupture, emergency cesarean and improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis, considering the emergency cesarean factor only.

Conclusion

The authors of the present study not only question surgical antimicrobial prophylaxis use based on data presented here and in literature, but suggest that the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing cesarean section. Further research with greater number of patients and evaluated risk factors are fundamental for better understanding of the causes and evolution of surgical site infection after cesarean delivery.

Strategies to Prevent Catheter-Associated Urinary Tract 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 catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

The impact of influenza vaccination requirements for hospital personnel in California: knowledge, attitudes, and vaccine uptake

BACKGROUND

Seasonal influenza infections are a leading cause of illness, death, and lost productivity. Vaccinating health care personnel (HCP) can reduce transmission of influenza virus to patients and reduce influenza-related absenteeism, enabling the health care system to meet elevated demand for care during influenza outbreaks.

OBJECTIVES

We evaluated the impact of California's 2006 influenza vaccination requirement for hospital workers (requiring vaccination or signed declinations) on uptake and vaccination-related attitudes, beliefs, and knowledge among hospital HCP.

METHODS

We used a causal difference-in-differences approach to compare changes over the prior 10 years in the self-reported frequency of influenza vaccination for California hospital HCP and those from other states without similar laws using data from a stratified sample (N = 3,529) of HCP drawn from online survey panels. We also examined cross-sectional differences in awareness of vaccination policies, promotion efforts, and attitudes toward influenza vaccination. All analyses used propensity score weighting to balance the observable characteristics of the 2 samples.

RESULTS

We found that compared with their counterparts in other states, California hospital HCP were (1) more likely to report working under a formal written policy for influenza vaccination, (2) no more likely to be vaccinated, and (3) less likely to report working for an employer who provided financial incentives for vaccination or rewarded or recognized employees for being vaccinated.

CONCLUSION

Our results suggest that state-level vaccination requirements such as those enacted by California, may not be sufficient to increase uptake among hospital HCP.

Using electronic medical records to increase the efficiency of catheter-associated urinary tract infection surveillance for National Health and Safety Network reporting

BACKGROUND

Streamlining health care-associated infection surveillance is essential for health care facilities owing to the continuing increases in reporting requirements.

METHODS

Stanford Hospital, a 583-bed adult tertiary care center, used their electronic medical record (EMR) to develop an electronic algorithm to reduce the time required to conduct catheter-associated urinary tract infection (CAUTI) surveillance in adults. The algorithm provides inclusion and exclusion criteria, using the National Healthcare Safety Network definitions, for patients with a CAUTI. The algorithm was validated by trained infection preventionists through complete chart review for a random sample of cultures collected during the study period, September 1, 2012, to February 28, 2013.

RESULTS

During the study period, a total of 6,379 positive urine cultures were identified. The Stanford Hospital electronic CAUTI algorithm identified 6,101 of these positive cultures (95.64%) as not a CAUTI, 191 (2.99%) as a possible CAUTI requiring further validation, and 87 (1.36%) as a definite CAUTI. Overall, use of the algorithm reduced CAUTI surveillance requirements at Stanford Hospital by 97.01%.

CONCLUSIONS

The electronic algorithm proved effective in increasing the efficiency of CAUTI surveillance. The data suggest that CAUTI surveillance using the National Healthcare Safety Network definitions can be fully automated.

Avaliação das práticas de prevenção e controle de infecção da corrente sanguínea em um hospital governamental

O objetivo deste estudo foi avaliar as práticas de prevenção e controle de infecção da corrente sanguínea associada ao cateter venoso central (ICS-ACVC) de curta permanência, por meio da aplicação de indicadores clínicos processuais. A amostra foi constituída por 5.877 avaliações distribuídas entre as práticas selecionadas. Obteve-se ampla variação de conformidade: 91,6% - registro de indicação e tempo de permanência do CVC; 51,5% - cuidados e manutenção do curativo da inserção do CVC e seus dispositivos; 10,7% - higienização das mãos na realização de procedimentos de cuidado e manutenção do CVC; 0,0% - inserção do cateter venoso central (CVC). Os resultados demonstram necessidade de elaboração de novas estratégias que assegurem conformidade duradoura para a maioria das práticas de prevenção e controle de ICS-ACVC avaliadas. Conclui-se pela vantagem na aplicação de avaliação processual, pela possibilidade de não somente identificar seus índices de conformidade em relação à melhor prática esperada, como também favorecer, sobremaneira, reconhecimento das situações específicas que contribuíram para os valores encontrados.

Risk factors for surgical site infection in breast surgery

AIMS AND OBJECTIVES

To study risks of surgical site infection in breast surgery. The objectives were to measure the association of postoperative infection with patient- and procedure-related factors.

BACKGROUND

The infection rate in breast surgery is expected to be low but it varies a lot. The variation is recommended to be assessed by measuring procedure-related factors.

DESIGN

A retrospective chart review of 982 breast surgery patients was completed.

METHODS

The data on patient demographics, procedure types, patient and surgery-related factors were collected. A multivariate logistic regression model for all breast operations (n=982), lumpectomies (n=700) and mastectomies (n=282) was performed.

RESULTS

The infection rate was 6.7%. In a multivariate logistic regression model for all operations, a contaminated or dirty wound, high American Society of Anesthesiologists score, high body mass index, use of surgical drains and re-operation predicted increased infection risk. In lumpectomies high body mass index and use of surgical drains predicted increased risk. In mastectomies, the significant predictor was re-operation.

CONCLUSIONS

The surgical site infection rate was high. In addition to the two classical risks (high wound class and anaesthesia risk), high body mass index, re-operation and use of surgical drain increased the infection risk among all patients.

RELEVANCE TO CLINICAL PRACTICE

In breast surgery careful assessment, documentation and adherence to aseptic practices are important with all patients. Patients with heavy weight need special attention. The need for antimicrobial prophylaxis in re-operations and the need of surgical drains in lumpectomies are important to consider carefully.

Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program

BACKGROUND

Most Clostridium difficile infection (CDI) surveillance programs neither specify the diagnostic method to be used nor stratify rates accordingly. We assessed the difference in healthcare-associated CDI (HA-CDI) incidence and complication rates obtained by 2 validated diagnostic methods.

METHODS

This was a prospective cohort study of patients for whom a C. difficile test was ordered between 1 August 2010 and 31 July 2011. All specimens were tested in parallel by a commercial polymerase chain reaction (PCR) assay targeting toxin B gene tcdB, and a 3-step algorithm detecting glutamate dehydrogenase and toxins A and B by enzyme immunoassay and cell culture cytotoxicity assay (EIA/CCA). CDI incidence rate ratios were calculated using univariate Poisson regression.

RESULTS

A total of 1321 stool samples were tested during a period totaling 95 750 patient-days. Eighty-five HA-CDI cases were detected by PCR and 56 cases by EIA/CCA (P = .01). The overall incidence rate was 8.9 per 10 000 patient-days (95% confidence interval [CI], 7.1-10.9) by PCR and 5.8 per 10 000 patient-days (95% CI, 4.4-7.4) by EIA/CCA (P = .01). The incidence rate ratio comparing PCR and EIA/CCA was 1.52 (95% CI, 1.08-2.13; P = .015). Overall complication rate was 27% (23/85) when CDI was diagnosed by PCR and 39% (22/56) by EIA/CCA (P = .16). Cases detected by PCR only were less likely to develop a complication of CDI compared with cases detected by both PCR and EIA/CCA (3% vs 39%, respectively; P < .001).

CONCLUSIONS

Performing PCR instead of EIA/CCA is associated with a >50% increase in the CDI incidence rate. Standardization of diagnostic methods may be indicated to improve interhospital comparison.

Surveillance length and validity of benchmarks for central line-associated bloodstream infection incidence rates in intensive care units

Introduction

Several national and regional central line-associated bloodstream infections (CLABSI) surveillance programs do not require continuous hospital participation. We evaluated the effect of different hospital participation requirements on the validity of annual CLABSI incidence rate benchmarks for intensive care units (ICUs).

Methods

We estimated the annual pooled CLABSI incidence rates for both a real regional (<100 ICUs) and a simulated national (600 ICUs) surveillance program, which were used as a reference for the simulations. We simulated scenarios where the annual surveillance participation was randomly or non-randomly reduced. Each scenario's annual pooled CLABSI incidence rate was estimated and compared to the reference rates in terms of validity, bias, and proportion of simulation iterations that presented valid estimates (ideal if≥90%).

Results

All random scenarios generated valid CLABSI incidence rates estimates (bias −0.37 to 0.07 CLABSI/1000 CVC-days), while non-random scenarios presented a wide range of valid estimates (0 to 100%) and higher bias (−2.18 to 1.27 CLABSI/1000 CVC-days). In random scenarios, the higher the number of participating ICUs, the shorter the participation required to generate ≥90% valid replicates. While participation requirements in a countrywide program ranged from 3 to 13 surveillance blocks (1 block = 28 days), requirements for a regional program ranged from 9 to 13 blocks.

Conclusions

Based on the results of our model of national CLABSI reporting, the shortening of participation requirements may be suitable for nationwide ICU CLABSI surveillance programs if participation months are randomly chosen. However, our regional models showed that regional programs should opt for continuous participation to avoid biased benchmarks.

Agreement among health care professionals in diagnosing case Vignette-based surgical site infections

OBJECTIVE

To assess agreement in diagnosing surgical site infection (SSI) among healthcare professionals involved in SSI surveillance.

METHODS

Case-vignette study done in 2009 in 140 healthcare professionals from seven specialties (20 in each specialty, Anesthesiologists, Surgeons, Public health specialists, Infection control physicians, Infection control nurses, Infectious diseases specialists, Microbiologists) in 29 University and 36 non-University hospitals in France. We developed 40 case-vignettes based on cardiac and gastrointestinal surgery patients with suspected SSI. Each participant scored six randomly assigned case-vignettes before and after reading the SSI definition on an online secure relational database. The intraclass correlation coefficient (ICC) was used to assess agreement regarding SSI diagnosis on a seven-point Likert scale and the kappa coefficient to assess agreement for superficial or deep SSI on a three-point scale.

RESULTS

Based on a consensus, SSI was present in 21 of 40 vignettes (52.5%). Intraspecialty agreement for SSI diagnosis ranged across specialties from 0.15 (95% confidence interval, 0.00-0.59) (anesthesiologists and infection control nurses) to 0.73 (0.32-0.90) (infectious diseases specialists). Reading the SSI definition improved agreement in the specialties with poor initial agreement. Intraspecialty agreement for superficial or deep SSI ranged from 0.10 (-0.19-0.38) to 0.54 (0.25-0.83) (surgeons) and increased after reading the SSI definition only among the infection control nurses from 0.10 (-0.19-0.38) to 0.41 (-0.09-0.72). Interspecialty agreement for SSI diagnosis was 0.36 (0.22-0.54) and increased to 0.47 (0.31-0.64) after reading the SSI definition.

CONCLUSION

Among healthcare professionals evaluating case-vignettes for possible surgical site infection, there was large disagreement in diagnosis that varied both between and within specialties.

Use of benchmarking and public reporting for infection control in four high-income countries

Benchmarking of surveillance data for health-care-associated infection (HCAI) has been used for more than three decades to inform prevention strategies and improve patients' safety. In recent years, public reporting of HCAI indicators has been mandated in several countries because of an increasing demand for transparency, although many methodological issues surrounding benchmarking remain unresolved and are highly debated. In this Review, we describe developments in benchmarking and public reporting of HCAI indicators in England, France, Germany, and the USA. Although benchmarking networks in these countries are derived from a common model and use similar methods, approaches to public reporting have been more diverse. The USA and England have predominantly focused on reporting of infection rates, whereas France has put emphasis on process and structure indicators. In Germany, HCAI indicators of individual institutions are treated confidentially and are not disseminated publicly. Although evidence for a direct effect of public reporting of indicators alone on incidence of HCAIs is weak at present, it has been associated with substantial organisational change. An opportunity now exists to learn from the different strategies that have been adopted.

[Determinants of influenza vaccination in health staff: 2009-2010 season]

OBJECTIVES

To determine vaccination coverage against seasonal influenza and the new A (H1N1) influenza virus among healthcare personnel during the 2009-2010 season and to identify its determining factors.

METHODS

We performed a cross-sectional study among healthcare staff at the General University Hospital in Alicante (Spain) during the 2008-2009 and 2009-2010 influenza vaccination campaigns. The 2009-2010 vaccination campaign was subdivided into two phases. In the first phase, from 1st October to 19th November, 2009, the seasonal influenza vaccine was administered; in the second phase, from 16th November to 30th December, 2009, vaccination against the new A (H1N1) influenza virus was performed. Each of the vaccine programs was preceded by a specific vaccination promotion campaign. Healthcare staff were asked to complete a brief self-administered questionnaire containing a list of reasons for being vaccinated. Coverage during both vaccination campaigns was calculated, and the results, both overall and for each profession, were then compared using a Chi-square test.

RESULTS

Coverage against seasonal influenza was 31% and that against the new A (H1N1) influenza virus was 22.2% (p<0.05); these percentages were 36% and 34% respectively in medical personnel (NS), 33% and 24% respectively in nursing personnel (p<0.001), and 21% and 12% respectively in nursing assistants (p<0.001). The main reason given for being vaccinated was self-protection.

CONCLUSIONS

The low coverage achieved is a public health problem. Specific intervention programs should be implemented.

Secular trends of healthcare-associated infections at a teaching hospital in Taiwan, 1981-2007

The National Taiwan University Hospital (NTUH) adopted international guidelines for surveillance and control of healthcare-associated infection (HCAI) in 1981. This report describes the secular trends in HCAI at the NTUH over the past 27 years according to site of infection, aetiological agents and control measures. Clinical and microbiological data were collected by infection prevention and control nurses using a standardised case-record form. Specific control programmes were implemented and/or intensified as needed. Poisson or negative binomial regression analysis was used to quantify time trends of the incidence of HCAI. The annual number of discharges increased from 25 074 to 91 234 with a parallel increase in the Charlson comorbidity index. Active HCAI surveillance and periodic feedback were associated with a marked decrease in surgical site infections from 1981 to 2007 (2.5 vs 0.5 episodes per 100 procedures, P < 0.0001). On the other hand, there was a 4.8-fold increase in bloodstream infections (BSIs) (0.39 vs 1.88 episodes per 100 discharges, P < 0.0001). The average annual increase of pathogen-specific HCAI incidence during 1981–2007 was 11.4% for meticillin-resistant Staphylococcus aureus (MRSA), 75.4% for extensively drug-resistant A. baumannii (XDRAB), and 7.5% for Candida albicans (P < 0.0001, respectively). The infection prevention and control programme was upgraded in 2004 by implementing annual, intensive, project-based control programmes, and decreases in rates of HCAI, BSI, MRSA and XDRAB were observed. This long term study demonstrates the need to couple surveillance of HCAI with focused control programmes. Hospitals must invest in adequate manpower to accomplish these goals.

Validation of the surveillance and reporting of central line-associated bloodstream infection data to a state health department

BACKGROUND

The primary goal of health care-associated infection reporting is to identify and measure progress towards achieving the irreducible minimum number of infections. Assessing the accuracy of reporting data using independent validation is critical to this goal. In January 2008, all 30 acute care hospitals in Connecticut began mandatory reporting of central line-associated bloodstream infections (CLABSI) to the National Healthcare Safety Network (NHSN) system.

METHODS

A state nurse epidemiologist performed a blinded retrospective chart review for NHSN-reported CLABSI based on positive blood cultures from October to December 2008.

RESULTS

Of 476 septic events, 48 met the NHSN CLABSI definition, of which 23 (48%) had been reported to NHSN. Concordance of non-CLABSI events was 99% sensitive. Components of the case definition that were a source of misinterpretation included the following: NHSN surveillance definition of primary and secondary bacteremia (45%), CLABSI rules (19%), CLABSI terms (10%), and differentiation between laboratory-confirmed bloodstream criterion 1 (recognized pathogen) and criterion 2 (skin contaminant) (13%).

CONCLUSION

The validation study identified >50% underreporting of CLABSI, most related to misinterpretation of components of the NHSN definition. Continued validation and training will be needed in Connecticut to improve completeness of reported health care-associated infection data and to assure that publicly reported data are valid.

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

CONTEXT

Central line-associated bloodstream infection (BSI) rates, determined by infection preventionists using the Centers for Disease Control and Prevention (CDC) surveillance definitions, are increasingly published to compare the quality of patient care delivered by hospitals. However, such comparisons are valid only if surveillance is performed consistently across institutions.

OBJECTIVE

To assess institutional variation in performance of traditional central line-associated BSI surveillance.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective cohort study of 20 intensive care units among 4 medical centers (2004-2007). Unit-specific central line-associated BSI rates were calculated for 12-month periods. Infection preventionists, blinded to study participation, performed routine prospective surveillance using CDC definitions. A computer algorithm reference standard was applied retrospectively using criteria that adapted the same CDC surveillance definitions.

MAIN OUTCOME MEASURES

Correlation of central line-associated BSI rates as determined by infection preventionist vs the computer algorithm reference standard. Variation in performance was assessed by testing for institution-dependent heterogeneity in a linear regression model.

RESULTS

Forty-one unit-periods among 20 intensive care units were analyzed, representing 241,518 patient-days and 165,963 central line-days. The median infection preventionist and computer algorithm central line-associated BSI rates were 3.3 (interquartile range [IQR], 2.0-4.5) and 9.0 (IQR, 6.3-11.3) infections per 1000 central line-days, respectively. Overall correlation between computer algorithm and infection preventionist rates was weak (ρ = 0.34), and when stratified by medical center, point estimates for institution-specific correlations ranged widely: medical center A: 0.83; 95% confidence interval (CI), 0.05 to 0.98; P = .04; medical center B: 0.76; 95% CI, 0.32 to 0.93; P = .003; medical center C: 0.50, 95% CI, -0.11 to 0.83; P = .10; and medical center D: 0.10; 95% CI -0.53 to 0.66; P = .77. Regression modeling demonstrated significant heterogeneity among medical centers in the relationship between computer algorithm and expected infection preventionist rates (P < .001). The medical center that had the lowest rate by traditional surveillance (2.4 infections per 1000 central line-days) had the highest rate by computer algorithm (12.6 infections per 1000 central line-days).

CONCLUSIONS

Institutional variability of infection preventionist rates relative to a computer algorithm reference standard suggests that there is significant variation in the application of standard central line-associated BSI surveillance definitions across medical centers. Variation in central line-associated BSI surveillance practice may complicate interinstitutional comparisons of publicly reported central line-associated BSI rates.

Infectious risk associated with arterial catheters compared with central venous catheters

BACKGROUND

Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence.

OBJECTIVES

To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters.

METHODS

We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data.

RESULTS

We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion.

CONCLUSIONS

The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement.

Rates of surgical site infection as a performance measure: Are we ready?

With the introduction of quality assurance in health care delivery, there has been a proliferation of research studies that compare patient outcomes for similar conditions among many health care delivery facilities. Since the 1990s, increasing interest has been placed in the incorporation of clinical adverse events as quality indicators in hospital quality assurance programs. Adverse post-operative events, and very especially surgical site infection (SSI) rates after specific procedures, gained popularity as hospital quality indicators in the 1980s. For a SSI rate to be considered a valid indicator of the quality of care, it is essential that a proper adjustment for patient case mix be performed, so that meaningful comparisons of SSI rates can be made among surgeons, institutions, or over time. So far, a significant impediment to developing meaningful hospital-acquired infection rates that can be used for intra- and inter-hospital comparisons has been the lack of an adequate means of adjusting for case mix. This paper discusses what we have learned in the last years regarding risk adjustment of SSI rates for provider performance assessment, and identifies areas in which significant improvement is still needed.