Bed occupancy rates and hospital-acquired infections--should beds be kept empty?

Forecasting Hospital Room and Ward Occupancy Using Static and Dynamic Information Concurrently: Retrospective Single-Center Cohort Study

BACKGROUND

Predicting the bed occupancy rate (BOR) is essential for efficient hospital resource management, long-term budget planning, and patient care planning. Although macro-level BOR prediction for the entire hospital is crucial, predicting occupancy at a detailed level, such as specific wards and rooms, is more practical and useful for hospital scheduling.

OBJECTIVE

The aim of this study was to develop a web-based support tool that allows hospital administrators to grasp the BOR for each ward and room according to different time periods.

METHODS

We trained time-series models based on long short-term memory (LSTM) using individual bed data aggregated hourly each day to predict the BOR for each ward and room in the hospital. Ward training involved 2 models with 7- and 30-day time windows, and room training involved models with 3- and 7-day time windows for shorter-term planning. To further improve prediction performance, we added 2 models trained by concatenating dynamic data with static data representing room-specific details.

RESULTS

We confirmed the results of a total of 12 models using bidirectional long short-term memory (Bi-LSTM) and LSTM, and the model based on Bi-LSTM showed better performance. The ward-level prediction model had a mean absolute error (MAE) of 0.067, mean square error (MSE) of 0.009, root mean square error (RMSE) of 0.094, and R2 score of 0.544. Among the room-level prediction models, the model that combined static data exhibited superior performance, with a MAE of 0.129, MSE of 0.050, RMSE of 0.227, and R2 score of 0.600. Model results can be displayed on an electronic dashboard for easy access via the web.

CONCLUSIONS

We have proposed predictive BOR models for individual wards and rooms that demonstrate high performance. The results can be visualized through a web-based dashboard, aiding hospital administrators in bed operation planning. This contributes to resource optimization and the reduction of hospital resource use.

Multidrug-resistant organisms may be associated with bed allocation and utilization efficiency in healthcare institutions, based on national monitoring data from China (2014-2020)

Analyzing the influence of the bed allocation and utilization efficiency in healthcare institutions on the isolation proportion of Multidrug-resistant organisms (MDROs) to provide data to support prevention and control of MDROs. In this study, the provincial panel data from 2014 to 2020 in China on health resource indicators, including the number of beds per 1,000 population, hospital bed utilization rate, and average hospital stay from 2014 to 2020 in China were used to analyze the relationship between bed allocation or utilization efficiency and MDROs by the panel data quantile regression model. It was shown that the number of beds per 1,000 population had a negative effect on the isolation proportion of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, methicillin-resistant coagulase-negative Staphylococcus, and cefotaxime or ceftriaxone resistant Escherichia coli (regression coefficient < 0, P < 0.05). The utilization rate of hospital bed had a positive effect on the isolation proportion of methicillin-resistant Staphylococcus aureus, methicillin-resistant coagulase-negative Staphylococcus, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, cefotaxime or ceftriaxone resistant Escherichia coli, carbapenem-resistant Escherichia coli, cefotaxime or ceftriaxone resistant Klebsiella pneumoniae, carbapenem-resistant Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii (regression coefficient > 0, P < 0.05). The average hospital stay had a positive effect on the isolation proportion for several antibiotic-resistant organisms, including methicillin-resistant Staphylococcus aureus, methicillin-resistant coagulase-negative Staphylococcus, vancomycin-resistant Enterococcus faecalis, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, cefotaxime or ceftriaxone resistant Escherichia coli, carbapenem-resistant Escherichia coli, quinolone-resistant Escherichia coli, cefotaxime or ceftriaxone resistant Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii (regression coefficient > 0, P < 0.05). Bed allocation and utilization efficiency in healthcare institutions may affect the isolation proportion of MDROs in varying degrees.

Assessment of Infection Prevention and Control (IPC) Implementation and Strategies Used for IPC Preparedness at Facility Level in Underdeveloped Areas of Pakistan

Background

During outbreaks of infectious diseases like COVID-19, the healthcare-associated infections (HCAIs) pose a burden on public health system. There are very limited data about infection prevention and control (IPC) implementation in the healthcare facilities of Pakistan. The aim of the study was to conduct assessment with the IPC Assessment Framework (IPCAF) tool in healthcare facilities of the least developed areas.

Methods

A cross-sectional survey was conducted in 12 tertiary level healthcare facilities (HCF) located in the least developed provinces of Pakistan. The facilities were selected through multistage cluster random methods. A well-structured questionnaire, the "IPCAF tool", was used for data collection. The IPCAF comprises eight sections with a 100 score of each section, thus with a maximum score of 800. The scores from 0 to 800 of the HCFs were divided into four gradual ratings through IPCAF, ie from inadequate to advanced.

Results

The median score of all facilities was 405, with a range from inadequate to advanced. One facility (8.3%) fell into the "inadequate" category with a score of 172.5; 5 (41.6%) facilities achieved "basic" category, another 5 (41.6%) being "intermediate", and only one (8.3%) hospital achieved "advanced" status. Region-wise median score of facilities of GB was 307.5, facilities in AJK scored 342.5, and a score of 520 was found for health facilities in KPK. The components of Education and Training, HCAIs Surveillance, and Multimodal Strategies achieved the lowest scores.

Conclusion

Most of the facilities have developed an IPC program with key focal persons and IPC committees, but did not have relevant education and training. IPC core capacities are being implemented. Equitable attention is required on all eight components of IPC in all facilities.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Risk stratification for selecting empiric antibiotherapy during and after COVID-19

PURPOSE OF REVIEW

SARS-CoV-2 deeply modified the risk of bacterial infection, bacterial resistance, and antibiotic strategies. This review summarized what we have learned.

RECENT FINDINGS

During the COVID-19 pandemic, we observed an increase in healthcare-acquired infection and multidrug-resistant organism-related infection, triggered by several factors: structural factors, such as increased workload and ongoing outbreaks, underlying illnesses, invasive procedures, and treatment-induced immunosuppression. The two most frequently healthcare-acquired infections described in patients hospitalized with COVID-19 were bloodstream infection, related or not to catheters, health-acquired pneumonia (in ventilated or nonventilated patients). The most frequent species involved in bacteremia were Gram-positive cocci and Gram-negative bacilli in health-acquired pneumonia. The rate of Gram-negative bacilli is particularly high in late-onset ventilator-associated pneumonia, and the specific risk of Pseudomonas aeruginosa- related pneumonia increased when the duration of ventilation was longer than 7 days. A specificity that remains unexplained so far is the increase in enterococci bacteremia.

SUMMARY

The choice of empiric antibiotimicrobials depends on several factors such as the site of the infection, time of onset and previous length of stay, previous antibiotic therapy, and known multidrug-resistant organism colonization. Pharmacokinetics of antimicrobials could be markedly altered during SARS-CoV-2 acute respiratory failure, which should encourage to perform therapeutic drug monitoring.

Scenarios to Improve the Patient Experience Time in a Tertiary Academic Hospital Using Simulation

Background Shortening the patient experience time (PET) in the emergency department (ED) improves patient quality and satisfaction and reduces mortality and morbidity. Worldwide, the PET target in the ED is ≤ 6 hours; however, the PET awaiting admission to inpatient Medicine at Hamad General Hospital (HGH) in the Qatar State, through ED is currently 15.3±6.4 (mean ± SD) hours. Aim Identify solutions to reduce the PET duration at HGH-ED to the international target. Method A cohort study was done using the Discrete-event simulation (DES) model, utilizing a commercial simulation software package (Process Model Inc., Utah, version 5.2.0). One-year data, January 1, 2019 - December 30, 2019, was analyzed and found to follow seven subprocesses. The duration of each subprocess was recorded, and the average time was calculated. A computer simulation scheme was developed for all the subprocesses of the actual PET duration. The simulated PET was validated, and scenarios were proposed and assessed for each subprocess separately and in combination, A constructed simulatory design using an iterative process involving a construction model. This model starts with the logical organization of submitted tasks based on their cycle times. A subject-matter expert interview was conducted to determine the appropriateness and frequency of actions. The duration of each activity in the considered process was defined using a triangular distribution. Results The actual PET duration for the Medical Department was 15.3±6.4 (mean + SD) hours. The three most prolonged PET subprocess durations were in the referral to internal medicine, the decision to admit, and finding a free bed; these represent 17.9%, 53.8%, and 16.7% of the PET, respectively. Adding two physicians to each shift, which shortens the subprocess of the decision to admit, reduced the PET duration by 27.5%. Moreover, creating a new admitting team (unit) that takes care of new patients admitted to the ED reduced PET duration by another 12.5%. Combining these two scenarios reduced the average PET duration to only 10.2±0.5 hours. In addition to these scenarios, the PET can be further decreased to six hours by increasing the number of inpatient beds. Conclusions The simulated scenarios indicated that restructuring the medical teams, adding two physicians to each shift, and creating an admissions team dedicated to the ED would reduce the total PET duration to 10.2 hours, Furthermore, PET's further reduction to six hours is predictable by increasing the bed number.

Is the Pendulum of Antimicrobial Drug Resistance Swinging Back after COVID-19?

The COVID-19 pandemic may have had an effect on antimicrobial resistance. We compared the prevalence of ESKAPE multidrug-resistant (MDR) bacterial infections in COVID-19 affected/unaffected patients admitted to intensive care units (ICU) or infectious disease units at the “Mater Domini” University Hospital of Catanzaro between 1 March 2020 and 31 July 2021. Moreover, an analysis of MDR rates in ICU comparing the pre-pandemic period with the pandemic period was performed, and the possible consequence on in-hospital mortality was explored. One hundred and eighty-four ESKAPE isolates were analyzed from 362 SARS-CoV-2 positive and 199 negative patients. In total, 116 out of 171 Gram-negative isolates were classified as MDR, and a higher frequency was observed in COVID-19 compared with non-COVID-19 patients (74.2% vs. 60.3%; p = 0.052). A higher rate of MDR ESKAPE bacteria was observed in COVID-19 patients admitted to the ICU compared with COVID-19 unaffected patients admitted to the same ward in 2019 (88% vs. 80.4%; p = 0.186). Acinetobacter baumannii was the main pathogen in COVID-19 patients (58.7%), where it was the most frequent cause of bloodstream infection with the highest mortality rate (68.7%). Increase in MDR appeared to be associated with COVID-19 but only in the ICU setting. Acinetobacter baumannii was associated with the risk of death, indicating the importance of implementing infection control measures urgently.

It is complicated: Potential short- and long-term impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance—An expert review

As of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has claimed millions of deaths and caused disruptions in health systems around the world. The short- and long-term effects of COVID-19 on antimicrobial resistance (AMR), which was already a global threat before the pandemic, are manifold and complex. In this expert review, we summarize how COVID-19 might be affecting AMR in the short term (by influencing the key determinants antibiotic use, infection control practices and international/local mobility) and which additional factors might play a role in the long term. Whereas reduced outpatient antibiotic use in high-income countries, increased awareness for hand hygiene, and reduced mobility have likely mitigated the emergence and spread of AMR in the short term, factors such as overuse of antibiotics in COVID-19 patients, shortage of personal protective equipment, lack of qualified healthcare staff, and patient overcrowding have presumably facilitated its propagation. Unsurprisingly, international and national AMR surveillance data for 2020 show ambiguous trends. Although disruptions in antibiotic stewardship programs, AMR surveillance and research might promote the spread of AMR, other developments could prove beneficial to the cause in the long term. These factors include the increased public awareness for infectious diseases and infection control issues, the strengthening of the One Health perspective as outlined by the Centers for Disease Control and Prevention, and the unprecedented number of international research collaborations and platforms. These factors could even serve as leverage and provide opportunities to better combat AMR in the future.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

The effects of trained observers (dofficers) and audits during a facility-wide COVID-19 outbreak: A mixed-methods quality improvement analysis

Background

In response to a facility-wide COVID-19 outbreak, our tertiary acute care hospital implemented an evidence-based bundle of infection control practices including the use of audits and trained observers “dofficers” to provide real-time constructive feedback.

Methods

We trained furloughed staff to perform the role of dofficer. They offered support and corrective feedback on proper PPE use and completed 21-point audits during a 4-week intervention period. Audits tracked appropriate signage, placement and availability of supplies (equipment), correct PPE use, enhanced environmental cleaning, along with cohorting and social distancing rates. Audit data was used to provide weekly quality improvement reports to units.

Results

Nine hundred and sixty two separate audits recorded 36,948 observations, over 7,696 observer-hours. The most common errors were with environmental cleaning and PPE use; the least common were with regards to equipment availability and cohorting and social distancing. Mean error rates decreased from 9.81% to 2.88% (P < .001). The largest reduction, 22.57%, occurred in the category of PPE doffing errors.

Conclusions

Dofficer led audits effectively identified areas for improvement. Feedback through weekly reports and real-time correction of PPE errors by dofficers led to statistically significant improvements; however, error rates remained high. Further research is needed establish if these relationships are causal.

Ward-level factors associated with methicillin-resistant Staphylococcus aureus acquisition-an electronic medical records study in Singapore

Background

Methicillin-Resistant Staphylococcus aureus (MRSA) is endemic in hospitals worldwide. Intrahospital transfers may impact MRSA acquisition risk experienced by patients. In this study, we investigated ward characteristics and connectivity that are associated with MRSA acquisition.

Methods

We analysed electronic medical records on patient transfers and MRSA screening of in-patients at an acute-care tertiary hospital in Singapore to investigate whether ward characteristics and connectivity within a network of in-patient wards were associated with MRSA acquisition rates over a period of four years.

Results

Most patient transfers concentrated in a stable core network of wards. Factors associated with increased rate of MRSA acquisition were MRSA prevalence among patients transferred from other wards (rate ratio (RR): 7.74 [95% confidence interval (CI): 3.88, 15.44], additional 5 percentage point), critical care ward (RR: 1.72 [95% CI: 1.09, 2.70]) and presence of MRSA cohorting beds (RR: 1.39 [95% CI: 1.03, 1.90]. Oncology ward (RR: 0.66 [95% CI: 0.46, 0.94]) (compared to medical ward), and median length of stay (RR: 0.70 [95% CI: 0.55, 0.90], additional 1.5 days) were associated with lower acquisition rates. In addition, we found evidence of interaction between MRSA prevalence among patients transferred from other wards and weighted in-degree although the latter was not associated with MRSA acquisition after controlling for confounders.

Conclusion

Wards with higher MRSA prevalence among patients transferred from other wards were more likely to have higher MRSA acquisition rate. Its effect further increased in wards receiving greater number of patients. In addition, critical care ward, presence of MRSA cohorting beds, ward specialty, and median length of stay were associated with MRSA acquisition.

Risk factors for wound infection caused by Methicillin Resistant Staphylococcus aureus among hospitalized patients: a case control study from a tertiary care hospital in India

Background

Methicillin Resistant Staphylococcus aureus (MRSA) causes infection in hospitals and communities. The prevalence and risk factors of MRSA infection is not homogenous across the globe.

Objective

To find the risk factors of MRSA infection among hospitalized patients.

Methods

Cross-sectional case control study was conducted at a tertiary care hospital in India. The risk factors were collected using checklist from 130 MRSA and 130 Methicillin sensitive staphylococcus aureus (MSSA) infected patients. The pathogens were isolated from the wound swabs according to Clinical and Laboratory Standards Institute guidelines.

Results

Both the groups were comparable in terms of age, gender, diabetic status, undergoing invasive procedures, urinary catheterization and smoking (p>0.05). Multivariate logistic regression revealed surgical treatment (OR 4.355; CI 1.03, 18.328; p=0.045), prolonged hospitalization (OR 0.307; CI 0.11, 0.832; p=0.020), tracheostomy (OR 5.298, CI 1.16, 24.298; p=0.032), pressure/venous ulcer (OR 7.205; CI 1.75, 29.606; p=0.006) and previous hospitalization (OR 2.883; CI 1.25, 6.631; p=0.013) as significant risk factors for MRSA infection.

Conclusion

Surgical treatment, prolonged and history of hospitalization, having tracheostomy for ventilation and pressure/venous ulcer were the key risk factors. Therefore, special attention has to be given to the preventable risk factors while caring for hospitalized patients to prevent MRSA infection.

Rapid Spread and Control of Multidrug-Resistant Gram-Negative Bacteria in COVID-19 Patient Care Units

We describe rapid spread of multidrug-resistant gram-negative bacteria among patients in dedicated coronavirus disease care units in a hospital in Maryland, USA, during May–June 2020. Critical illness, high antibiotic use, double occupancy of single rooms, and modified infection prevention practices were key contributing factors. Surveillance culturing aided in outbreak recognition and control.

Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region

OBJECTIVES

Community-acquired (CAIs) and healthcare-associated (HAIs) infections are associated with significant morbidity and mortality. Data related to the epidemiology of these infections in the Middle East is scarce. The aim of this study is to estimate the prevalence of infections and antimicrobial use in the acute hospital setting in this region.

METHODS

A multicentre Point-Prevalence Survey was conducted in seven Middle Eastern countries: Egypt, Kingdom of Saudi Arabia, United Arab Emirates, Lebanon, Oman, Kuwait and Bahrain. Data were collected by the infection control and infectious diseases teams of the respective hospitals. Study surveys were completed in one day (03 April 2018).

RESULTS

The overall point prevalence of infection was 28.3%; HAI and CAI point prevalence was 11.2% and 16.8%, respectively. The majority of patients with an infection (98.2%) were receiving antimicrobial therapy. There were high levels of resistance to antimicrobials among Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and other Klebsiella sp.

CONCLUSIONS

Our findings indicate that the point prevalence of both HAI and CAI is high in a sample of Middle Eastern countries. These findings along with the increased use of antimicrobials represent a significant public health problem in the region; particularly in light of the growing regional antimicrobial resistance.

The quality of antimicrobial prescribing in acute care hospitals: results derived from a national point prevalence survey, Germany, 2016

BackgroundRobust data on the quality of antimicrobial prescriptions in German acute care hospitals are scarce. To establish and implement antimicrobial stewardship (AMS) measures and to increase prudent antimicrobial use (AMU), the identification of appropriate process and quality indicators is pertinent.AimOur main objective was to identify parameters associated with adequate AMU and inadequate AMU by analysing point prevalence data. Our secondary goal was to describe the current state of AMS implementation in Germany.MethodsA national point prevalence survey for healthcare-associated infections and AMU was conducted in German hospitals in 2016. Data on structure and process parameters were also collected. Recorded antimicrobial prescriptions were divided into adequate, inadequate and undefinable AMU. A multivariable linear regression analysis was performed to examine the correlation of selected structure and process parameters with the adequacy of recorded antimicrobials.ResultsData from 218 acute care hospitals, 64,412 patients and 22,086 administered antimicrobials were included. Multivariable linear regression analysis revealed that documentation of a reason for AMU in the patient notes increased the likelihood of adequate AMU and decreased the likelihood of inadequate AMU significantly (p < 0.001), while tertiary care hospital type had the opposite effect (p < 0.001).ConclusionThrough associating structural and process parameters with adequacy of AMU, we identified parameters that increased the odds of prudent AMU. Documentation was a key element for improving AMU. Revealed deficits regarding the implementation of AMS in German hospitals concerning dedicated staff for AMS activities and establishment of regular AMU training and AMU audits should be tackled.

Thinking outside the box: Association of antimicrobial resistance with climate warming in Europe - A 30 country observational study

The association of antimicrobial resistance (AMR) with climatic factors gained higher attention since resistance increased with increasing local temperatures in the USA. We aimed to investigate whether the explanatory strength of climatic factors holds true in a region encompassing diverse healthcare systems, like Europe. In particular, we determined whether exposure to temporal climate warming is associated with an increase in AMR prevalence for clinically relevant pathogens. A 30-country cross-sectional study was conducted. The six-year prevalence of carbapenem-resistant Pseudomonas aeruginosa (CRPA), Klebsiella pneumoniae (CRKP), Multiresistant Escherichia coli (MREC), and Methicillin-resistant Staphylococcus aureus (MRSA) was determined based on > 900 k clinical isolates. Bi- and multivariate analysis were performed to identify associations with climatic variables using healthcare and socio-economic confounders. CRPA was significantly associated with the warm-season change in temperature, which, alongside corruption perception, explained 78% of total CRPA variance. Accordingly, a 0.5 °C increase of year-wise temperature change (exposition) resulted in a 1.02-fold increase (p = 0.035) in CRPA prevalence (outcome). For a given country, exposition status doubled the odds of outcome attainment compared to non-exposition (OR = 2.03, 95%-CI [1.03-3.99]). Moreover, we found significant associations of CRKP, MREC, and MRSA with the warm-season mean temperature, which had a higher contribution to MRSA variance explanation than outpatient antimicrobial drug use. We identified a novel association between AMR and climatic factors in Europe, which reveals two aspects: climatic factors significantly contribute to the explanation of AMR in different types of healthcare systems, while climate change (i.e. warming) might increase AMR transmission, in particular CRPA.

A systematic review of the global seasonality of infections caused by Acinetobacter species in hospitalized patients

BACKGROUND

Acinetobacter is a leading multidrug resistant pathogen in hospitals worldwide that has been seen to exhibit periodic surges during summer months. However, winter peaks and lack of seasonality have also been noted.

OBJECTIVES

To systematically collate and examine the evidence describing seasonal patterns in the incidence of Acinetobacter infection in hospitalized patients.

DATA SOURCES

MEDLINE/Ovid, EMBASE, Scopus and Web of Science.

STUDY ELIGIBILITY CRITERIA

Longitudinal observational studies investigating seasonal variation in the incidence of Acinetobacter infection.

PARTICIPANTS

Patients receiving hospital care.

INTERVENTIONS

Routine hospital care.

METHODS

Systematic review with narrative evidence synthesis structured around clinical and methodological heterogeneity and internal validity of retrieved studies, seasonal patterns and risk factors detected, and stated hypotheses of mechanisms underlying seasonality. To examine consistency in reported seasonal patterns across different conditions, monthly incidence data were extracted, standardised, weighted and presented graphically.

RESULTS

Twenty-five studies reporting 37006 cases of Acinetobacter infection or colonization during 1954 months of follow-up were reviewed. Standardised monthly incidence data pooled across studies exhibited a global seasonal pattern with an incidence peak in summer/warmer months and a trough in winter/colder months. This seasonal pattern remained consistent under different weighting schemes accounting for study size, length of follow-up and overall quality assessment rating. Seasonality persisted in different clinical settings and for different types and sources of infection. Nine studies provided consistent evidence of temperature-associated variation in Acinetobacter incidence, while there were controversial findings regarding other environmental variables. No study detected patient-related or clinical practice-related seasonal variation in Acinetobacter incidence.

CONCLUSIONS

Despite substantial clinical and methodological heterogeneity in retrieved studies, a consistent global seasonal pattern in Acinetobacter infection incidence was evident in this review. This merits attention when designing or evaluating infection control interventions in hospitals. Future research should focus on elucidating driving mechanisms underlying the observed seasonality.

The implications of high bed occupancy rates on readmission rates in England: A longitudinal study

Hospital bed occupancy rates in the English National Health Service have risen to levels considered clinically unsafe. This study assesses the association of increased bed occupancy with changes in the percentage of overnight patients discharged from hospital on a given day, and their subsequent 30-day readmission rate. Longitudinal panel data methods are used to analyse secondary care records (n = 4,193,590) for 136 non-specialist Trusts between April 2014 and February 2016. The average bed occupancy rate across the study period was 90.4%. A 1% increase in bed occupancy was associated with a 0.49% rise in the discharge rate, and a 0.011% increase in the 30-day readmission rate for discharged patients. These associations became more pronounced once bed occupancy exceeded 95%. When bed occupancy rates were high, hospitals discharged a greater proportion of their patients. Those were mostly younger and less clinically complex, suggesting that hospitals are successfully prioritising early discharge amongst least vulnerable patients. However, while increased bed occupancy was not associated with a substantial increase in overall 30-day readmission rates, the relationship was more pronounced in older and sicker patients, indicating possible links with short-fallings in discharge processes.

Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments

BACKGROUND

Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement.

METHODS

This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines.

RESULTS

We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics).

CONCLUSIONS

We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

The relationship between workload and length of stay in Singapore

Prior studies link higher workload with longer length of stay (LOS) in the US. Unlike U.S. hospitals, Singaporean hospitals, like other major hospitals in the Asia-Pacific, are partially occupied by patients with non-acute needs due to insufficient alternative facilities. We examined the association between workload and length of stay (LOS) and the impact of workload on 30-day re-hospitalization and inpatient mortality rates in retrospective cohort in this setting. We defined workload as the daily number of patients per physician team. 13,097 hospitalizations of 10,000 patients were included. We found that higher workload was associated with shorter LOS (coefficient, -0.044 [95%CI, -0.083, -0.01]), especially for patients with longer stays (hazard ratios, not significantly greater than 1 before Day 4, 1.04 [95%CI, 1.01, 1.07] at Day 4 and 1.16 [95%CI, 1.10, 1.24] at Day 10), without affecting inpatient mortality (odds ratio (OR), 1.03 [95%CI, 0.99, 1.05]) or 30-day re-hospitalization (OR, 1.01 [95%CI, 0.99, 1.04]). This result differs from studies in the US and may reflect regional differences in the use of acute hospital beds for non-acute needs.

Occupancy rate and adverse patient outcomes in general hospitals in Thailand: A predictive study

Patient outcomes are important indicators of the quality of care. Occupancy rate is one factor that significantly affects adverse patient outcomes. The aim of the present study was to determine factors associated with adverse patient outcomes in Thailand. A retrospective study was conducted with 146 inpatient units from 16 general hospitals. Hospital characteristics and adverse patient outcomes were recorded, and data were analyzed by using frequency, percentage, and binomial logistic regression. The results revealed that the average number of beds per hospital was 430.5 (standard deviation [SD] = 108.6), the average number of beds per unit was 27.9 (SD = 8.9), and the average occupancy rate was 81.1% (SD = 20.6, range = 28.8-133.1%). Data were adjusted for hospital size, unit type, and number of beds in each unit; a 1% increase in occupancy rate increased the likelihood of pressure ulcers by 4.3% (P = 0.001), of hospital-acquired pneumonia by 2.4% (P = 0.032), and of hospital-acquired urinary tract infections by 2.1% (P = 0.033). The findings suggest that a higher level of occupancy rates predicted a greater likelihood of adverse patient outcomes.

Improving the Hospital Quality of Care during Winter Periods by Optimizing Budget Allocation Between Rotavirus Vaccination and Bed Expansion

BACKGROUND

During each winter the hospital quality of care (QoC) in pediatric wards decreases due to a surge in pediatric infectious diseases leading to overcrowded units. Bed occupancy rates often surpass the good hospital bed management threshold of 85%, which can result in poor conditions in the workplace. This study explores how QoC-scores could be improved by investing in additional beds and/or better vaccination programs against vaccine-preventable infectious diseases.

METHODS

The Cobb-Douglas model was selected to define the improvement in QoC (%) as a function of two strategies (rotavirus vaccination coverage [%] and addition of extra hospital beds [% of existing beds]), allowing improvement-isocurves to be produced. Subsequently, budget minimization was applied to determine the combination of the two strategies needed to reach a given QoC improvement at the lowest cost. Data from Jessa Hospital (Hasselt, Belgium) were chosen as an example. The annual population in the catchment area to be vaccinated was 7000 children; the winter period was 90 days with 34 pediatric beds available. Rotavirus vaccination cost per course was €118.26 and the daily cost of a pediatric bed was €436.53. The target QoC increase was fixed at 50%. The model was first built with baseline parameter values.

RESULTS

The model predicted that a combination of 64% vaccine coverage and 39% extra hospital beds (≈ 13 extra beds) in winter would improve QoC-scores by 50% for the minimum budget allocation.

CONCLUSION

The model allows determination of the most efficient allocation of the healthcare budget between rotavirus vaccination and bed expansion for improving QoC-scores during the annual epidemic winter seasons.

The Weekend Effect in Hospitalized Patients: A Meta-Analysis

BACKGROUND

The presence of a "weekend effect" (increased mortality rate during Saturday and/or Sunday admissions) for hospitalized inpatients is uncertain.

PURPOSE

We performed a systematic review to examine the presence of a weekend effect on hospital inpatient mortality.

DATA SOURCES

PubMed, EMBASE, SCOPUS, and Cochrane databases (January 1966-April 2013) were utilized for our search.

STUDY SELECTION

We examined the mortality rate for hospital inpatients admitted during the weekend compared with those admitted during the workweek. To be included, the study had to provide discrete mortality data around the weekends (including holidays) versus weekdays, include patients who were admitted as inpatients over the weekend, and be published in English.

DATA EXTRACTION

The primary outcome was all-cause weekend versus weekday mortality with subgroup analysis by personnel staffing levels, rates and times to procedures rates and delays, or illness severity.

DATA SYNTHESIS

A total of 97 studies (N = 51,114,109 patients) were examined. Patients admitted on the weekends had a significantly higher overall mortality (relative risk, 1.19; 95% confidence interval, 1.14-1.23). With regard to the subgroup analyses, patients admitted on the weekends consistently had higher mortality than those admitted during the week, regardless of the levels of weekend/weekday differences in staffing, procedure rates and delays, and illness severity.

CONCLUSIONS

Hospital inpatients admitted during weekends may have a higher mortality rate compared with inpatients admitted during the weekdays.

Development and evaluation of the automated risk assessment system for multidrug-resistant organisms (autoRAS-MDRO)

BACKGROUND

A high proportion of infections acquired in hospitals are caused by multidrug-resistant organisms (MDROs). The priority in MDRO prevention is to detect high-risk patients and implement preventive intervention as soon as possible.

AIM

To develop an automated risk assessment system for MDROs (autoRAS-MDRO) to screen for patients at MDRO infection risk and evaluate the predictive validity of the autoRAS-MDRO.

METHODS

Data for 4200 variables were extracted from the electronic health records (EHRs) for constructing the MDRO risk-scoring algorithm, which was based on a logistic regression model. The autoRAS-MDRO was designed such that the MDRO risk classification (high, moderate, low risk) could be automatically displayed on the nursing Kardex screen in the EHRs system. For the development of the MDRO risk-scoring algorithm, 1000 patients with MDROs and 4000 patients without MDROs were selected; similarly, for the evaluation, 2173 and 8692 patients with and without MDROs, respectively, were selected.

FINDINGS

The predictive validity of the autoRAS-MDRO was as follows: (i) at the 6-month evaluation: sensitivity, 81%; specificity, 79%; positive predictive value (PPV), 49%; negative predictive value (NPV), 94%; and Youden index, 0.60; (ii) at the 12-month evaluation: sensitivity 79%, specificity 78%, PPV 47%, NPV 94%, and Youden index, 0.57.

CONCLUSION

The autoRAS-MDRO had moderate predictive validity. It could be useful in redirecting nurses' time and efforts required for MDRO risk assessment and implementation of infection control measures, and in reducing the incidence of MDRO infection in hospitals, thereby contributing to patient safety.

Intrahospital transfers and the impact on nursing workload

AIMS AND OBJECTIVES

To determine the rate of patient moves and the impact on nurses' time.

BACKGROUND

Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured.

DESIGN

A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study.

METHODS

Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75).

RESULTS

Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month.

CONCLUSION

Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems.

RELEVANCE TO CLINICAL PRACTICE

Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care.

Description of the rates, trends and surgical burden associated with revision for prosthetic joint infection following primary and revision knee replacements in England and Wales: an analysis of the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

OBJECTIVES

To describe the prevalence rates of revision surgery for the treatment of prosthetic joint infection (PJI) for patients undergoing knee replacement, their time trends, the cumulative incidence function of revision for PJI and estimate the burden of PJI at health service level.

DESIGN

We analysed revision knee replacements performed due to a diagnosis of PJI and the linked index procedures recorded in the National Joint Registry from 2003 to 2014 for England and Wales. The cohort analysed consisted of 679 010 index primary knee replacements, 33 920 index revision knee replacements and 8247 revision total knee replacements performed due to a diagnosis of PJI. The prevalence rates, their time trends investigated by time from index surgery to revision for PJI, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression.

RESULTS

The incidence of revision total knee replacement due to PJI at 2 years was 3.2/1000 following primary and 14.4/1000 following revision knee replacement, respectively. The prevalence of revision due to PJI in the 3 months following primary knee replacement has risen by 2.5-fold (95% CI 1.2 to 5.3) from 2005 to 2013 and 7.5-fold (95% CI 1.0 to 56.1) following revision knee replacement. Over 1000 procedures per year are performed as a consequence of knee PJI, an increase of 2.8 from 2005 to 2013. Overall, 75% of revisions were two-stage with an increase in use of single-stage from 7.9% in 2005 to 18.8% in 2014.

CONCLUSIONS

Although the risk of revision due to PJI following knee replacement is low, it is rising, and coupled with the established and further predicted increased incidence of both primary and revision knee replacements, this represents an increasing and substantial treatment burden for orthopaedic service delivery in England and Wales. This has implications for future service design and the funding of individual and specialist centres.

Increased Total Anesthetic Time Leads to Higher Rates of Surgical Site Infections in Spinal Fusions

STUDY DESIGN

A retrospective review of a consecutive series of spinal fusions comparing patient and procedural characteristics of patients who developed surgical site infections (SSIs) after spinal fusion.

OBJECTIVE

It is known that increased surgical time (incision to closure) is associated with a higher rate of postoperative SSIs. We sought to determine whether increased total anesthetic time (intubation to extubation) is a factor in the development of SSIs as well.

SUMMARY AND BACKGROUND DATA

In spine surgery for deformity and degenerative disease, SSI has been associated with operative time, revealing a nearly 10-fold increase in SSI rates in prolonged surgery. Surgical time is associated with infections in other surgical disciplines as well. No studies have reported whether total anesthetic time (intubation to extubation) has an association with SSIs.

METHODS

Surgical records were searched in a retrospective fashion to identify all spine fusion procedures performed between January 2010 and July 2012. All SSIs during that timeframe were recorded and compared with the list of cases performed between 2010 and 2012 in a case-control design.

RESULTS

There were 20 (1.7%) SSIs in this fusion cohort. On univariate analyses of operative factors, there was a significant association between total anesthetic time (Infection 7.6 ± 0.5 hrs vs. no infection -6.0 ± 0.1 hrs, P < 0.001) and increasing operative time (infection 5.5 ± 0.4 hrs vs. no infection - 4.4 ± 0.06 hrs, P < 0.01) with infections, whereas level of pathology and emergent surgery were not significant. On multivariate logistic analysis, BMI and total anesthetic time remained independent predictors of SSI whereas ASA status and operative time did not.

CONCLUSION

Increasing BMI and total anesthetic time were independent predictors of SSIs in this cohort of over 1000 consecutive spinal fusions.

LEVEL OF EVIDENCE

3.

Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry

Objectives

We used the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) to investigate the risk of revision due to prosthetic joint infection (PJI) for patients undergoing primary and revision hip arthroplasty, the changes in risk over time, and the overall burden created by PJI.

Methods

We analysed revision total hip arthroplasties (THAs) performed due to a diagnosis of PJI and the linked index procedures recorded in the NJR between 2003 and 2014. The cohort analysed consisted of 623 253 index primary hip arthroplasties, 63 222 index revision hip arthroplasties and 7585 revision THAs performed due to a diagnosis of PJI. The prevalence, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression.

Results

We demonstrated a prevalence of revision THA due to prosthetic joint infection of 0.4/100 procedures following primary and 1.6/100 procedures following revision hip arthroplasty. The prevalence of revision due to PJI in the three months following primary hip arthroplasty has risen 2.3-fold (95% confidence interval (CI) 1.3 to 4.1) between 2005 and 2013, and 3.0-fold (95% CI 1.1 to 8.5) following revision hip arthroplasty. Over 1000 procedures are performed annually as a consequence of hip PJI, an increase of 2.6-fold between 2005 and 2013.

Conclusions

Although the risk of revision due to PJI following hip arthroplasty is low, it is rising and, coupled with the established and further predicted increased incidence of both primary and revision hip arthroplasty, this represents a growing and substantial treatment burden.

Cite this article: E. Lenguerrand, M. R. Whitehouse, A. D. Beswick, S. A. Jones, M. L. Porter, A. W. Blom. Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry. Bone Joint Res 2017;6:391–398. DOI: 10.1302/2046-3758.66.BJR-2017-0003.R1.

Assessing Occupancy and Its Relation to Healthcare-Associated Infections

Occupancy has been associated with risk for healthcare-associated infections, yet its definition varies widely. Occupancy can be modeled as a function of census, acuity of the patient care unit, staffing ratio, or some combination. This article discusses the appropriate parameterization of these measures and how to interpret their impact.

Infect Control Hosp Epidemiol 2016:1–3

Patient safety work in Sweden: quantitative and qualitative analysis of annual patient safety reports

Background

There is widespread recognition of the problem of unsafe care and extensive efforts have been made over the last 15 years to improve patient safety. In Sweden, a new patient safety law obliges the 21 county councils to assemble a yearly patient safety report (PSR). The aim of this study was to describe the patient safety work carried out in Sweden by analysing the PSRs with regard to the structure, process and result elements reported, and to investigate the perceived usefulness of the PSRs as a tool to achieve improved patient safety.

Methods

The study was based on two sources of data: patient safety reports obtained from county councils in Sweden published in 2014 and a survey of health care practitioners with strategic positions in patient safety work, acting as key informants for their county councils. Answers to open-ended questions were analysed using conventional content analysis.

Results

A total of 14 structure elements, 31 process elements and 23 outcome elements were identified. The most frequently reported structure elements were groups devoted to working with antibiotics issues and electronic incident reporting systems. The PSRs were perceived to provide a structure for patient safety work, enhance the focus on patient safety and contribute to learning about patient safety.

Conclusion

Patient safety work carried out in Sweden, as described in annual PSRs, features a wide range of structure, process and result elements. According to health care practitioners with strategic positions in the county councils’ patient safety work, the PSRs are perceived as useful at various system levels.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1350-5) contains supplementary material, which is available to authorized users.

Costs and possible benefits of a two-tier infection control management strategy consisting of active screening for multidrug-resistant organisms and tailored control measures

BACKGROUND

Multidrug-resistant organisms (MDROs) are an economic burden, and infection control (IC) measures are cost- and labour-intensive. A two-tier IC management strategy was developed, including active screening, in order to achieve effective use of limited resources. Briefly, high-risk patients were differentiated from other patients, distinguished according to type of MDRO, and IC measures were implemented accordingly.

AIM

To evaluate costs and benefits of this IC management strategy.

METHODS

The study period comprised 2.5 years. All high-risk patients underwent microbiological screening. Gram-negative bacteria (GNB) were classified as multidrug-resistant (MDR) and extensively drug-resistant (XDR). Expenses consisted of costs for staff, materials, laboratory, increased workload and occupational costs.

FINDINGS

In total, 39,551 patients were screened, accounting for 24.5% of all admissions. Of all screened patients, 7.8% (N=3,104) were MDRO positive; these patients were mainly colonized with vancomycin-resistant enterococci (37.3%), followed by meticillin-resistant Staphylococcus aureus (30.3%) and MDR-GNB (28.3%). The median length of stay (LOS) for all patients was 10 days (interquartile range 3-20); LOS was twice as long in colonized patients (P<0.001). Screening costs totalled 255,093.82€, IC measures cost 97,701.36€, and opportunity costs were 599,225.52€. The savings of this IC management strategy totalled 500,941.84€. Possible transmissions by undetected carriers would have caused additional costs of 613,648.90-4,974,939.26€ (i.e. approximately 600,000-5 million €).

CONCLUSION

Although the costs of a two-tier IC management strategy including active microbiological screening are not trivial, these data indicate that the approach is cost-effective when prevented transmissions are included in the cost estimate.

Optimizing hospital infection control: the role of mathematical modeling

Multidrug-resistant bacteria are major causes of nosocomial infections and are associated with considerable morbidity, mortality, and healthcare costs. Preventive strategies have therefore become increasingly important. Mathematical modeling has been widely used to understand the transmission dynamics of nosocomial infections and the quantitative effects of infection control measures. This review will explore the principles of mathematical modeling used in nosocomial infections and discuss the effectiveness of infection control measures investigated using mathematical modeling.

High bed occupancy rates: Are they a risk for patients and staff?

AIM

In order to produce empirical evidence on the relationship between high bed occupancy and its potential hazards, this study correlates bed occupancy rates with hospital patient safety and staff overload indicators.

METHODS

Data from nine medium to large scale public hospitals, all pertaining to the Hospital Foundation of Minas Gerais, Brazil, were gathered for the period January 2007 to June 2011. Indicators were aggregated by month, resulting in 486 observations (54 months × 9 hospitals). Bivariate linear regressions were performed, aiming to estimate the effect of bed occupancy rates on each response variable (hospital infection rates, institutional mortality and sick leave incidence). In addition, to directly test the hypothesis that bed occupancy rates over 85% are unsafe, it was included in the models as a categorical instead of continuous variable, using 85% as the cut-off value.

RESULTS

Bed occupancy rates showed an inverse correlation to mortality rates (b = -0.056; P < 0.001) and presented no significant correlation to the nosocomial infection rates (P = 0.512). High bed occupancy (>85%) was associated with a slight increment of short sick leaves, especially short leaves (<7 days) (+0.14%; P = 0.008).

CONCLUSIONS

The increase in hospital loading was unexpectedly associated with reduced institutional mortality and was not related to nosocomial infection incidences. High bed occupancy was associated to a slight increment of short sick leaves.

Acinetobacter baumannii infection in prior ICU bed occupants is an independent risk factor for subsequent cases of ventilator-associated pneumonia

OBJECTIVE

We aimed to evaluate risk factors for ventilator-associated pneumonia (VAP) due to Acinetobacter baumannii (AbVAP) in critically ill patients.

METHODS

This was a prospective observational study conducted in an intensive care unit (ICU) of a district hospital (6 beds). Consecutive patients were eligible for enrolment if they required mechanical ventilation for >48 hours and hospitalization for >72 hours. Clinical, microbiological, and laboratory parameters were assessed as risk factors for AbVAP by univariate and multivariate analysis.

RESULTS

193 patients were included in the study. Overall, VAP incidence was 23.8% and AbVAP, 11.4%. Previous hospitalization of another patient with Acinetobacter baumannii infection was the only independent risk factor for AbVAP (OR (95% CI) 12.016 (2.282-19.521) P < 0.001). ICU stay (25 ± 17 versus 12 ± 9  P < 0.001), the incidence of other infections (OR (95% CI) 9.485 (1.640-10.466) P = 0.002) (urinary tract infection, catheter related infection, and bacteremia), or sepsis (OR (95% CI) 10.400 (3.749-10.466) P < 0.001) were significantly increased in patients with AbVAP compared to patients without VAP; no difference was found with respect to ICU mortality.

CONCLUSION

ICU admission or the hospitalization of patients infected by Acinetobacter baumannii increases the risk of AbVAP by subsequent patients.

Associations between in-hospital bed occupancy and unplanned 72-h revisits to the emergency department: a register study

Background

A possible downstream effect of high in-hospital bed occupancy is that patients in the emergency department (ED) who would benefit from in-hospital care are denied admission. The present study aimed at evaluating this hypothesis through investigating associations between in-hospital bed occupancy at the time of presentation in the ED and the probability for unplanned 72-hour (72-h) revisits to the ED among patients discharged at index. A second outcome was unplanned 72-h revisits resulting in admission.

Methods

All visits to the ED of a 420-bed emergency hospital in southern Sweden between 1 January 2011 and 31 December 2012, which did not result in admission, death, or transfer to another hospital were included. Revisiting fractions were computed for in-hospital occupancy intervals <85%, 85% to 90%, 90% to 95%, 95% to 100%, 100% to 105%, and ≥105%. Multivariate models were constructed in an attempt to take confounding factors from, e.g., presenting complaints, age, referral status, and triage priority into account.

Results

Included in the study are 81,878 visits. The fraction of unplanned 72-h revisits/unplanned 72-h revisits resulting in admission was 5.8%/1.4% overall, 6.2%/1.4% for occupancy <85%, 6.4%/1.5% for occupancy 85% to 90%, 5.8%/1.4% for occupancy 90% to 95%, 6.0%/1.6% for occupancy 95% to 100%, 5.4%/1.6% for occupancy 100% to 105%, and 4.9%/1.4% for occupancy ≥105%.

In the multivariate models, a trend to lower probability of unplanned 72-h revisits was observed at occupancy ≥105% compared to occupancy <95% (OR 0.88, CI 0.76 to 1.01). No significant associations between in-hospital occupancy at index and the probability of making unplanned 72-h revisits resulting in admission were observed.

Conclusions

The lack of associations between in-hospital occupancy and unplanned 72-h revisits does not support the hypothesis that ED patients are inappropriately discharged when in-hospital beds are scarce. The results are reassuring as they indicate that physicians are able to make good decisions, also while resources are constrained.

Control of the spread of vancomycin-resistant enterococci in hospitals: epidemiology and clinical relevance

BACKGROUND

The spread of vancomycin-resistant enterococci (VRE), particularly E. faecium, in hospitals leads to many cases of colonization, but only sporadic infections. Detailed and valid risk assessment is needed so that patients at risk can be protected from VRE infection. The principal aims of risk assessment must include not only lowering VRE-associated morbidity and mortality in patients at risk, but also refraining from unnecessary anti-infective measures among those who are not at risk.

METHODS

We selectively searched the PubMed database for pertinent articles on the epidemiology and clinical relevance of VRE in order to derive a uniform and practical hygiene strategy from the available scientific evidence.

RESULTS

Only low-level evidence is available for the interventions studied to date, and most of the recommendations that have been issued can be characterized as expert opinion. As a rule, VRE are not highly pathogenic; they tend to have high rates of colonization, but low rates of infection. The risk factors for colonization with VRE include (among others) the administration of antibiotics and immunosuppressants, prior hospitalization, diarrhea, intubation, and other invasive treatments. The areas of highest risk are hematology/oncology wards, liver transplantation wards, dialysis units, and neonatology wards.

CONCLUSION

The chain of infection can be broken by improved and consistently applied standard hygienic measures (hand and surface disinfection). Some patients are nonetheless at elevated risk of VRE infection. In specific clinical situations, the optimal protection of these patients against VRE infection demands the obligatory enforcement of stricter hygienic measures (contact isolation).

Limits of patient isolation measures to control extended-spectrum beta-lactamase-producing Enterobacteriaceae: model-based analysis of clinical data in a pediatric ward

Background

Extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-E) are a growing concern in hospitals and the community. How to control the nosocomial ESBL-E transmission is a matter of debate. Contact isolation of patients has been recommended but evidence supporting it in non-outbreak settings has been inconclusive.

Methods

We used stochastic transmission models to analyze retrospective observational data from a two-phase intervention in a pediatric ward, successively implementing single-room isolation and patient cohorting in an isolation ward, combined with active ESBL-E screening.

Results

For both periods, model estimates suggested reduced transmission from isolated/cohorted patients. However, most of the incidence originated from sporadic sources (i.e. independent of cross-transmission), unaffected by the isolation measures. When sporadic sources are high, our model predicted that even substantial efforts to prevent transmission from carriers would have limited impact on ESBL-E rates.

Conclusions

Our results provide evidence that, considering the importance of sporadic acquisition, e.g. endogenous selection of resistant strains following antibiotic treatment, contact-isolation measures alone might not suffice to control ESBL-E. They also support the view that estimating cross-transmission extent is key to predicting the relative success of contact-isolation measures. Mathematical models could prove useful for those estimations and guide decisions concerning the most effective control strategy.