Is it financially beneficial for hospitals to prevent nosocomial infections?

Associations between Child Opportunity Index and Pediatric Cardiac Surgical Outcomes

OBJECTIVE

To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia.

STUDY DESIGN

In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes.

RESULTS

Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models.

CONCLUSION

COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity.

Link of Infection Prevention Climate to Patient-Centered Care: Role of Workplace Safety and Risk Mitigation

Background

Healthcare-associated infections pose a substantial threat to the quality of healthcare services. Consequently, it is imperative for hospital organizations to actively support an infection prevention climate, fostering workplace safety and risk mitigation, thereby promoting patient-centered care.

Purpose

This study aims to explore the interconnectedness between the infection prevention climate, workplace safety, risk mitigation, and patient-centered care.

Methods

A cross-sectional study design was employed, utilizing a questionnaire administered to 235 healthcare professionals in intensive care and inpatient units at Bandung Kiwari Regional General Hospital. Data analysis was conducted using partial least squares structural equation modeling (PLS-SEM) with SmartPLS 4 and SPSS 25.

Results

The study revealed several significant relationships, including (1) between infection prevention climate and patient-centered care; (2) infection prevention climate and workplace safety; (3) workplace safety and patient-centered care; (4) infection prevention climate and patient-centered care mediated by workplace safety; (5) infection prevention climate and risk mitigation; (6) risk mitigation and patient-centered care; (7) and the relationship between infection prevention climate and patient-centered care mediated by risk mitigation.

Conclusion

Infection prevention climate emerges as a crucial intangible value that hospital organizations can cultivate to shape workplace safety. This, in turn, encourages healthcare workers' compliance in implementing infection prevention controls as a form of risk mitigation, ultimately contributing to the provision of patient-centered care.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units

BACKGROUND

Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate.

AIM

To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach.

METHODS

A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative.

RESULTS

The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%.

CONCLUSION

Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Evaluation of a novel surface-coating formulation with time-extended antimicrobial activity for healthcare environment disinfection

BACKGROUND

The importance of environmental contamination in the transmission of pathogens among hospitalized patients is universally recognized, and disinfection of surfaces is a widely accepted modality for reducing healthcare-associated infections. Nevertheless, hospital disinfection is still suboptimal. In this study, we evaluated the sustained effects of the novel formulation OxiLast™ which extends the antimicrobial effects of chlorine-based disinfectants.

METHODS

In an experimental lab phase, PVC surfaces were coated with OxiLast™ and then inoculated with representative Gram-positive and Gram-negative pathogenic bacteria. Cells were recovered at different contact times (5, 15, 30 min) to assess the reduction in bacterial counts compared to uncoated surfaces and also subject to various challenges to assess robustness. A similar methodology was then applied in an unoccupied hospital room to evaluate the sustained effect of OxiLast™ on high-touch surfaces.

RESULTS

OxiLast™ demonstrated notable activity against the range of bacterial strains tested with ≥ 4 log10 reduction in bacterial counts observed for up to seven days following one surface application, for various strains and contact times. Similar results were observed following challenges such as simulated abrasion of coated surfaces, organic contamination or successive inoculations. The results were confirmed in a simulated patient care environment.

CONCLUSIONS

The addition of OxiLast™ to common chlorine-based disinfectants has shown a substantial and sustained reduction in bacterial pathogen counts for up to 7 days following one application. The consistent results in the laboratory and hospital are promising and should be tested in a real-life clinical scenario.

The TIGIT+ T regulatory cells subset associates with nosocomial infection and fatal outcome in COVID-19 patients under mechanical ventilation

The TIGIT+FOXP3+Treg subset (TIGIT+Tregs) exerts robust suppressive activity on cellular immunity and predisposes septic individuals to opportunistic infection. We hypothesized that TIGIT+Tregs could play an important role in intensifying the COVID-19 severity and hampering the defense against nosocomial infections during hospitalization. Herein we aimed to verify the association between the levels of the TIGIT+Tregs with the mechanical ventilation requirement, fatal outcome, and bacteremia during hospitalization. TIGIT+Tregs were immunophenotyped by flow cytometry from the peripheral blood of 72 unvaccinated hospitalized COVID-19 patients at admission from May 29th to August 6th, 2020. The patients were stratified during hospitalization according to their mechanical ventilation requirement and fatal outcome. COVID-19 resulted in a high prevalence of the TIGIT+Tregs at admission, which progressively increased in patients with mechanical ventilation needs and fatal outcomes. The prevalence of TIGIT+Tregs positively correlated with poor pulmonary function and higher plasma levels of LDH, HMGB1, FGL2, and TNF. The non-survivors presented higher plasma levels of IL-33, HMGB1, FGL2, IL-10, IL-6, and 5.54 times more bacteremia than survivors. Conclusions: The expansion of the TIGIT+Tregs in COVID-19 patients was associated with inflammation, lung dysfunction, bacteremia, and fatal outcome.

Analysis of impact of nosocomial infections on cost of patient hospitalisation

OBJECTIVES

The scale of the economic problem of the occurrence of nosocomial infections and the resulting high additional costs of treatment can only be assessed using economic analyses. The aim of the study was to analyse the impact of a nosocomial infection in a patient in the treatment process and the direct costs of patient hospitalisation. The article contributes to a cost analysis, which is a relevant basis for adopting effective solutions and decisions on the introduction of new programmes and measures to reduce nosocomial infections and associated costs.

METHODS

In the first phase of the micro-economic analysis, we analysed the course of hospitalisation of a non-colonised patient treated in an ordinary hospital room. In the second phase, we analysed the process of hospitalisation of a patient who developed a nosocomial infection and was transferred to an isolation room. The difference in cost of both types of treatment allowed us to carry out an economic analysis to estimate the direct costs of nosocomial infection, which are not related to the initial diagnosis of the patient but only to the patient hospitalisation. To calculate the individual types of direct costs of both alternative treatments, we first used the process flow diagram method, which then enabled us to analyse the impact of the occurrence of nosocomial infection on the efficiency and costs of the hospital.

RESULTS

The results showed that the total direct cost of hospitalisation of a non-colonised patient was 1,317.58 euro per day, and the direct cost of hospitalisation of a patient with a nosocomial infection was 2,268.14 euro per day of hospitalisation.

CONCLUSIONS

We found that reducing nosocomial infections would have a significant impact on the savings or reduction in healthcare costs associated with a different work process for patients in isolation. It would save 950.56 euro per patient for each day of hospitalisation for individual treatment of a patient hospitalised in an isolation room as consequence of a nosocomial infection.

Evaluating the safety of same-day discharge following pediatric pyeloplasty and ureteral reimplantation; A NSQIP analysis 2012-2020

INTRODUCTION

Same-day discharge (SDD) is a safe option for several adult urologic surgeries, benefiting patients and hospitals. By decreasing length of stay while maintaining patient safety, SDD is in-line with recent goals to provide high value care while minimizing costs. Literature on SDD in the pediatric population, however, is scarce, and no study has identified the efficacy of SDD for pediatric pyeloplasty (PP) and ureteral reimplantation (UR).

OBJECTIVE

The aim of this study was to identify trends in the usage of SDD as well as its efficacy and safety based on surgical outcomes for pediatric PP and UR.

STUDY DESIGN

The 2012-2020 files of the American College of Surgeon's National Surgical Quality Improvement Project pediatric database were queried for PP and UR. Patients were stratified as SDD or standard-length discharge (SLD). Trends in SDD usage, differences in baseline characteristics, surgical approach, and surgical outcomes including 30-day readmission, complication, and reoperation rates were analyzed between SDD and SLD groups.

RESULTS

8213 PP (SDD: 202 [2.46%]) and 10,866 UR (469 [4.32%]) were included in analysis. There were no significant changes in SDD rates between 2012 and 2020, averaging 2.39% (PP), and 4.39% (UR). For both procedures, SDD was associated with higher rates of open versus minimally invasive (MIS) surgical approach and with shorter operative and anesthesia durations. For PP, there were no differences in readmission, complication, or reoperation rates in the SDD group. For UR, there was a 1.69% increase in CD I/II complications in those receiving SDD, correlating to 1.96-fold higher odds of CD I/II in all SDD patients compared to SLD patients.

DISCUSSION

These results suggest that while the rate of SDD has not increased in recent years, the current screening methods for SDD have been generally effective in maintaining the safety of SDD for pediatric procedures. Though SDD for UR did show a very small increase in minor complications, this may be due to less strict screening protocols, and may be alleviated via MIS surgical approach. While this is the first paper to investigate SDD for pediatric urology procedures, these results are similar to those found for adult procedures. This study is limited by the lack of clinical data reported in the database.

CONCLUSION

SDD is a generally safe option for pediatric PP and UR, and further research should identify proper screening protocols to continue to allow for safe SDD.

Impact of septic episodes caused by Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa in a tertiary hospital: clinical and economic considerations in years 2018-2020

OBJECTIVE

To evaluate incidence, therapy and antibiotic resistance trends in septic episodes caused by three multi-drug resistant bacteria in a tertiary hospital, by also estimating their economic impact.

METHODS

An observational, retrospective-cohort analysis was based on data related to patients admitted to the "SS. Antonio e Biagio e Cesare Arrigo" Hospital in Alessandria (Italy) between 2018 and 2020, that developed sepsis from multi-drug resistant bacteria of the examined species. Data were retrieved from medical records and from the hospital's management department.

RESULTS

Inclusion criteria led to enrolment of 174 patients. A relative increase in A. baumannii cases (p < 0.0001) and an increasing resistance trend for K. pneumoniae (p < 0.0001) were detected in 2020 compared to 2018-2019. Most patients were treated with carbapenems (72.4%), although the use of colistin rose significantly in 2020 (62.5% vs 36%, p = 0.0005). Altogether, these 174 cases caused 3295 additional hospitalisation days (mean 19 days/patient): the consequent expenditure attained ≈ 3 million Euros, 85% of which (≈2.5 million Euros) due to the cost of extra hospital stay. Specific antimicrobial therapy accounted for 11.2% of the total (≈336,000 €).

CONCLUSIONS

Healthcare-related septic episodes cause a considerable burden. Moreover, a trend could be spotted towards higher relative incidence of complex cases recently.

Preadmission assessment of extended length of hospital stay with RFECV-ETC and hospital-specific data

Background

Patients who exceed their expected length of stay in the hospital come at a cost to stakeholders in the healthcare sector as bed spaces are limited for new patients, nosocomial infections increase and the outcome for many patients is hampered due to multimorbidity after hospitalization.

Objectives

This paper develops a technique for predicting Extended Length of Hospital Stay (ELOHS) at preadmission and their risk factors using hospital data.

Methods

A total of 91,468 records of patient’s hospital information from a private acute teaching hospital were used for developing a machine learning algorithm relaying on Recursive Feature Elimination with Cross-Validation and Extra Tree Classifier (RFECV-ETC). The study implemented Synthetic Minority Oversampling Technique (SMOTE) and tenfold cross-validation to determine the optimal features for predicting ELOHS while relying on multivariate Logistic Regression (LR) for computing the risk factors and the Relative Risk (RR) of ELOHS at a 95% confidence level.

Results

An estimated 11.54% of the patients have ELOHS, which increases with patient age as patients < 18 years, 18–40 years, 40–65 years and ≥ 65 years, respectively, have 2.57%, 4.33%, 8.1%, and 15.18% ELOHS rates. The RFECV-ETC algorithm predicted preadmission ELOHS to an accuracy of 89.3%. Age is a predominant risk factors of ELOHS with patients who are > 90 years—PAG (> 90) {RR: 1.85 (1.34–2.56), P:  < 0.001} having 6.23% and 23.3%, respectively, higher likelihood of ELOHS than patient 80–90 years old—PAG (80–90) {RR: 1.74 (1.34–2.38), P:  < 0.001} and those 70–80 years old—PAG (70–80) {RR: 1.5 (1.1–2.05), P: 0.011}. Those from admission category—ADC (US1) {RR: 3.64 (3.09–4.28, P:  < 0.001} are 14.8% and 70.5%, respectively, more prone to ELOHS compared to ADC (UC1) {RR: 3.17 (2.82–3.55), P:  < 0.001} and ADC (EMG) {RR: 2.11 (1.93–2.31), P:  < 0.001}. Patients from SES (low) {RR: 1.45 (1.24–1.71), P:  < 0.001)} are 13.3% and 45% more susceptible to those from SES (middle) and SES (high). Admission type (ADT) such as AS2, M2, NEWS, S2 and others {RR: 1.37–2.77 (1.25–6.19), P:  < 0.001} also have a high likelihood of contributing to ELOHS while the distance to hospital (DTH) {RR: 0.64–0.75 (0.56–0.82), P:  < 0.001}, Charlson Score (CCI) {RR: 0.31–0.68 (0.22–0.99), P:  < 0.001–0.043} and some VMO specialties {RR: 0.08–0.69 (0.03–0.98), P:  < 0.001–0.035} have limited influence on ELOHS.

Conclusions

Relying on the preadmission assessment of ELOHS helps identify those patients who are susceptible to exceeding their expected length of stay on admission, thus, making it possible to improve patients’ management and outcomes.

Bacterial Colonization on Healthcare Workers' Mobile Phones and Hands in Municipal Hospitals of Chongqing, China: Cross-contamination and Associated Factors

BACKGROUND

Mobile phones are widely used in clinical settings and could be colonized by potential pathogenic bacteria which may lead to hospital-acquired infections (HAIs) transmission. This study aimed to determine the prevalence of bacterial contamination of healthcare workers' (HCWs) mobile phones, identify bacterial isolates, and assess the factors associated with mobile phone contamination.

METHODS

Self-administered questionnaire was used to collect the information on the demographic characteristics and the use of mobile phones. A total of 111 HCWs' hands and their mobile phones were swabbed, then bacterial culture, isolation, and identification were performed. Univariate and multivariable logistic regression were applied to identify factors associated with mobile phone bacterial contamination.

RESULTS

Totally 106 (95.5%) of the 111 mobile phones investigated were contaminated with bacteria. Staphylococcus epidermidis (13/111), Acinetobacter baumannii (4/111) and Staphylococcus aureus (3/111) were the predominant bacterial isolates from HCWs' mobile phones. Univariate analyses showed that age, gender, profession and the frequency of mobile phone utilization were significantly associated with the number of bacterial colonization. Frequency of phone utilization (OR 8.366; 95% CI 1.496-46.797) was found to be the most significant factors associated with the qualified rate of mobile phones bacterial load. In addition, phone cover using was associated with the increased risk of mobile phone bacterial contamination.

CONCLUSION

There was cross-contamination between hands and phones. It is necessary to develop guidelines for mobile phone cleaning. Special attention needs to be paid to the disinfection of mobile phone covers to reduce contamination and transmission of pathogens.

Perception of Professionals from Different Healthcare Units Regarding the Use of Spray Technology for the Instantaneous Decontamination of Personal Protective Equipment during the Coronavirus Disease Pandemic: A Short Analysis

Within the context of the coronavirus disease (COVID-19) pandemic, different disinfection technologies have been developed to efficiently exercise microbial control, especially to minimize the potential risks that are associated with transmission and infection among healthcare professionals. Thus, the aim of this work was to evaluate the perception of professionals regarding the use of a new technology (chamber) for the instantaneous decontamination of personal protective equipment before the doffing stage. This was a cross-sectional descriptive study where the study data were obtained by using a questionnaire with qualitative questions. In total, 245 professionals participated in the study in three hospitals. Healthcare professionals represented 72.24% (n = 177) of the investigated sample. Approximately 69% of the professionals considered the disinfection chamber as a safe technology, and 75.10% considered it as an important and effective protective barrier for healthcare professionals in view of its application before the doffing process. The results found in this study demonstrate that the use of spray technology in the stage prior to the doffing process is acceptable to professionals, and that it can be an important tool for ensuring the additional protection of the professionals who work directly with patients who are diagnosed with COVID-19.

Can inverse probability treatment weighting (IPTW) be used to assess differences of CRBSI rates between non-tunneled femoral and jugular CVCs in PICU patients?

BACKGROUND

In children in the ICU, catheter-related bloodstream infections (CRBSI) have also been linked to mortality, morbidity, and healthcare costs. Although CRBSI poses many potential risks, including the need to avoid femoral access, there is debate regarding whether jugular access is preferable to femoral access in adults. Study reports support both perspectives. There is no consensus in meta-analyses. Children have yet to be examined in depth. Based on compliance with the central line bundle check lists, we aim to determine CRBSI risk in pediatric intensive care units for patients with non-tunneled femoral and internal jugular venous access.

METHODS

A retrospective cohort study was conducted on patients with central venous catheters in the pediatric ICU of King Abdulaziz University Hospital between January 1st, 2017 and January 30th, 2018. For the post-match balance, we use a standardized mean difference of less than 0.1 after inverse probability treatment weighting for all baseline covariates, and then we draw causal conclusions. As a final step, the Rosenbaum sensitivity test was applied to see if any bias influenced the results.

RESULTS

We recorded 145 central lines and 1463 central line days with 49 femoral accesses (33.79%) and 96 internal jugular accesses (66.21%). CRBSI per 1000 central line days are 4.10, along with standardized infections of 3.16. CRBSI risk differed between non-tunneled femoral vein access and internal jugular vein access by 0.074 (- 0.021, 0.167), P-value 0.06, and relative risk was 4.67 (0.87-25.05). Using our model, the actual probability was 4.14% (0.01-0.074) and the counterfactual probability was 2.79% (- 0.006, 0.062). An unobserved confounding factor was not identified in the sensitivity analysis.

CONCLUSIONS

So long as the central line bundle is maintained, a femoral line does not increase the risk of CRBSI. Causation can be determined through propensity score weighting, as this is a trustworthy method of estimating causality. There is no better way to gain further insight in this regard than through the use of randomized, double-blinded, multicenter studies.

Midline Catheters: Could They Replace a Central Vascular Access Device?

In the past 30 years, midline catheter use has grown rapidly. For several reasons, many providers and facilities are attempting to reduce the number of central venous catheters and subsequent central line-associated bloodstream infections (CLABSIs) by using midline catheters. Vessel preservation requires attention to all vascular access device (VAD)-associated complications and not only central line bloodstream infection. There is still much confusion about the appropriate tip location and the characteristics of fluids and medications that can safely be infused through a midline catheter residing in a peripheral vein. The Infusion Therapy Standards of Practice (the Standards) focuses on assessment of characteristics of infusion therapies that must be considered for VAD selection as an evidence-based list of fluids and medications for infusion through peripheral veins has yet to be established. This review of midline catheter studies evaluates the evidence regarding the substitution of a midline catheter for a central venous catheter. Many issues need to be addressed, such as studies that include an outcome list that mixes defined clinical complications (eg, thrombosis) with signs and symptoms of complications (eg, leaking). Another issue is basing a major change of clinical practice on retrospective chart reviews. Although a midline catheter may be appropriate for some patients, additional studies of a higher level of evidence are needed before this major practice change should occur.

Association of CLABSI With Hospital Length of Stay, Readmission Rates, and Mortality: A Retrospective Review

BACKGROUND

An evidence-based practice (EBP) approach to implementing change is relevant and pertinent to the strategy to improve outcomes for hospitalized patients with central venous catheters (CVC). As health systems endeavor to achieve the ambitious goals of improving the patient experience of care, improving the health of populations, and reducing the cost of health care, it is imperative to understand the impact of a central line-associated bloodstream infection (CLABSI) on outcomes.

AIMS

The purpose of the study was to contribute to the evidence of the association of CLABSI with the outcomes of hospital length of stay (LOS), readmission rates, and mortality rates for hospitalized patients.

METHODS

A retrospective study was conducted, including all hospitalized patients with a CVC within four hospitals in an integrated health system in northwest Ohio and southeast Michigan. The sample population was stratified into two groups, CLABSI and no CLABSI, and the outcomes of interest for each group were compared.

RESULTS

The findings substantiate the association between CLABSI and the hospital mortality rate, LOS, and readmission. Patients with a CVC who develop a CLABSI were 36.6% more likely to die in the hospital and 37.0% more likely to be readmitted compared with patients with a CVC who did not develop a CLABSI. In addition, hospital LOS increased an average of 2 days compared with patients without CLABSI. This study evokes implications for EBP change to reduce the rate of CLABSI and for quality improvement during in-hospital care.

LINKING EVIDENCE TO ACTION

There is an association between CLABSI and hospital mortality rate, LOS, and 30-day readmission outcomes, presenting a profound sense of urgency for EBP change. There were potential variances in processes or practice relative to insertion, maintenance, and removal in the hospitals studied, representing an opportunity to examine the best practices in the hospitals that are performing well. Implementation of EBP requires selecting effective and innovative strategies, with a focus on stakeholder involvement and needs.

Ten Thousand-Fold Higher than Acceptable Bacterial Loads Detected in Kenyan Hospital Environments: Targeted Approaches to Reduce Contamination Levels

Microbial monitoring of hospital surfaces can help identify target areas for improved infection prevention and control (IPCs). This study aimed to determine the levels and variations in the bacterial contamination of high-touch surfaces in five Kenyan hospitals and identify the contributing modifiable risk factors. A total of 559 high-touch surfaces in four departments identified as high risk of hospital-acquired infections were sampled and examined for bacterial levels of contamination using standard bacteriological culture methods. Bacteria were detected in 536/559 (95.9%) surfaces. The median bacterial load on all sampled surfaces was 6.0 × 10⁴ CFU/cm² (interquartile range (IQR); 8.0 × 10³–1.0 × 10⁶). Only 55/559 (9.8%) of the sampled surfaces had acceptable bacterial loads, <5 CFU/cm². Cleaning practices, such as daily washing of patient sheets, incident rate ratio (IRR) = 0.10 [95% CI: 0.04–0.24], providing hand wash stations, IRR = 0.25 [95% CI: 0.02–0.30], having running water, IRR = 0.19 [95% CI: 0.08–0.47] and soap for handwashing IRR = 0.21 [95% CI: 0.12–0.39] each significantly lowered bacterial loads. Transporting dirty linen in a designated container, IRR = 72.11 [95% CI: 20.22–257.14], increased bacterial loads. The study hospitals can best reduce the bacterial loads by improving waste-handling protocols, cleaning high-touch surfaces five times a day and providing soap at the handwash stations.