Relationship between hospital ward design and healthcare-associated infection rates: a systematic review and meta-analysis

Organizational and infrastructural risk factors for health care-associated Clostridioides difficile infections or methicillin-resistant Staphylococcus aureus in hospitals

BACKGROUND

This study explores the infrastructural and organizational risk factors for health care-associated (HCA) Clostridioides difficile infections (CDIs) and methicillin-resistant Staphylococcus aureus (MRSA) in hospitals.

METHODS

This is a retrospective observational study involving all eligible inpatient units from 12 hospitals in British Columbia, Canada, from April 1, 2020 to September 16, 2021. The outcomes were the average HCA CDI or MRSA rates. Covariates included, but were not limited to, infection control factors (eg, hand hygiene rate), infrastructural factors (eg, unit age), and organizational factors (eg, hallway bed utilization). Multivariable regression was performed to identify statistically significant risk factors.

RESULTS

Older units were associated with higher HCA CDI rates (adjusted relative risk [aRR]: 0.012; 95% confidence interval (CI) [0.004, 0.020]). Higher HCA MRSA rates were associated with decreased hand hygiene rate (aRR: -0.035; 95% CI [-0.063, -0.008]), higher MRSA bioburden (aRR: 9.008; 95% CI [5.586, 12.429]), increased utilization of hallway beds (aRR: 0.680; 95% CI [0.094, 1.267]), increased nursing overtime rate (aRR: 5.018; 95% CI [1.210, 8.826]), and not keeping the clean supply room door closed (aRR: -0.283; 95% CI [-0.536, -0.03]).

CONCLUSIONS

The study confirmed the multifaceted nature of infection prevention and emphasized the importance of interdepartmental collaboration to improve patient safety.

Decontamination of patient bathroom surfaces with 405 nm violet-blue light irradiation in a real-life setting

BACKGROUND

Irradiation with violet-blue light (VBL), in the spectrum of 405-450 nm, has been reported to be effective against pathogenic bacteria.

AIM

To investigate whether VBL irradiation could reduce the level of surface contamination at seven shared patient bathrooms in two wards at a hospital in Sweden.

METHODS

Repeated sampling of five separate surfaces (door handle, tap water handle, floor, toilet seat, and toilet armrest) was performed in the bathrooms where 405 nm light-emitting diode spotlights had been installed. A prospective study with a cross-over design was carried out, which included two study periods, first with the spotlights either switched on or off and a second study period with the opposite spotlight status.

FINDINGS

In total, 665 surface samples were collected during the study (133 samples per surface). Bacterial growth was found in 84% of all samples. The most common findings were coagulase-negative staphylococci and Bacillus spp. The median number of colony-forming units (cfu)/cm2 was 15 (interquartile range: 5-40) for all surfaces. In our main outcome, mean cfu/cm2 of all surfaces in a bathroom, no difference was observed with or without VBL. Clean surfaces (<5 cfu/cm2) were more commonly observed in bathrooms with VBL, also when controlling for confounding factors. No difference was observed in the number of heavily contaminated surfaces.

CONCLUSION

This study did not safely demonstrate an additive effect on bacterial surface levels when adding VBL to routine cleaning in shared patient bathrooms.

Contextual Hospital Conditions and the Risk of Nosocomial SARS-CoV-2 Infection: A Matched Case-Control Study with Density Sampling in a Large Portuguese Hospital

Objective: Knowledge of the role of hospital conditions in SARS-CoV-2 transmission should inform strategies for the prevention of nosocomial spread of this pathogen and of similarly transmitted viruses. This study aimed to identify risk factors for nosocomial acquisition of SARS-CoV-2. Methods: We ran a nested case-control study with incidence density sampling among adult patients hospitalized for >7 days (August-December 2020). Patients testing positive for SARS-CoV-2 after the 7th day of hospitalization were defined as cases and matched with controls (1:4) by date of admission, hospitalization duration until index date, and type of department. Individual and contextual characteristics were gathered, including admission characteristics and exposures during the risk period. Conditional logistic regression was used to estimate the odds ratios (ORs) with respective 95% confidence intervals (CI) separately for probable (diagnosed on day 8-13) and definitive (diagnosed after day 14) nosocomial sets. Results: We identified 65 cases (31 probable; 34 definitive) and 219 controls. No individual characteristic was related to nosocomial acquisition of SARS-CoV-2. Contextual risk factors for nosocomial acquisition were staying in a non-refurbished room (probable nosocomial: OR = 3.6, 1.18-10.87), contact with roommates with newly diagnosed SARS-CoV-2 (probable nosocomial: OR = 9.9, 2.11-46.55; definitive nosocomial: OR = 3.4, 1.09-10.30), and contact with roommates with a first positive test 21-90 days before the beginning of contact (probable nosocomial: OR = 10.7, 1.97-57.7). Conclusions: Hospital conditions and contact with recently infected patients modulated nosocomial SARS-CoV-2 transmission. These results alert us to the importance of the physical context and of agile screening procedures to shorten contact with patients with recent infection.

Risk of nosocomial coronavirus disease 2019: comparison between single- and multiple-occupancy rooms

BACKGROUND

There is an ongoing controversy regarding whether single-occupancy rooms are superior to multiple-occupancy rooms in terms of infection prevention. We investigated whether treatment in a multiple-occupancy room is associated with an increased incidence of nosocomial coronavirus disease 2019 (COVID-19) compared with treatment in a single-occupancy room.

METHODS

In this retrospective cohort study, every hospitalization period of adult patients aged ≥ 18 years at a tertiary hospital in Korea from January 1, 2022, to December 31, 2022, was analyzed. If COVID-19 was diagnosed more than 5 days after hospitalization, the case was classified as nosocomial. We estimated the association between the number of patients per room and the risk of nosocomial COVID-19 using a Cox proportional hazards regression model.

RESULTS

In total, 25,143 hospitalizations per room type were analyzed. The incidence rate of nosocomial COVID-19 increased according to the number of patients per room; it ranged from 3.05 to 38.64 cases per 10,000 patient-days between single- and 6-bed rooms, respectively. Additionally, the hazard ratios of nosocomial COVID-19 showed an increasing trend according to the number of patients per room, ranging from 0.14 (95% confidence interval 0.001-1.03) to 2.66 (95% confidence interval 1.60-4.85) between single- and 6-bed rooms, respectively.

CONCLUSIONS

We demonstrated that the incidence of nosocomial COVID-19 increased according to the number of patients per room. To reduce nosocomial infections by respiratory viruses, the use of multiple-occupancy rooms should be minimized.

Navigation benchmarking for autonomous mobile robots in hospital environment

The widespread adoption of robotic technologies in healthcare has opened up new perspectives for enhancing accuracy, effectiveness and quality of medical procedures and patients' care. Special attention has been given to the reliability of robots when operating in environments shared with humans and to the users' safety, especially in case of mobile platforms able to navigate autonomously. From the analysis of the literature, it emerges that navigation tests carried out in a hospital environment are preliminary and not standardized. This paper aims to overcome the limitations in the assessment of autonomous mobile robots navigating in hospital environments by proposing: (i) a structured benchmarking protocol composed of a set of standardized tests, taking into account conditions with increasing complexity, (ii) a set of quantitative performance metrics. The proposed approach has been used in a realistic setting to assess the performance of two robotic platforms, namely HOSBOT and TIAGo, with different technical features and developed for different applications in a clinical scenario.

Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub

BACKGROUND

Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission.

AIM

To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs).

METHODS

An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period.

FINDINGS

A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001).

CONCLUSION

Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.

Hospital patient experiences of contact isolation for antimicrobial resistant organisms in relation to health care-associated infections: A systematic review and narrative synthesis of the evidence

BACKGROUND

The alarming growth of antimicrobial resistance organisms (AMRs) and the threat caused by health care-associated infections require hospitalized individuals who are infected or colonized with AMRs to be cared for in isolation, predominantly in single rooms. None of the existing reviews focus on or specifically address the patient's experience of being cared for in contact isolation when affected by AMRs exploring this specific context.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for the conduct of systematic reviews was applied. Five databases were searched from inception to April 2019, with keywords related to adult patient experiences, AMR, and contact isolation. The evidence was certified by 2 reviewers. Principles of thematic analysis were used to produce a narrative synthesis of the findings.

RESULTS

Eighteen eligible studies were identified. Narrative synthesis resulted in 3 overarching categories reflecting the patient experience: privacy versus loneliness; emotional responses to isolation; quality of care, recovery, and safety in isolation.

CONCLUSIONS

This review synthesizes existing evidence reflecting the patient experience of contact isolation. Study findings were often contradictory and may not reflect contemporary health care, such as shorter hospital stays, or societal preferences for greater privacy. Further research focusing on contemporary health care contexts is recommended.

Tailored positioning and number of hand rub dispensers: the fundamentals for optimized hand hygiene compliance

BACKGROUND

Availability of alcohol-based hand rub (ABHR) dispensers at positions adapted to the work flow of healthcare workers (HCWs) is decisive in order to carry out indication-based hand rubbing. Although requirements and guidelines regarding the positioning of ABHR dispensers are in place, scientific evidence is often lacking.

METHODS

In order to analyse the impact of the location and number of ABHR dispensers on hand hygiene performance, additional dispensers were systematically placed in patient rooms in a surgical 38-bed ward at Marburg University Hospital, Germany to complement the existing dispenser locations. ABHR use was monitored continuously before and after complementation using the NosoEx hand hygiene monitoring system. The ward had 53 dispensers before the intervention and 82 dispensers after the intervention.

RESULTS

The addition of dispensers increased ABHR consumption across the entire ward. Before the intervention, mean consumption was 20.6 mL/patient-day, whereas mean consumption after the intervention was 25.3 mL/patient-day. Depending on the combination of dispenser locations, consumption increased through targeted supplementation in patient rooms. The presence of two or three dispensers per patient room resulted in significantly greater ABHR consumption compared with one dispenser per patient room. The preferred location combinations were entrance-front bed-back bed and entrance-foot end.

CONCLUSION

ABHR consumption can be increased significantly by optimizing the position and number of dispensers. The outstanding factors are visibility and integrability of dispenser use into the work flow; in particular, a dispenser should be positioned in the entrance area. Recommendations should be optimized with regard to the required number and location of dispensers in patient rooms.

Impact of a new hospital with close to 100% single-occupancy rooms on environmental contamination and incidence of vancomycin-resistant Enterococcus faecium colonization or infection: a genomic surveillance study

BACKGROUND

Vancomycin-resistant Enterococcus faecium (VRE) is a leading cause of nosocomial infection, driven by its ability to spread between patients and persist in the hospital environment.

AIM

To investigate the impact of a long-established cardiothoracic hospital moving to new premises with close to 100% single-occupancy rooms on the rates of environmental contamination and infection or colonization by VRE.

METHODS

Prospective environmental surveillance for VRE was conducted at five time-points between April and November 2019, once in the original building, and four times in the new building. Incidence rate ratios (IRRs) of VRE infection/colonization were determined for the one-year period before and after the hospital move, and compared to a nearby hospital.

FINDINGS

In the original location, the first environmental screen found 29% VRE positivity. The following four screens in the new location showed a significant reduction in positivity (1-6%; P<0.0001). The VRE infection/colonization rates were halved in the new location (IRR: 0.56; 95% confidence interval: 0.38-0.84), compared to the original location, contrasting with an increase in a nearby hospital (1.62; 1.17-2.27) over the same time-period. Genomic analysis of the environmental isolates was consistent with reduced transmission in the new hospital.

CONCLUSION

The use of single-occupancy rooms was associated with reduced environmental contamination with VRE, and lower transmission and isolation of VRE from clinical samples. The cost-effectiveness of single-occupancy room hospitals in reducing healthcare-associated infections should be reassessed in the context of operational costs of emerging pandemic and increasing antimicrobial resistance threats.

Validity of self-reported compliance and behavioural determinants of observed compliance: an application of the COM-B hand hygiene questionnaire in nine Dutch hospitals

BACKGROUND

Hand hygiene compliance (HHC) can be influenced by behavioural determinants, but knowledge on this is still scarce. The Capability, Opportunity, Motivation-Behaviour (COM-B) hand hygiene questionnaire was developed by Lydon et al. to gain insight in self-reported behavioural determinants and self-reported HHC.

AIM

To determine the validity of self-reported HHC, by using the COM-B questionnaire. To investigate the influence of self-reported behavioural determinants on observed HHC, while taking environmental determinants into account.

METHODS

Cross-sectional study, from September to November 2019, in nine hospitals in the Netherlands. Healthcare workers (HCW) filled in the COM-B questionnaire and direct hand hygiene observations were performed. In addition, information on environmental determinants (workload, ward category, type of hospital, infrastructure of a ward) was collected. Validity of self-reported HHC was determined by the intraclass correlation coefficient (ICC). Univariable and multivariable regression analyses were performed to investigate the relation between behavioural- and environmental determinants and observed HHC.

FINDINGS

The ICC showed no association between self-reported HHC and observed HHC (0.04 (-0.14, 0.21)). In the univariable regression analyses, ward category and the subscales opportunity and motivation were significantly associated with observed HHC. In the multivariable regression analysis, only ward category and motivation remained significant.

CONCLUSION

The self-reported HHC is not a valid substitute for direct hand hygiene observations. The behavioural determinant motivation was significantly associated with HCC, while almost none of the environmental determinants had an effect on observed HHC. In further development of hand hygiene interventions, increasing the intrinsic motivation of HCW should get extra attention.

Between paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres

INTRODUCTION

Injured adolescents may be treated at pediatric trauma centres (PTCs) or adult trauma centres (ATCs). Patient and parent experiences are an integral component of high-quality health care and can influence patient clinical trajectory. Despite this knowledge, there is little research on differences between PTCs and ATCs with respect to patient and caregiver-reported experience. We sought to identify differences in patient and parent-reported experiences between the regional PTC and ATC using a recently developed Patient and Parent-Reported Experience Measure.

METHODS

We prospectively enrolled patients (caregivers) aged 15-17 (inclusive), admitted to the local PTC and ATC for injury management (01/01/2020 - 31/05/2021) We provided a survey 8-weeks post-discharge to query acute care and follow-up experience. Patient and parent experiences were compared between the PTC and ATC using descriptive statistics, chi-square tests for categorical and independent t-tests for continuous variables.

RESULTS

We identified 90 patients for inclusion (51 PTC, and 39 ATC). From this population, we had 77 surveys (32 patient and 35 caregiver) completed at the PTC, and 41 (20 patient and 21 caregiver) at the ATC. ATC patients tended to be more severely injured. We identified few differences in reported experience on the patient measure but identified lower ratings from caregivers of adolescents treated in ATCs for the domains of information and communication, follow-up care, and overall hospital scores. Patients and parents reported poorer family accommodation at the ATC.

CONCLUSION

Patient experiences were similar between centres. However, caregivers report poorer experiences at the ATC in several domains. These differences are multifaceted, and may reflect differing patient volumes, effects of COVID-19, and healthcare paradigms. However, further work should target information and communication improvement in adult paradigms given its impact on other domains of care.

COVID-19 patient and personal safety - lessons learnt for pandemic preparedness and the way to the next normal

BACKGROUND

The COVID-19 pandemic has profoundly challenged societies and healthcare systems in particular. To prevent the spread of SARS-CoV-2, infection prevention and control (IPC) strategies had to be developed on the local, national and international level. The aim of this study is to provide details of the COVID-19 experience at the Vienna General Hospital (VGH) in the context of the national and international COVID-19 response for learning and improvement.

METHODS

This is a retrospective report, outlining the evolution of IPC measures and challenges encountered at the health facility (VGH), the national (Austria) and global level between February 2020 and October 2022.

RESULTS

The IPC strategy at the VGH has been continuously adapted to changes in the epidemiological setting, new legal directives and Austrian by-laws. The current strategy, nationally and internationally, focuses on endemicity rather than maximum transmission risk reduction. For the VGH, this has recently resulted in an increase in COVID-19 clusters. To protect our particularly vulnerable patients, many COVID-19 precautions have been maintained. Barriers to adequate IPC implementation at the VGH and other hospitals include a lack of sufficient isolation options and non-adherence with universal face mask regulations. Globally, misinformation on COVID-19 hampered an effective response.

CONCLUSIONS

This retrospective analysis of the COVID-19 response at the VGH and international reports underline the need for pandemic preparedness, readiness and response by improving future hospital design and infrastructure, conducting regular trainings for protective attire and increasing health literacy as now recently published in a concise document by WHO.

Environmental contamination with highly resistant microorganisms after relocating to a new hospital building with 100% single-occupancy rooms: A prospective observational before-and-after study with a three-year follow-up

INTRODUCTION

Inanimate surfaces within hospitals can be a source of transmission for highly resistant microorganisms (HRMO). While many hospitals are transitioning to single-occupancy rooms, the effect of single-occupancy rooms on environmental contamination is still unknown. We aimed to determine differences in environmental contamination with HRMO between an old hospital building with mainly multiple-occupancy rooms and a new hospital building with 100% single-occupancy rooms, and the environmental contamination in the new hospital building during three years after relocating.

METHODS

Environmental samples were taken twice in the old hospital, and fifteen times over a three-year period in the new hospital. Replicate Organism Direct Agar Contact-plates (RODACs) were used to determine colony forming units (CFU). Cotton swabs premoistened with PBS were used to determine presence of methicillin-resistant Staphylococcus aureus, carbapenemase-producing Pseudomonas aeruginosa, highly resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and vancomycin-resistant Enterococcus faecium. All identified isolates were subjected to whole genome sequencing (WGS) using Illumina technology.

RESULTS

In total, 4993 hospital sites were sampled, 724 in the old and 4269 in the new hospital. CFU counts fluctuated during the follow-up period in the new hospital building, with lower CFU counts observed two- and three years after relocating, which was during the COVID-19 pandemic. The CFU counts in the new building were equal to or surpassed the CFU counts in the old hospital building. In the old hospital building, 24 (3.3%) sample sites were positive for 49 HRMO isolates, compared to five (0.1%) sample sites for seven HRMO isolates in the new building (P < 0.001). In the old hospital, 89.8% of HRMO were identified from the sink plug. In the new hospital, 71.4% of HRMO were identified from the shower drain, and no HRMO were found in sinks.

DISCUSSION

Our results indicate that relocating to a new hospital building with 100% single-occupancy rooms significantly decreases HRMO in the environment. Given that environmental contamination is an important source for healthcare associated infections, this finding should be taken into account when considering hospital designs for renovations or the construction of hospitals.

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

OBJECTIVES

To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process.

METHODS

A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities.

RESULTS

Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis.

CONCLUSION

Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Silica nanoparticles with encapsulated DNA (SPED) to trace the spread of pathogens in healthcare

Background

To establish effective infection control protocols, understanding pathogen transmission pathways is essential. Non-infectious surrogate tracers may safely explore these pathways and challenge pre-existing assumptions. We used silica nanoparticles with encapsulated DNA (SPED) for the first time in a real-life hospital setting to investigate potential transmission routes of vancomycin-resistant enterococci in the context of a prolonged outbreak.

Methods

The two study experiments took place in the 900-bed University Hospital Zurich, Switzerland. A three-run ‘Patient experiment’ investigated pathogen transmission via toilet seats in a two-patient room with shared bathroom. First, various predetermined body and fomite sites in a two-bed patient room were probed at baseline. Then, after the first patient was contaminated with SPED at the subgluteal region, both patients sequentially performed a toilet routine. All sites were consequently swabbed again for SPED contamination. Eight hours later, further spread was tested at predefined sites in the patient room and throughout the ward. A two-run ‘Mobile device experiment’ explored the potential transmission by mobile phones and stethoscopes in a quasi-realistic setting. All SPED contamination statuses and levels were determined by real-time qPCR.

Results

Over all three runs, the ‘Patient experiment’ yielded SPED in 59 of 73 (80.8%) predefined body and environmental sites. Specifically, positivity rates were 100% on subgluteal skin, toilet seats, tap handles, and entertainment devices, the initially contaminated patients’ hands; 83.3% on patient phones and bed controls; 80% on intravenous pumps; 75% on toilet flush plates and door handles, and 0% on the initially not contaminated patients’ hands. SPED spread as far as doctor’s keyboards (66.6%), staff mobile phones (33.3%) and nurses’ keyboards (33.3%) after eight hours. The ‘Mobile device experiment’ resulted in 16 of 22 (72.7%) positive follow-up samples, and transmission to the second patient occurred in one of the two runs.

Conclusions

For the first time SPED were used to investigate potential transmission pathways in a real hospital setting. The results suggest that, in the absence of targeted cleaning, toilet seats and mobile devices may result in widespread transmission of pathogens departing from one contaminated patient skin region.

Coronavirus disease 2019 (COVID-19) incidence after exposures in shared patient rooms in a tertiary-care center in Iowa, July 2020-May 2021

The incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure in shared patient rooms was low at our institution: 1.8 per 1,000 shared-room patient days. However, the secondary attack rate (21.6%) was comparable to that reported in household exposures. Lengthier exposures were associated with SARS-CoV-2 conversion. Hospitals should implement measures to decrease shared-room exposures.

Hand Hygiene in the Intensive Care Unit: Knowledge, Compliance and Factors Influencing Nursing Adherence, a Descriptive Study

Background:

Nosocomial infections are particularly common among hospitalized patients who undergo resuscitation compared with other types of care. Hand hygiene remains the simplest and most effective measure to prevent and control the risk of infection.

Objective:

The main objectives are to evaluate hand hygiene compliance among nursing staff in the different intensive care units and to identify the factors influencing the adherence of nursing staff to the practice.

Methods:

It was a quantitative descriptive study using a questionnaire and an observation grid with all the nursing staff working in all the intensive care units of our university hospital.

Results:

The study showed a hand contamination rate of (80%), a hand hygiene compliance rate of (21.3%), it also showed the different factors explaining non-adherence, these are not necessarily related to training, nor to the availability of material resources but related to hidden reasons, non-apparent factors, which are often more important. (Workload and work environment)

Conclusion:

This study examined hand hygiene in the ICU setting, obtained data on overall compliance, which remains poor, and the various factors influencing nurses' adherence to the practice.

Undervalued and overlooked: the importance of private space in liaison psychiatry

Access to private space for psychiatric assessments is crucial to facilitate the effective gathering of salient information while preserving the dignity of patients. In this article, we discuss the current availability of private space for liaison psychiatry services on in-patient wards in general hospitals and reflect on how this affects communication with patients. Additionally, we propose solutions for healthcare trusts in addressing this issue.

The effect of 100% single-occupancy rooms on acquisition of extended-spectrum beta-lactamase-producing Enterobacterales and intra-hospital patient transfers: a prospective before-and-after study

BACKGROUND

Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) are a well-known cause of healthcare-associated infections. The implementation of single-occupancy rooms is believed to decrease the spread of ESBL-E. Additionally, implementation of single-occupancy rooms is expected to reduce the need for intra-hospital patient transfers. We studied the impact of a new hospital with 100% single-occupancy rooms on the acquisition of ESBL-E and on intra-hospital patient transfers.

METHODS

In 2018, the Erasmus MC University Medical Center moved from an old, 1200-bed hospital with mainly multiple-occupancy rooms, to a newly constructed 522-bed hospital with 100% single-occupancy rooms. Adult patients admitted between January 2018 and September 2019 with an expected hospitalization of ≥ 48 h were asked to participate in this study. Perianal samples were taken at admission and discharge. Patient characteristics and clinical information, including number of intra-hospital patient transfers, were collected from the patients' electronic health records.

RESULTS

Five hundred and ninety-seven patients were included, 225 in the old and 372 in the new hospital building. Fifty-one (8.5%) ESBL-E carriers were identified. Thirty-four (66.7%) patients were already positive at admission, of which 23 without recent hospitalization. Twenty patients acquired an ESBL-E, seven (3.1%) in the old and 13 (3.5%) in the new hospital building (P = 0.801). Forty-one (80.4%) carriers were only detected by the active screening performed during this study. Only 10 (19.6%) patients, six before and four during hospitalization, showed ESBL-E in a clinical sample taken on medical indication. Fifty-six (24.9%) patients were transferred to other rooms in the old hospital, compared to 53 (14.2%) in the new hospital building (P = 0.001). Intra-hospital patient transfers were associated with ESBL-E acquisition (OR 3.18, 95%CI 1.27-7.98), with increasing odds when transferred twice or more.

CONCLUSION

Transitioning to 100% single-occupancy rooms did not decrease ESBL-E acquisition, but did significantly decrease the number of intra-hospital patient transfers. The latter was associated with lower odds on ESBL-E acquisition. ESBL-E carriers remained largely unidentified through clinical samples.

TRIAL REGISTRATION

This study was retrospectively registered in the Dutch National Trial Register on 24-02-2020, with registration number NL8406.

Comprehensive risk assessment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia

Background

Social and hospital environmental factors that may be associated with hospital-acquired pneumonia (HAP) have not been evaluated. Comprehensive risk assessment for the incidence of HAP including sociodemographic, clinical, and hospital environmental factors was conducted using national health insurance claims data.

Methods

This is a population-based retrospective cohort study of adult patients who were hospitalized for more than 3 days from the Health Insurance Review and Assessment Service-National Inpatient Sample data between January 1, 2016 and December 31, 2018 in South Korea. Multivariable logistic regression analyses were conducted to identify the factors associated with the incidence of HAP.

Results

Among the 512,278 hospitalizations, we identified 25,369 (5.0%) HAP cases. In multivariable analysis, well-known risk factors associated with HAP such as older age (over 70 vs. 20–29; adjusted odds ratio [aOR], 3.66; 95% confidence interval [CI] 3.36–3.99), male sex (aOR, 1.35; 95% CI 1.32–1.39), pre-existing lung diseases (asthma [aOR, 1.73; 95% CI 1.66–1.80]; chronic obstructive pulmonary disease [aOR, 1.62; 95% CI 1.53–1.71]; chronic lower airway disease [aOR, 1.79; 95% CI 1.73–1.85]), tube feeding (aOR, 3.32; 95% CI 3.16–3.50), suctioning (aOR, 2.34; 95% CI 2.23–2.47), positioning (aOR, 1.63; 95% CI 1.55–1.72), use of mechanical ventilation (aOR, 2.31; 95% CI 2.15–2.47), and intensive care unit admission (aOR, 1.29; 95% CI 1.22–1.36) were associated with the incidence of HAP. In addition, poverty (aOR, 1.08; 95% CI 1.04–1.13), general hospitals (aOR, 1.54; 95% CI 1.39–1.70), higher bed-to-nurse ratio (Grade ≥ 5; aOR, 1.45; 95% CI 1.32–1.59), higher number of beds per hospital room (6 beds; aOR, 3.08; 95% CI 2.77–3.42), and ward with caregiver (aOR, 1.19; 95% CI 1.12–1.26) were related to the incidence of HAP.

Conclusions

The incidence of HAP was associated with various sociodemographic, clinical, and hospital environmental factors. Thus, taking a comprehensive approach to prevent and treat HAP is important.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01816-9.

Reduction in the acquisition rate of carbapenem-resistant Acinetobacter baumannii (CRAB) after room privatization in an intensive care unit

BACKGROUND

Acinetobacter baumannii is one of the major pathogens responsible for healthcare-associated infections, especially in intensive care units (ICUs).

AIM

To evaluate the effect of room privatization in an ICU on the acquisition of carbapenem-resistant A. baumannii (CRAB).

METHODS

Between March and August 2017, a medical ICU was renovated from a multibed bay room to single rooms. Acquisition of CRAB was compared between patients admitted to the ICU over 18 months pre-renovation (September 2015 to February 2017) and post-renovation (September 2017 to February 2019). A Cox proportional hazard model was used with adjustment for demographics and comorbidities.

FINDINGS

Of the 901 patients, who contributed 8,276 patient-days, 95 (10.5%) acquired CRAB during their ICU stay. The CRAB acquisition rate was significantly higher during the pre-renovation period (1.87 per 100 patient-days) than during the post-renovation period (0.39 per 100 patient-days) (P < 0.001). In the multivariable Cox regression model, CRAB acquisition was significantly associated with the presence of a feeding tube (adjusted hazard ratio [aHR], 6.08; 95% confidence interval [CI], 2.46-15.06; P < 0.001), continuous renal replacement therapy (aHR, 1.66; 95% CI, 1.09-2.53; P = 0.019) and admission after renovation of the ICU to single rooms (aHR, 0.23; 95% CI, 0.12-0.41; P < 0.001).

CONCLUSIONS

Renovation of ICUs to single rooms is an efficient strategy to prevent transmission of multidrug-resistant organisms and hospital-acquired infections.

Organization of a Hospital Ward Aimed at Admitting Patients with SARS-CoV-2: An Economic and Epidemiological Perspective

The SARS-CoV-2 epidemic requires dynamic action on the part of the entire health care system to provide infected patients whose condition requires hospitalization with access to appropriate medical care and infrastructure, including oxygen devices and ventilators. The demand for specialized inpatient care has increased rapidly and in many areas exceeds the resources available to date. Individual hospitals must make investment and organizational decisions to increase their capacity to handle patients with SARS-CoV-2. The aim of the article is to present the organizational and investment steps taken to establish and maintain an infectious hospital ward as well as the clinical and financial consequences of this decision. The study was conducted in a hospital ward that was launched at the end of October 2020 to care for patients with SARS-CoV-2. A case study method was used. The department was characterized taking into account its importance for: (1) the regional level of health coverage of the population, (2) the organization of the hospital's activities, (3) the financial and economic situation of the hospital.

Healthcare-Associated Infections-Related Bacteriome and Antimicrobial Resistance Profiling: Assessing Contamination Hotspots in a Developing Country Public Hospital

Hospital-built environment colonization by healthcare-associated infections-related bacteria (HAIrB) and the interaction with their occupants have been studied to support more effective tools for HAI control. To investigate HAIrB dynamics and antimicrobial resistance (AMR) profile we carried out a 6-month surveillance program in a developing country public hospital, targeting patients, hospital environment, and healthcare workers, using culture-dependent and culture-independent 16S rRNA gene sequencing methods. The bacterial abundance in both approaches shows that the HAIrB group has important representativeness, with the taxa Enterobacteriaceae, Pseudomonas, Staphylococcus, E. coli, and A. baumannii widely dispersed and abundant over the time at the five different hospital units included in the survey. We observed a high abundance of HAIrB in the patient rectum, hands, and nasal sites. In the healthcare workers, the HAIrB distribution was similar for the hands, protective clothing, and mobile phones. In the hospital environment, the healthcare workers resting areas, bathrooms, and bed equipment presented a wide distribution of HAIrB and AMR, being classified as contamination hotspots. AMR is highest in patients, followed by the environment and healthcare workers. The most frequently detected beta-lactamases genes were, bla_SHV–like, bla_{OXA–23–like}, bla_{OXA–51–like}, bla_KPC–like, bla_CTX–M–1, bla_CTX–M–8, and bla_CTX–M–9 groups. Our results demonstrate that there is a wide spread of antimicrobial resistance due to HAIrB in the hospital environment, circulating among patients and healthcare workers. The contamination hotspots identified proved to be constant over time. In the fight for patient safety, these findings can reorient practices and help to set up new guidelines for HAI control.

Bacterial colonization dynamics and antibiotic resistance gene dissemination in the hospital environment after first patient occupancy: a longitudinal metagenetic study

BACKGROUND

Humans spend the bulk of their time in indoor environments. This space is shared with an indoor ecosystem of microorganisms, which are in continuous exchange with the human inhabitants. In the particular case of hospitals, the environmental microorganisms may influence patient recovery and outcome. An understanding of the bacterial community structure in the hospital environment is pivotal for the prevention of hospital-acquired infections and the dissemination of antibiotic resistance genes. In this study, we performed a longitudinal metagenetic approach in a newly opened ward at the Charité Hospital (Berlin) to characterize the dynamics of the bacterial colonization process in the hospital environment after first patient occupancy.

RESULTS

The sequencing data showed a site-specific taxonomic succession, which led to stable community structures after only a few weeks. This data was further supported by network analysis and beta-diversity metrics. Furthermore, the fast colonization process was characterized by a significant increase of the bacterial biomass and its alpha-diversity. The compositional dynamics could be linked to the exchange with the patient microbiota. Over a time course of 30 weeks, we did not detect a rise of pathogenic bacteria in the hospital environment, but a significant increase of antibiotic resistance determinants on the hospital floor.

CONCLUSIONS

The results presented in this study provide new insights into different aspects of the environmental microbiome in the clinical setting, and will help to adopt infection control strategies in hospitals and health care-related buildings. Video Abstract.

The cost-effectiveness of temporary single-patient rooms to reduce risks of healthcare-associated infection

BACKGROUND

The use of single rooms for patient isolation often forms part of a wider bundle to prevent certain healthcare-associated infections (HAIs) in hospitals. Demand for single rooms often exceeds what is available and the use of temporary isolation rooms may help resolve this. Changes to infection prevention practice should be supported by evidence showing that cost-effectiveness is plausible and likely.

AIM

To perform a cost-effectiveness evaluation of adopting temporary single rooms into UK National Health Service (NHS) hospitals.

METHODS

The cost-effectiveness of a decision to adopt a temporary, single-patient, isolation room to the current infection prevention efforts of an NHS hospital was modelled. Primary outcomes are the expected change to total costs and life-years from an NHS perspective.

FINDINGS

The mean expected incremental cost per life-year gained (LYG) is £5,829. The probability that adoption is cost-effective against a £20,000 threshold per additional LYG is 93%, and for a £13,000 threshold the probability is 87%. The conclusions are robust to scenarios for key model parameters. If a temporary single-patient isolation room reduces risks of HAI by 16.5% then an adoption decision is more likely to be cost-effective than not. Our estimate of the effectiveness reflects guidelines and reasonable assumptions and the theoretical rationale is strong.

CONCLUSION

Despite uncertainties about the effectiveness of temporary isolation rooms for reducing risks of HAI, there is some evidence that an adoption decision is likely to be cost-effective for the NHS setting. Prospective studies will be useful to reduce this source of uncertainty.

Handrub dispensers per acute care hospital bed: a study to develop a new minimum standard

Background

Accessibility to alcohol-based handrub (ABHR) dispenser is crucial to improve compliance to hand hygiene (HH), being offered as wall-mounted dispensers (ABHR-Ds), and/or pocket bottles. Nevertheless, information on the distribution and density of ABHR-Ds and their impact on HH have hardly been studied. Institutions such as the World Health Organisation or the Centers for Disease Control and Prevention do not provide guidance. The Robert-Koch-Institute (RKI) from Germany recommends an overall density of > 0.5 dispensers per patient bed. We aimed to investigate current conditions in hospitals to develop a standard on the minimal number of ABHR-D.

Methods

Between 07 and 09/2019, we applied a questionnaire to 178 hospitals participating in the Swissnoso National Surveillance Network to evaluate number and location of ABHR-Ds per bed in acute care hospitals, and compared the data with consumption and compliance with HH.

Results

110 of the 178 (62%) hospitals provided data representing approximately 20,000 hospital beds. 83% hospitals provided information on both the total number of ABHR-Ds and patient beds, with a mean of 2.4 ABHR-Ds per bed (range, 0.4–22.1). While most hospitals (84%) had dispensers located at the room entrance, 47% reported also locations near or at the bed. Additionally, pocket-sized dispensers (100 mL) are available in 97% of hospitals.

Conclusions

Swiss hospitals provide 2.4 dispensers per bed, much more than governmental recommendation. The first study on the number of ABHR-Ds in hospitals may help to define a minimal standard for national and international recommendations

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00949-0.

Use of single-bed rooms may decrease the incidence of hospital-acquired infections in geriatric patients: A retrospective cohort study in Central Denmark region

OBJECTIVE

Patients accommodated in single-bed rooms may have a reduced risk of hospital-acquired infections (HAIs) compared to those in multi-bed rooms. This study aimed to examine the effect of single-bed accommodation on HAIs in older patients admitted to a geriatric ward.

METHODS

A retrospective cohort study of patients admitted to geriatric wards in a university hospital in Central Denmark Region linked to a move to a newly built hospital, involving all consecutively admitted patients aged 65 years and over from 15 September to 19 December 2016 and a similar cohort admitted in the same three months in 2017. We compared the incidence of HAIs in patients in single-bed accommodation to those in multi-bed accommodation using retrospective review of electronic patient records, with all infections verified microbiologically or by X-ray with onset between 48 hours after admission to 48 hours after discharge from hospital.

RESULTS

In total 446 patients were included. The incidence of HAIs in multi-bed accommodation was 30% compared to 20% in single-bed accommodation. The hazard ratio was 0.62 (95% Confidence Interval 0.43-0.91, p = 0.01) for single-bed accommodation. This finding remained robust after adjustment for age, sex, infection at admission, risk of sepsis, use of catheter, treatment with prednisone or methotrexate, and comorbidity index.

CONCLUSION

Accommodation in single-bed rooms appeared to reduce HAIs compared to multi-bed rooms in two geriatric wards. This finding should be considered as hypothesis-generating and be examined further using an experimental design.

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

IMPORTANCE

Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

OBJECTIVE

To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

EXPOSURES

The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

MAIN OUTCOMES AND MEASURES

The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

RESULTS

Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

CONCLUSIONS AND RELEVANCE

In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

Importance

Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

Objective

To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

Design, Setting, and Participants

This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

Exposures

The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

Main Outcomes and Measures

The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

Results

Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

Conclusions and Relevance

In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in a UK hospital network

Background

Intrahospital transfers have become more common as hospital staff balance patient needs with bed availability. However, this may leave patients more vulnerable to potential pathogen transmission routes via increased exposure to contaminated surfaces and contacts with individuals.

Objective

This study aimed to quantify the association between the number of intrahospital transfers undergone during a hospital spell and the development of a hospital-acquired infection (HAI).

Methods

A retrospective case–control study was conducted using data extracted from electronic health records and microbiology cultures of non-elective, medical admissions to a large urban hospital network which consists of three hospital sites between 2015 and 2018 (n=24 240). As elderly patients comprise a large proportion of hospital users and are a high-risk population for HAIs, the analysis focused on those aged 65 years or over. Logistic regression was conducted to obtain the OR for developing an HAI as a function of intrahospital transfers until onset of HAI for cases, or hospital discharge for controls, while controlling for age, gender, time at risk, Elixhauser comorbidities, hospital site of admission, specialty of the dominant healthcare professional providing care, intensive care admission, total number of procedures and discharge destination.

Results

Of the 24 240 spells, 2877 cases were included in the analysis. 72.2% of spells contained at least one intrahospital transfer. On multivariable analysis, each additional intrahospital transfer increased the odds of acquiring an HAI by 9% (OR=1.09; 95% CI 1.05 to 1.13).

Conclusion

Intrahospital transfers are associated with increased odds of developing an HAI. Strategies for minimising intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.

The Effect of Single-Room Care Versus Open-Bay Care on the Incidence of Bacterial Nosocomial Infections in Pre-Term Neonates: A Retrospective Cohort Study

INTRODUCTION

Nosocomial infections (NIs) are a major source of iatrogenic harm in neonatal intensive care units (NICUs). The influence of the infrastructure of NICUs on NIs is not well documented. This study aims to examine the effect of single-room units (SRU) versus open-bay units (OBU) on the incidence of NIs, including central-line-associated bloodstream infections (CLABSI), in preterm neonates.

METHODS

All preterm neonates (< 32 weeks gestational age) admitted to our NICU were included. Two study periods were compared: one prior to (May 2015-May 2017) and one following (May 2017-May 2019) transition from OBU to SRU. Incidence density (number of infections per 1000 patient-days) and cumulative incidence (number of infections per 100 neonates) for NIs were calculated. CLABSIs were calculated per 1000 central-line days. U chart analysis was performed to determine special-cause variation in quarterly CLABSI and NI rates. Multivariate competing risk regression was performed to identify independent NI risk factors.

RESULTS

Of the 712 included infants, 164 (23%) infants acquired ≥ 1 NIs. No differences were found in incidence density (13.68 vs. 12.62, p = 0.62) or cumulative incidence of NI (23.97 vs. 22.02, p = 0.59) between OBU and SRU. CLABSIs showed a similar non-significant reduction after the move (14.00 vs. 10.59, p = 0.51). U chart analysis did not identify unit transition as a potential source of special-cause variation for CLABSI and NI. Competing risks regression analysis revealed longer duration of invasive mechanical ventilation as a significant risk factor for NI (subhazards ratio: 1.03 per day on ventilation, p = 0.01).

CONCLUSION

Single-rooms are not associated with a significant reduction in NIs in the NICU. This study therefore does not add evidence that could support the transition to SRUs if based only on a large multimodal infection control strategy. Recommendations to build SRUs would require a wider justification, also taking into account other SRU benefits.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40121-020-00380-9.

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.

Infection prevention and control research priorities: what do we need to combat healthcare-associated infections and antimicrobial resistance? Results of a narrative literature review and survey analysis

BACKGROUND

Infection prevention and control (IPC) is one of the most cost-effective interventions against antimicrobial resistance (AMR). Yet, IPC knowledge gaps often receive little prominence in AMR research agendas. In this article, we construct IPC research priorities, in order to draw attention to these critical research needs.

METHODS

We developed a 4-step framework to identify IPC knowledge gaps from literature (narrative review). These gaps were then translated into research priorities and sent to two groups of European IPC experts for validation and critique through an online survey.

RESULTS

Seventy-nine publications were retrieved from the literature review, identifying fifteen IPC research gaps. Forty-four IPC experts, clustered in two groups, vetted them. The experts classified all research gaps as medium or high priority. Overall agreement between both groups was average (Kendall's τ = 0.43), with strong alignment on the highest priorities: (i) the assessment of organizational, socio-economic, and behavioural barriers/facilitators for the implementation of IPC programmes, (ii) the impact of overcrowding on the spread of infections and (iii) the impact of infrastructural changes, at facility level, on the reduction of infections. Feedback from experts also identified an additional research gap on the interaction between the human and hospital microbiomes.

CONCLUSIONS

We formulated a list of sixteen research priorities and identified three urgent needs. Now, we encourage researchers, funding agencies, policymakers and relevant stakeholders to start addressing the identified gaps.

Containment of a healthcare-associated COVID-19 outbreak in a university hospital in Seoul, Korea: A single-center experience

Background

Our hospital experienced the first healthcare-associated COVID-19 outbreak in Seoul at the time the first COVID-19 cases were confirmed in Korea. The first confirmed COVID-19 patient was a hospital personnel who was in charge of transferring patients inside our hospital. To contain the virus spread, we shutdown our hospital, and tested all inpatients, medical staff members, and employees.

Methods

We retrospectively analyzed the results of SARS-CoV-2 RT-PCR testing according to the contact history, occupation, and presence of respiratory symptoms. Closed-circuit television (CCTV) was reviewed in the presence of an epidemiologist to identify individuals who came into contact with confirmed COVID-19 patients.

Results

A total of 3,091 respiratory samples from 2,924 individuals were obtained. Among 2,924 individuals, two inpatients, and one caregiver tested positive (positivity rate, 0.1%). Although all confirmed cases were linked to a general ward designated for pulmonology patients, no medical staff members, medical support personnel, or employees working at the same ward were infected. Contact with confirmed COVID-19 cases was frequent among inpatients and medical support personnel. The most common contact area was the general ward for pulmonology patients and medical support areas, including clinical and imaging examination rooms. Finally, the total number of hospital-associated infections was 14, consisting of four diagnosed at our hospital and ten diagnosed outside the hospital.

Conclusions

The robust control of the COVID-19 outbreak further minimized the transmission of SARS-CoV-2 in the hospital and local communities. However, there was also a debate over the appropriate period of hospital shutdown and testing of all hospital staff and patients. Future studies are required to refine and establish the in-hospital quarantine and de-isolation guidelines based on the epidemiological and clinical settings.

Nurses' Perception of Safety on Hospital Interior Environments and Infectious Diseases: An Exploratory Study

Introduction

Healthcare environments consist of a variety of different fomites containing infectious agents. From the 2003 outbreaks of Severe Acute Respiratory Syndrome to the recent concerns about the Ebola and Zika viruses, interest in the role of healthcare environment fomites in spreading infectious diseases has increased. Because of a high risk of being exposed to infections, the goal of this study was to learn how hospital interior environments impact nurses' perceptions of safety about infectious diseases.

Methods

Semistructured, in-depth interviews were conducted with six nurses at a public hospital.

Results

The following three themes were identified: (1) perceptions of safety from infectious diseases were diverse among the participants; (2) various interior environments in hospital settings can prevent as well as promote the spreading of infectious diseases; and (3) the different perceptions influenced the ways participants developed their contrasting behaviors of treating interior environments to cope with their fears (e.g., how they open doors).

Conclusion

The findings from this study contribute to the existing body of knowledge on designing hospital interior environments to better understand nurses' perception of infectious diseases.

One Health in hospitals: how understanding the dynamics of people, animals, and the hospital built-environment can be used to better inform interventions for antimicrobial-resistant gram-positive infections

Despite improvements in hospital infection prevention and control, healthcare associated infections (HAIs) remain a challenge with significant patient morbidity, mortality, and cost for the healthcare system. In this review, we use a One Health framework (human, animal, and environmental health) to explain the epidemiology, demonstrate key knowledge gaps in infection prevention policy, and explore improvements to control Gram-positive pathogens in the healthcare environment. We discuss patient and healthcare worker interactions with the hospital environment that can lead to transmission of the most common Gram-positive hospital pathogens – methicillin-resistant Staphylococcus aureus, Clostridioides (Clostridium) difficile, and vancomycin-resistant Enterococcus – and detail interventions that target these two One Health domains. We discuss the role of animals in the healthcare settings, knowledge gaps regarding their role in pathogen transmission, and the absence of infection risk mitigation strategies targeting animals. We advocate for novel infection prevention and control programs, founded on the pillars of One Health, to reduce Gram-positive hospital-associated pathogen transmission.

What's in a Building? A Descriptive Survey of Adult Inpatient Rehabilitation Facility Buildings in Victoria, Australia

OBJECTIVE

To identify all the services that offer inpatient rehabilitation in Victoria, Australia, and to describe the buildings in which these services are housed, including their size, age, whether or not they were purpose-built, whether or not they are colocated with a tertiary hospital, the proportion of single-bed rooms, and ward layout.

DESIGN

Cross-sectional survey of inpatient rehabilitation buildings. Data were collected via telephone questionnaire and websites.

PARTICIPANTS

Sixty-four rehabilitation facilities were identified and all participated in the survey (37 public, 27 private).

RESULTS

Results revealed heterogeneity on most variables measured, including size (number of beds ranged from 2-104), age (oldest building built in 1860, and 26% built since 2010), purpose-built status (48% purpose-built), freestanding status (34% freestanding), percentage of single-bed rooms (ranged from 0%-100%), and layout. All facilities had a therapy gym, and most had a communal area (96%).

CONCLUSION

Since 2010, the proportion of buildings being purpose-built and colocated with a tertiary hospital has increased. The proportion of single-bed rooms has also increased and is especially high in privately funded facilities. Results suggest that rehabilitation design is influenced by norms and evidence from acute medical health care despite the purpose of care being different: acute care (short-term, medical illness) and rehabilitation (longer-term, recovery, relearning).

Spatiotemporal clustering of in-hospital Clostridioides difficile infection

OBJECTIVE

To determine whether Clostridioides difficile infection (CDI) exhibits spatiotemporal interaction and clustering.

DESIGN

Retrospective observational study.

SETTING

The University of Iowa Hospitals and Clinics.

PATIENTS

This study included 1,963 CDI cases, January 2005 through December 2011.

METHODS

We extracted location and time information for each case and ran the Knox, Mantel, and mean and maximum component size tests for time thresholds (T = 7, 14, and 21 days) and distance thresholds (D = 2, 3, 4, and 5 units; 1 unit = 5-6 m). All tests were implemented using Monte Carlo simulations, and random CDI cases were constructed by randomly permuting times of CDI cases 20,000 times. As a counterfactual, we repeated all tests on 790 aspiration pneumonia cases because aspiration pneumonia is a complication without environmental factors.

RESULTS

Results from the Knox test and mean component size test rejected the null hypothesis of no spatiotemporal interaction (P < .0001), for all values of T and D. Results from the Mantel test also rejected the hypothesis of no spatiotemporal interaction (P < .0003). The same tests showed no such effects for aspiration pneumonia. Our results from the maximum component size tests showed similar trends, but they were not consistently significant, possibly because CDI outbreaks attributable to the environment were relatively small.

CONCLUSION

Our results clearly show spatiotemporal interaction and clustering among CDI cases and none whatsoever for aspiration pneumonia cases. These results strongly suggest that environmental factors play a role in the onset of some CDI cases. However, our results are not inconsistent with the possibility that many genetically unrelated CDI cases occurred during the study period.

A Decision-Making Algorithm for Rearchitecting of Healthcare Facilities to Minimize Nosocomial Infections Risks

Most of the healthcare facilities (HFs) have to face the nosocomial infections (NIs), which increase the rates of morbidity, mortality, and financial burden on the HFs and the patients. The control of the NIs is a global issue and requires additional effort. Because the pathogenic microbes can be transmitted among all the HF departments, the layout and design of the HFs (or the department configuration) is considered to play a significant role in control of the NIs. A few of the departments transmit the microbes more than other departments, called ‘cause’, while some other departments are more infected than others, called ‘effect’. Here, the researchers have stated that both the cause and effect departments are risky. This research tried to propose a comprehensive mathematical algorithm for choosing the high-risk department(s) by applying the NI and the managerial criteria to minimize NIs through rearchitecting of the HFs. To develop the algorithm, the researchers applied the multiple criteria decision-making (MCDM) methods. They used Decision-Making Trial and Evaluation Laboratory (DEMATEL) and modified weighted sum method (WSM) methods, and their hybrid, along with a modified nominal group technique (NGT) for data collection. The proposed algorithm was later validated by implementation in a HF as a case study. Based on all results of the algorithm, the high-risk departments in the HF were identified and proposed to be eliminated from the HF in such a way that the facility would retain its functionality. The algorithm was seen to be valid, and the feasibility of the algorithm was approved by the top managers of the HF after the algorithm was implemented in the case study. In conclusion, the proposed algorithm was seen to be an effective solution for minimizing the NIs risk in every HF by eliminating the high-risk departments, which could simplify the HF manager’s decisions.

Environmental contamination by carbapenem-resistant Acinetobacter baumannii: The effects of room type and cleaning methods

OBJECTIVE

We evaluated environmental contamination by carbapenem-resistant Acinetobacter baumannii (CRAB), the effectiveness of cleaning practices, the performance of aerosolized hydrogen-peroxide (aHP) technology, and the correlation between measures of cleaning and environmental contamination.

DESIGN

Serial testing of environmental contamination during a 7-month period.

SETTING

Single-patient rooms in intensive care units (ICUs) and multipatient step-up and regular rooms in internal medicine wards in a tertiary-care hospital with endemic CRAB.

METHODS

CRAB environmental contamination was determined semiquantitatively using sponge sampling.

RESULTS

In step-up rooms, 91% of patient units (56% of objects) were contaminated, and half of them were heavily contaminated. In regular rooms, only 21% of patient units (3% of objects) were contaminated. In ICUs, 76% of single-patient rooms (24% of objects) were contaminated. Cleaning did not reduce the number of contaminated objects or patient units in step-up rooms. After refresher training, cleaning reduced the proportion of contaminated objects by 2-fold (P = .001), but almost all patient units remained contaminated. Using aerosolized hydrogen peroxide (aHP) disinfection after discharge of a known CRAB-carrier decreased room contamination by 78%, similar to the reduction achieved by manual hypochloride cleaning. Measuring cleaning efficacy using fluorescent gel did not correlate with recovery of CRAB by sponge cultures.

CONCLUSIONS

In step-up rooms, the high number of objects contaminated combined with poor efficacy of cleaning resulted in failure to eliminate CRAB in patient units. Fluorescent gel is a poor detector of CRAB contamination. The role of aHP is still unclear. However, its use in multipatient rooms is limited because it can only be used in unoccupied rooms.

Time-Series Analysis of Health Care-Associated Infections in a New Hospital With All Private Rooms

IMPORTANCE

Health care-associated infections are often caused by multidrug-resistant organisms and substantially factor into hospital costs and avoidable iatrogenic harm. Although it is recommended that new facilities be built with single-room, low-acuity beds, this process is costly and evidence of reductions in health care-associated infections is weak.

OBJECTIVE

To examine whether single-patient rooms are associated with decreased rates of common multidrug-resistant organism transmissions and health care-associated infections.

DESIGN, SETTING, AND PARTICIPANTS

A time-series analysis comparing institution-level rates of new multidrug-resistant organism colonization and health care-associated infections before (January 1, 2013-March 31, 2015) and after (April 1, 2015-March 31, 2018) the move to the hospital with 100% single-patient rooms. In the largest hospital move in Canadian history, inpatients in an older, tertiary care, 417-bed hospital in Montréal, Canada, that consisted of mainly mixed 3- and 4-person ward-type rooms were moved to a new 350-bed facility with all private rooms.

EXPOSURES

A synchronized move of all patients on April 26, 2015, to a new hospital with 100% single-patient rooms equipped with individual toilets and showers and easy access to sinks for hand washing.

MAIN OUTCOMES AND MEASURES

Rates of nosocomial vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) colonization, VRE and MRSA infection, and Clostridioides difficile (formerly known as Clostridium difficile) infection (CDI) per 10 000 patient-days.

RESULTS

Compared with the 27 months before, during the 36 months after the hospital move, an immediate and sustained reduction in nosocomial VRE colonization (from 766 to 209 colonizations; incidence rate ratio [IRR], 0.25; 95% CI, 0.19-0.34) and MRSA colonization (from 129 to 112 colonizations; IRR, 0.57; 95% CI, 0.33-0.96) was noted, as well as VRE infection (from 55 to 14 infections; IRR, 0.30, 95% CI, 0.12-0.75). Rates of CDI (from 236 to 223 infections; IRR, 0.95; 95% CI, 0.51-1.76) and MRSA infection (from 27 to 37 infections; IRR, 0.89, 95% CI, 0.34-2.29) did not decrease.

CONCLUSION AND RELEVANCE

The move to a new hospital with exclusively single-patient rooms appeared to be associated with a sustained decrease in the rates of new MRSA and VRE colonization and VRE infection; however, the move was not associated with a reduction in CDI or MRSA infection. These findings may have important implications for the role of hospital construction in facilitating infection control.