Impact of COVID-19 on an infection prevention and control program, Iowa 2020-2021

Background

The COVID-19 pandemic has affected infection prevention and control (IPC) programs worldwide. We evaluated the impact of COVID-19 on the University of Iowa Hospitals & Clinics IPC program by measuring the volume of calls to the program, changes in healthcare-associated infection rates, and team member perceptions.

Methods

We retrieved the IPC call log and healthcare-associated infection trends for 2018-2020. We defined 2 periods: pre-COVID-19 (2018-2019) and COVID-19 (January-December 2020). We also conducted one-on-one interviews and focus group interviews with members of the IPC program and describe changes in their working conditions during the COVID-19 period.

Results

A total of 6,564 calls were recorded during 2018-2020. The pre-COVID-19 period had a median of 71 calls and/or month (range: 50-119). During the COVID-19 period, the median call volume increased to 368/month (range: 149-829), and most calls were related to isolation precautions (50%). During the COVID-19 period, the central line-associated bloodstream infection incidence increased significantly. Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges.

Conclusions

Our IPC program experienced a 500% increase in consultation requests. Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

BACKGROUND

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

METHODS

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

DISCUSSION

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05020418.

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan

BACKGROUND

Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children.

MATERIALS AND METHODS

Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients.

FINDINGS

Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%).

CONCLUSIONS

A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.

Bugs and Drugs: Collaboration Between Infection Prevention and Antibiotic Stewardship

Overall goals of antibiotic stewardship and infection prevention programs are to improve patient safety as it pertains to risk of infection or multidrug-resistant organism (MDRO) acquisition. Although the focus of day-to-day activities may differ, the themes of surveillance, education, clinician engagement, and multidisciplinary interactions are prevalent in both programs. Synergistic work between programs has yielded benefits in prevention of MDROs, surgical site infections, Clostridioides difficile infection, and reducing inappropriate testing and treatment for asymptomatic bacteriuria. Collaboration between programs can help maximize resources and minimize redundant work to keep issues related to bugs and drugs at bay.

Economic evaluations and their use in infection prevention and control: a narrative review

Background

The objective of this review is to provide a comprehensive overview of the different types of economic evaluations that can be utilized by Infection Prevention and Control practitioners with a particular focus on the use of the quality adjusted life year, and its associated challenges. We also highlight existing economic evaluations published within Infection Prevention and Control, research gaps and future directions.

Design

Narrative Review.

Conclusions

To date the majority of economic evaluations within Infection Prevention and Control are considered partial economic evaluations. Acknowledging the challenges, which include variable utilities within infection prevention and control, a lack of randomized controlled trials, and difficulty in modelling infectious diseases in general, future economic evaluation studies should strive to be consistent with published guidelines for economic evaluations. This includes the use of quality adjusted life years. Further research is required to estimate utility scores of relevance within Infection Prevention and Control.

The Infectious Disease Network (IDN): Development and Use for Evaluation of Potential Ebola Cases in Georgia

In response to the 2014 Ebola virus disease (EVD) outbreak in West Africa, the Georgia Department of Public Health developed the Infectious Disease Network (IDN) based on an EVD preparedness needs assessment of hospitals and Emergency Medical Services (EMS) providers. The network consists of 12 hospitals and 16 EMS providers with staff specially trained to provide a coordinated response and utilize appropriate personal protective equipment (PPE) for the transport or treatment of a suspected or confirmed serious communicable disease patient. To become a part of the network, each hospital and EMS provider had to demonstrate EVD capabilities in areas such as infection control, PPE, waste management, staffing and ongoing training, and patient transport and placement. To establish the network, the Georgia Department of Public Health provided training and equipment for EMS personnel, evaluated hospitals for EVD capabilities, structured communication flow, and defined responsibilities among partners. Since March 2015, the IDN has been used to transport, treat, and/or evaluate suspected or confirmed serious communicable disease cases while ensuring health care worker safety. Integrated infectious disease response systems among hospitals and EMS providers are critical to ensuring health care worker safety, and preventing or mitigating a serious communicable disease outbreak. (Disaster Med Public Health Preparedness. 2018;12:765-771).

Making change easy: A peer-to-peer guide on transitioning to new hand hygiene products

This report summarizes our experiences planning and implementing the transition to a new commercial line of hand hygiene products and their dispensing systems in a large academic health care facility in Toronto, Canada. Our lessons learned are organized into a practical guide made available in 2 different formats: this article and an illustrated peer-to-peer guide (http://www.baycrest.org/wp-content/uploads/HCE-PROG-HH_HighQuality.pdf).

Characteristics of national and statewide health care-associated infection surveillance programs: A qualitative study

BACKGROUND

There are many well-established national health care-associated infection surveillance programs (HAISPs). Although validation studies have described data quality, there is little research describing important characteristics of large HAISPs. The aim of this study was to broaden our understanding and identify key characteristics of large HAISPs.

METHODS

Semi-structured interviews were conducted with purposively selected leaders from national and state-based HAISPs. Interview data were analyzed following an interpretive description process.

RESULTS

Seven semi-structured interviews were conducted over a 6-month period during 2014-2015. Analysis of the data generated 5 distinct characteristics of large HAISPs: (1) triggers: surveillance was initiated by government or a cooperative of like-minded people, (2) purpose: a clear purpose is needed and determines other surveillance mechanisms, (3) data measures: consistency is more important than accuracy, (4) processes: a balance exists between the volume of data collected and resources, and (5) implementation and maintenance: a central coordinating body is crucial for uniformity and support.

CONCLUSIONS

National HAISPs are complex and affect a broad range of stakeholders. Although the overall goal of health care-associated infection surveillance is to reduce the incidence of health care-associated infection, there are many crucial factors to be considered in attaining this goal. The findings from this study will assist the development of new HAISPs and could be used as an adjunct to evaluate existing programs.

Current status of personnel and infrastructure resources for infection prevention and control programs in the Republic of Korea: A national survey

BACKGROUND

There is significant variability in personnel and infrastructural resources for infection prevention and control (IPC) among health care institutions. The aim of this study is to evaluate the current status of individual hospital-based IPC programs in the Republic of Korea (ROK).

METHODS

A multicenter cross-sectional survey of 100 hospitals participating in the national surveillance programs for multidrug-resistant organisms (MDROs) in the ROK was conducted in September 2015. The survey consisted of 140 standardized Web-based questionnaires.

RESULTS

The survey response rate was 41.0%. The responding hospitals are largely organized with multibed rooms, with an insufficient numbers of single rooms. Employment status of infection specialists and hand hygiene resources were better in larger hospitals. The responding hospitals had 1 full-time infection control nurse per 400.3 ± 154.1 beds, with wide variations in training and experience. Facilities have great diversity in their approach to preventing MDROs. There appeared to be no difference in supplies consumption and protocols for IPC among the hospitals, stratified according to size.

CONCLUSIONS

A greater availability of specialist personnel, single rooms, and a comprehensive IPC program, with the support of a policy-oriented management, is necessary to achieve effective IPC.

Improving Patient Safety: Resource Availability and Application for Reducing the Incidence of Healthcare-Associated Infection

Objective.

VHA Mountain States conducted a survey and analysis of infection control (IC) staffing resources, organizational structures, and clinical processes related to reducing the incidence of healthcare-associated infections (HAIs) in community healthcare facilities.

Methods.

Member participation was solicited for 2 study components. The first was a survey of demographic characteristics regarding the type and size of the facility and the structure and functions of IC departments. The second was an observational study of infection prevention practices related to general hand hygiene (GHH), ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI), and catheter-related urinary tract infection (CRUTI).

Results.

A total of 31 not-for-profit community healthcare facilities submitted data; the number of beds in participating centers ranged from less than 50 beds (1 facility) to more than 500 beds (7 facilities). IC department staffing ranged from 0.3 to 5.0 full-time equivalents. There was a positive correlation between average daily census and IC staffing (r = .879; P<.001). Observational studies revealed that compliance with the use of alcohol-based hand rubs (77%) was significantly better than compliance with the use of soap and water (64%; P<.001). Seven (30%) of 23 organizations observed 90% or better compliance with VAP process measures; 7 of 27 (26%) observed 90% or better compliance with guidelines for preventing CRBSI; and 14 (56%) demonstrated proper placement of urinary drainage bags at least 90% of the time.

Conclusions.

There was variation in IC department structure and processes among the participating organizations. Infection prevention practices were inconsistent. These findings emphasize the need for more-effective implementation of current evidence-based recommendations for preventing HAIs and reducing the risk of harm to patients.

Novel application of a discrete choice experiment to identify preferences for a national healthcare-associated infection surveillance programme: a cross-sectional study

OBJECTIVE

To identify key stakeholder preferences and priorities when considering a national healthcare-associated infection (HAI) surveillance programme through the use of a discrete choice experiment (DCE).

SETTING

Australia does not have a national HAI surveillance programme. An online web-based DCE was developed and made available to participants in Australia.

PARTICIPANTS

A sample of 184 purposively selected healthcare workers based on their senior leadership role in infection prevention in Australia.

PRIMARY AND SECONDARY OUTCOMES

A DCE requiring respondents to select 1 HAI surveillance programme over another based on 5 different characteristics (or attributes) in repeated hypothetical scenarios. Data were analysed using a mixed logit model to evaluate preferences and identify the relative importance of each attribute.

RESULTS

A total of 122 participants completed the survey (response rate 66%) over a 5-week period. Excluding 22 who mismatched a duplicate choice scenario, analysis was conducted on 100 responses. The key findings included: 72% of stakeholders exhibited a preference for a surveillance programme with continuous mandatory core components (mean coefficient 0.640 (p<0.01)), 65% for a standard surveillance protocol where patient-level data are collected on infected and non-infected patients (mean coefficient 0.641 (p<0.01)), and 92% for hospital-level data that are publicly reported on a website and not associated with financial penalties (mean coefficient 1.663 (p<0.01)).

CONCLUSIONS

The use of the DCE has provided a unique insight to key stakeholder priorities when considering a national HAI surveillance programme. The application of a DCE offers a meaningful method to explore and quantify preferences in this setting.

Automated surveillance system for hospital-acquired urinary tract infections in Denmark

BACKGROUND

The Danish Hospital-Acquired Infections Database (HAIBA) is an automated surveillance system using hospital administrative, microbiological, and antibiotic medication data.

AIM

To define and evaluate the case definition for hospital-acquired urinary tract infection (HA-UTI) and to describe surveillance data from 2010 to 2014.

METHODS

The HA-UTI algorithm defined a laboratory-diagnosed UTI as a urine culture positive for no more than two micro-organisms with at least one at ≥10(4)cfu/mL, and a probable UTI as a negative urine culture and a relevant diagnosis code or antibiotic treatment. UTI was considered hospital-acquired if a urine sample was collected ≥48h after admission and <48h post discharge. Incidence of HA-UTI was calculated per 10,000 risk-days. For validation, prevalence was calculated for each day and compared to point prevalence survey (PPS) data.

FINDINGS

HAIBA detected a national incidence rate of 42.2 laboratory-diagnosed HA-UTI per 10,000 risk-days with an increasing trend. Compared to PPS the laboratory-diagnosed HA-UTI algorithm had a sensitivity of 50.0% (26/52) and a specificity of 94.2% (1842/1955). There were several reasons for discrepancies between HAIBA and PPS, including laboratory results being unavailable at the time of the survey, the results considered clinically irrelevant by the surveyor due to an indwelling urinary catheter or lack of clinical signs of infection, and UTIs being considered HA-UTI in PPS even though the first sample was taken within 48h of admission.

CONCLUSION

The HAIBA algorithm was found to give valid and valuable information and has, among others, the advantages of covering the whole population and allowing continuous standardized monitoring of HA-UTI.

Necessary Infrastructure of Infection Prevention and Healthcare Epidemiology Programs: A Review

The scope of a healthcare institution's infection prevention and control/healthcare epidemiology program (IPC/HE) should be driven by the size and complexity of the patient population served, that population's risk for healthcare-associated infection (HAI), and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following: ∙ Surveillance.∙ Performance improvement to reduce HAI ∙ Acute event response, including outbreak investigation ∙ Education and training of both healthcare personnel and patients ∙ Reporting of HAI to the Centers for Disease Control and Prevention's National Healthcare Safety Network as well as entities required by law.

Bloodstream Infections in a Community Hospital: A 25-Year Follow-Up

Objective:

To examine the current status of bloodstream infections (BSIs) in a community hospital as part of a 25-year longitudinal study.

Design:

Retrospective descriptive epidemiologic study.

Setting:

Community teaching hospital.

Patients:

All inpatients in 1998 with a positive blood culture who met the CDC NNIS System case definition of BSI.

Methods:

Cases were stratified by underlying illness category using case mix adjustment categories (after McCabe) and reviewed for associations among mortality, underlying illness severity, and multiple clinical and laboratory parameters.

Results:

Of 19,289 patients discharged in 1998,185 had an episode of infection documented by blood culture (96 cases per 10,000 inpatients). BSI was twice as frequent in patients 65 years and older compared with younger patients. BSIs caused or contributed to the deaths of 22 patients for an overall case-fatality rate of 11.9% compared with 20.7% in 1982 (P = .02). Striking decreases were noted for in-hospital patient mortality in 1998 for BSIs with ultimately and rapidly fatal underlying illnesses (P = .02 and P < .10, respectively). Primary bacteremia decreased compared with 1982. Antibiotic use was vigorous, but resistance was modest in both nosocomial and community-acquired organisms and had changed little from 1982 and 1987.

Conclusions:

Compared with previous studies, case-fatality rates in patients with BSI were substantially lower in rapidly fatal and ultimately fatal underlying illness categories. Antibiotic use was extensive but prompt and appropriate. Microorganism resistance to antibiotics changed little from the 1980s.

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

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

Infection Control Programs in Italian Hospitals

Objective:

To quantify the frequency and features of infection control programs implemented in Italian public hospitals.

Methods:

In 2000, a questionnaire was mailed targeting all teaching and research hospitals and those with more than 300 beds, and a random sample of 50% of the district hospitals with fewer than 300 beds.

Results:

The overall response rate was 80%. Fifty percent of the 428 respondent hospitals claimed to have an infection control committee, 43% an infection control physician (average, 1 infection control physician per 2,963 beds), and 33% an infection control nurse (average, I infection control nurse per 572 beds). Having an infection control committee, nurse, and physician occurred significantly more frequently in Northern and Central Italy, where the Regional Authority had implemented a regional infection control policy, and in larger hospitals. Thirty-nine percent of the hospitals claimed to have ongoing surveillance in place, mostly based on laboratory results. Eighty percent of the hospitals had defined at least one written protocol related to infection control policies, mostly for housekeeping, cleaning, disinfecting and sterilizing patient equipment, or standard precautions; on the contrary, policies aimed at preventing specifie infections were less frequent.

Conclusion:

This national representative survey showed that the infrastructure for infection control is suboptimal when compared with the guidelines and surveys published in other countries.

Core Components for Infection Prevention and Control Programs: A World Health Organization Network Report

Under the leadership of the World Health Organization (WHO), the core components necessary for national and local infection prevention and control programs are identified. These components were determined by a network of international experts who are representatives from WHO regional offices and relevant WHO programs. The respective roles of the national authorities and the local healthcare facilities are delineated.

Attributable Cost and Length of Stay for Patients With Central Venous Catheter—Associated Bloodstream Infection in Mexico City Intensive Care Units A Prospective, Matched Analysis

Background.

No information is available about the financial impact of central venous catheter (CVC)-associated bloodstream infection (BSI) in Mexico.

Objective.

To calculate the costs associated with BSI in intensive care units (ICUs) in Mexico City.

Design.

An 18-month (June 2002 through November 2003), prospective, nested case-control study of patients with and patients without BSI.

Setting.

Adult ICUs in 3 hospitals in Mexico City.

Patients and Methods.

A total of 55 patients with BSI (case patients) and 55 patients without BSI (control patients) were compared with respect to hospital, type of ICU, year of hospital admission, length of ICU stay, sex, age, and mean severity of illness score. Information about the length of ICU stay was obtained prospectively during daily rounds. The daily cost of ICU stay was provided by the finance department of each hospital. The cost of antibiotics prescribed for BSI was provided by the hospitals' pharmacy departments.

Results.

For case patients, the mean extra length of stay was 6.1 days, the mean extra cost of antibiotics was $598, the mean extra hospital cost was $11,591, and the attributable extra mortality was 20%.

Conclusions.

In this study, the duration of ICU stay for patients with central venous catheter-associated BSI was significantly longer than that for control patients, resulting in increased healthcare costs and a higher attributable mortality. These conclusions support the need to implement preventive measures for hospitalized patients with central venous catheters in Mexico.

[Validation of the structure and resources of nosocomial infection control team in hospitals ascribed to VINCat program in Catalonia, Spain]

The main objective of this study was to validate the structure of the infection control team (ICT) in the hospitals adhered to VINCat program and secondary objective was to establish the consistency of resources of each center with the requirements established by the program. Qualitative research consisting of an ethnographic study using participant observation during the years 2008-2010. The centers were stratified in three groups by complexity and beds. The instrument was a semistructured interview to members of the ICT. The transcription of the interview was sent to informants for validation. In November 2010 a questionnaire regarding human resources and number hours dedicated to the ICT was sent. During 2008-2010, 65 centers had been adhered to VINCat program. In 2010, the ICT of Group I hospitals had a mean of two physician, one in full-time and one nurse for every 230 beds. In Group II, one physician part-time and one nurse per 180 beds and in Group III a physician and a nurse for every 98 beds, both part-time. In 2010, all hospitals had a structured ICT, an operative infection committee, and a hospital member representing the center at the program as well as enough electronic resources. The hospitals participating in the program have now VINCat an adequate surveillance structure and meet the minimum technical and human resources required to provide high-quality data. However human resources are not guaranteed.

State of infection prevention in US hospitals enrolled in the National Health and Safety Network

BACKGROUND

This report provides a national cross-sectional snapshot of infection prevention and control programs and clinician compliance with the implementation of processes to prevent health care-associated infections (HAIs) in intensive care units (ICUs).

METHODS

All hospitals, except Veterans Affairs hospitals, enrolled in the National Healthcare Safety Network (NHSN) were eligible to participate. Participation involved completing a survey assessing the presence of evidence-based prevention policies and clinician adherence and joining our NHSN research group. Descriptive statistics were computed. Facility characteristics and HAI rates by ICU type were compared between respondents and nonrespondents.

RESULTS

Of the 3,374 eligible hospitals, 975 provided data (29% response rate) on 1,653 ICUs, and there were complete data on the presence of policies in 1,534 ICUs. The average number of infection preventionists (IPs) per 100 beds was 1.2. Certification of IP staff varied across institutions, and the average hours per week devoted to data management and secretarial support were generally low. There was variation in the presence of policies and clinician adherence to these policies. There were no differences in HAI rates between respondents and nonrespondents.

CONCLUSIONS

Guidelines for IP staffing in acute care hospitals need to be updated. In future work, we will analyze the associations between HAI rates and infection prevention and control program characteristics, as well as the inplementation of and clinician adherence to evidence-based policies.

Public reporting of healthcare-associated infections: epidemiologists' perspectives

Public reporting of healthcare-associated infections is pervasive, with 33 states and the District of Columbia mandating public disclosure. We surveyed hospital epidemiologists on the perceived value of state public reports. Respondents believed consumers are unaware and do not consider the information important, but they indicated that epidemiologists have a role in consumer education.

Hospital epidemiology and infection control in acute-care settings

Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program.

Infection control and intravenous therapy in patients in the community

Recent efforts to reduce infections have been focused within the hospital setting. Early hospital discharge, shorter inpatient stays, day surgery and the movement of patients between acute and long-stay care facilities is likely to make community-acquired infection an increasing problem. There are, or course, universal precautions and general infection control issues to consider when undertaking any clinical procedure, both in hospital and the community, but when administering intravenous therapy (medicines and/or maintenance fluids) specific measures need to be considered. This is especially important if a patient is receiving intravenous therapy at home. There are many reasons why patients may need to receive intravenous therapy in the community and these will all present with specific problems. This paper will discuss some of the infection control procedures one must undertake when administering intravenous therapy to patients in the community.

Should we use closed or open infusion containers for prevention of bloodstream infections?

Background

Hospitalized patients in critical care settings are at risk for bloodstream infections (BSI). Most BSIs originate from a central line (CL), and they increase length of stay, cost, and mortality. Open infusion containers may increase the risk of contamination and administration-related (CLAB) because they allow the entry of air into the system, thereby also providing an opportunity for microbial entry. Closed infusion containers were designed to overcome this flaw. However, open infusion containers are still widely used throughout the world.

The objective of the study was to determine the effect of switching from open (glass, burettes, and semi-rigid) infusion containers to closed, fully collapsible, plastic infusion containers (Viaflex^®) on the rate and time to onset of central line-associated bloodstream infections CLABs.

Methods

An open label, prospective cohort, active healthcare-associated infection surveillance, sequential study was conducted in four ICUs in Mexico. Centers for Disease Control National Nosocomial Infections Surveillance Systems definitions were used to define device-associated infections.

Results

A total of 1,096 adult patients who had a central line in place for >24 hours were enrolled. The CLAB rate was significantly higher during the open versus the closed container period (16.1 versus 3.2 CLAB/1000 central line days; RR = 0.20, 95% CI = 0.11-0.36, P < 0.0001). The probability of developing CLAB remained relatively constant in the closed container period (1.4% Days 2-4 to 0.5% Days 8-10), but increased in the open container period (4.9% Days 2-4 to 5.4% Days 8-10). The chance of acquiring a CLAB was significantly decreased (81%) in the closed container period (Cox proportional hazard ratio 0.19, P < 0.0001). Mortality was statistically significantly lower during the closed versus the open container period (23.4% versus 16.1%; RR = 0.69, 95% CI = 0.54-0.88, P < 0.01).

Conclusions

Closed infusion containers significantly reduced CLAB rate, the probability of acquiring CLAB, and mortality.

Infection control and IV therapy in patients with Clostridium difficile

Clostridium difficile is a spore-forming anaerobe belonging to the family Clostridium, with the bacteria being found in low numbers in approximately 5% of the healthy adult population. Together with meticillin-resistant Staphylococcus aureus, it is a major healthcare-associated infection and is responsible for considerable morbidity and mortality. Antibiotics administered to patients can alter normal gut flora, allowing the proliferation of C. difficile and causing antibiotic-associated diarrhoea and colitis. Such diarrhoea, if severe, can lead to dangerous dehydration and even hypovolaemia, especially in the elderly. To limit the physiological impact of diarrhoea, it is sometimes necessary to administer intravenous therapy. Although good clinical practice demands that infection control should be considered in all clinical situations, specific infection control procedures need to be adhered to when administering intravenous therapy to patients with C. difficile.

Evaluation of home health care nurses' practice and their employers' policies related to bloodborne pathogens

The purpose of this descriptive study was to assess home health care nurses' exposure to bloodborne pathogens, evaluate Medicare Certified Home Healthcare Agency (MCHHA) and hospice organization practices related to the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogens Standard and the Needlestick Safety and Prevention Act, and link the two to recommend safety improvements. This study evaluated the experiences of 355 home health care nurses and 30 MCHHA and hospice employers in one mid-Atlantic state regarding bloodborne pathogen programs and practices and blood and sharps contact. An index was developed to evaluate employer compliance with OSHA's Bloodborne Pathogens Standard. Employer policies and nurse practice related to the OSHA Bloodborne Pathogens Standard did not meet all requirements despite identified risk. Thirty-eight home health care nurses from 12 of the 30 employers reported needlestick injuries within the past year, yet employers reported only 18 nurse needlestick injuries within the same year. Using the bloodborne pathogen compliance index, employers can review and revise their exposure control plans to ensure compliance. This intervention should benefit both employer policies and nurse practice to improve safety and decrease the risks from bloodborne pathogens in the home health care setting.

Who is monitoring your infections: shouldn't you be?

BACKGROUND

In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP).

METHODS

A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined.

RESULTS

A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%.

CONCLUSIONS

Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Changing the conversation--the occupational health nurse's role in integrated HS3

Occupational health nurses have the skills and knowledge to provide a holistic perspective in advancing their company's triple bottom line, healthy people, healthy planet, and healthy profits. The HS3 model provides a road map for integrating health, safety, sustainability, and stewardship, all of which directly impact every company's triple bottom line. Occupational health nurses can use the HS3 model to promote healthy lifestyles, reduce risk and injuries, protect the natural environment, and improve resource alignment. Occupational health nurses have a unique opportunity to demonstrate the value they bring to their employers using synergistic HS3 planning that cost-effectively links work injury management, health promotion, environmental protection, safety training and surveillance, and regulatory compliance. Implementing the HS3 model requires occupational health nurses to be innovators who can change the conversation.

Hospital staffing and health care-associated infections: a systematic review of the literature

In the past 10 years, many researchers have examined relationships between hospital staffing and patients' risk of health care-associated infection (HAI). To gain understanding of this evidence base, a systematic review was conducted, and 42 articles were audited. The most common infection studied was bloodstream infection (n=18; 43%). The majority of researchers examined nurse staffing (n=38; 90%); of these, only 7 (18%) did not find a statistically significant association between nurse staffing variable(s) and HAI rates. Use of nonpermanent staff was associated with increased rates of HAI in 4 studies (P<.05). Three studies addressed infection control professional staffing with mixed results. Physician staffing was not found to be associated with patients' HAI risk (n=2). The methods employed and operational definitions used for both staffing and HAI varied; despite this variability, trends were apparent. Research characterizing effective staffing for infection control departments is needed.

Catheter-related bloodstream infections in hematology

Central venous catheters are essential in the management of many malignant disorders, but catheter-related bloodstream infections (CR-BSIs) are significant complications in terms of morbidity, mortality, and healthcare expenditure. These outcome measures are useful for monitoring of infection control practice and the effect of preventive strategies. Unlike intensive care unit (ICU) populations, surveillance for CR-BSIs in the hematology population is not standardized, despite the potential value of detecting changes in rate, etiology, and changes in risk for infective complications in association with increasingly intensive chemotherapeutic regimens in this immunocompromised population. Essential components of a successful surveillance strategy include selection of a health outcome of significance, definition of goals of the surveillance system, involvement of key stakeholders in planning and development, application of valid case definitions, allocation of resources and trained personnel, risk stratification, and use of appropriate statistical methods for analysis. These are discussed with reference to patients with hematologic malignancy, together with review of previous surveillance strategies in this population. Only when these issues are addressed can a surveillance strategy reliably assess trends and compare data, leading to improved patient outcomes and a reduction in healthcare expenditure for patients with hematologic malignancy.

Coincidental outbreak of methicillin-resistant Staphylococcus aureus in a hematopoietic stem cell transplantation unit

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common nosocomial pathogens among hospital-acquired infections, and immunocompromised patients are highly susceptive to infection. The molecular typing of isolated strains is a common method for tracing an outbreak of MRSA, but experience with this approach is still limited in the hematopoietic stem cell transplantation (HSCT) ward.

METHODS

We experienced 6 cases of MRSA infection/colonization in our 26-bed HSCT ward during a 4-week period. This unusual outbreak strongly suggested that the same MRSA strain was involved despite strict isolation and aseptic patient care. Clarification of the transmission pattern was critical, and we applied pulsed-field gel electrophoresis (PFGE) and amplified fragment length polymorphism (AFLP) assays for evaluation.

RESULTS AND CONCLUSION

In four of the six cases, the pattern of bands examined by PFGE and AFLP analyses supported the idea that direct person-to-person transmission was very unlikely and the outbreak was coincidental. This experience highlights the clinical value of molecular typing methods for the clinical epidemiological assessment of MRSA outbreak.

Application of molecular techniques to the study of hospital infection

Nosocomial infections are an important source of morbidity and mortality in hospital settings, afflicting an estimated 2 million patients in United States each year. This number represents up to 5% of hospitalized patients and results in an estimated 88,000 deaths and 4.5 billion dollars in excess health care costs. Increasingly, hospital-acquired infections with multidrug-resistant pathogens represent a major problem in patients. Understanding pathogen relatedness is essential for determining the epidemiology of nosocomial infections and aiding in the design of rational pathogen control methods. The role of pathogen typing is to determine whether epidemiologically related isolates are also genetically related. To determine molecular relatedness of isolates for epidemiologic investigation, new technologies based on DNA, or molecular analysis, are methods of choice. These DNA-based molecular methodologies include pulsed-field gel electrophoresis (PFGE), PCR-based typing methods, and multilocus sequence analysis. Establishing clonality of pathogens can aid in the identification of the source (environmental or personnel) of organisms, distinguish infectious from noninfectious strains, and distinguish relapse from reinfection. The integration of molecular typing with conventional hospital epidemiologic surveillance has been proven to be cost-effective due to the associated reduction in the number of nosocomial infections. Cost-effectiveness is maximized through the collaboration of the laboratory, through epidemiologic typing, and the infection control department during epidemiologic investigations.

Implementation of antibiotic management teams in Belgian hospitals

In 2002-03, the Belgian government subsidized in part the activities of local Antibiotic Managers (AMs) in 36 hospitals selected based on the presence of an operational multidisciplinary Antibiotic Management Team (AMT). AMs were trained as Internists (28), Microbiologists (13) and Hospital Pharmacists (13). The hospitals were representative of Belgian hospitals in affiliation, regional origin and size. The financing scheme allowed the implementation of 175 antibiotic management interventions, with a mean of 5 interventions/hospital. The activities reported in the first 9-month progress reports were analyzed according to national guidelines for AMTs. All hospitals irrespective of size or affiliation had undertaken a wide range of measures: review of formulary (29), implementation of new clinical guidelines (24), restricted access to selected antibiotics (25), improvement of antibiotic susceptibility testing methods (12), development of antibiotic consumption database (35) and analysis of antibacterial susceptibility data (31). Advertisement type categorization of communication methods showed that education of prescribers was based on multimodal communication. All hospitals used at least one passive method, 39% at least one active method and 55% at least one personalized method. The quality of communication was higher in hospitals with teaching affiliation. In conclusion, hospitals that received a financial incentive under theAMT pilot phase have developed multimodal antibiotic policy interventions independently of the hospital size and teaching status. Extension to all Belgian hospitals appears warranted. The impact of AMTs and AMs on the quality of use of antibiotics and trends of antibiotic resistance and cost will be monitored based on standardized indicators.

Models for the organisation of hospital infection control and prevention programmes

Hospital infection control is an essential part of infectious disease management and must be firmly structured and professionally organised. Prevention, limitation and eradication of nosocomial infections requires specific expertise not fully provided by clinical microbiologists and/or infectious disease consultants. Therefore, dedicated infection control physicians and nurses are essential. The basic components for successful hospital infection control include: (1) personnel and supporting resources proportional to size, complexity and estimated risk of the population served; (2) trained hospital infection control practitioners; and (3) the necessary structure to implement changes in medical, nursing and logistical organisation. The identification of areas of concern, provision of written policies and education still constitute the backbone of infection control. The infection control team must propose priorities and necessary resources, objectives, development methods, implementation and follow-up. The strategic approach must be discussed and approved by the infection control committee, comprising the hospital administrator(s), medical and nursing directors, a microbiologist, a hospital pharmacist and a delegation of clinicians. Follow-up of the projects is regularly presented to the committee by the infection control team. To what extent may evolution in the organisation of hospital infection control contribute to the optimisation of allocated resources and fulfillment of these objectives? From the Belgian experience, we conclude that structural changes represent an essential incentive. The impact of changes is greater when they are directed by the national authorities, providing resources and imposing new standards. Recommendations for staffing must consider not only the number of beds but also the objectives, complexity and characteristics of the patient population.

Factors influencing hospital infection control policies in Italian hospitals

A study was undertaken to determine the resources available in Italian hospitals for the control of nosocomial infections and the factors favouring a successful approach. During January-May 2000 a questionnaire about infection control was sent to the hospital health director of all Italian National Health System hospitals treating acute patients and with more than 3500 admissions in 1999. An active programme was defined as a hospital infection control committee (HICC) meeting at least four times in 1999, the presence of a doctor with infection control responsibilities, a nurse employed in infection control and at least one surveillance activity and one infection control guideline issued or updated in the past two years. There was a response rate of 87.5% (463/529). Almost fifteen percent (69/463) of hospitals had an active programme for Infection Control and 76.2% (353/463) had a HICC. Seventy-one percent (330/463) of the hospitals had a hospital infection control physician and 53% (250/463) had infection control nurses. Fifty-two percent (242/463) reported at least one surveillance activity and 70.8% (328/463) had issued or updated at least one guidance document in the last two years. The presence of regional policies [odds ratio (OR) 8.7], operative groups (OR 4.2), at least one full-time nurse (OR 4.6) and a hospital annual plan which specified infection control (OR 2.1) were statistically associated with an active programme in the multivariate analysis.

An intranet-based automated system for the surveillance of nosocomial infections: prospective validation compared with physicians' self-reports

OBJECTIVE

To examine the reliability of the data produced by an automated system for the surveillance of nosocomial infections.

SETTING

A 906-bed, tertiary-care teaching hospital.

DESIGN

Three surveillance techniques were concurrently performed in seven high-risk units during an 11-week period: automated surveillance (AS) based on the prospective processing of computerized medical records; laboratory-based ward surveillance (LBWS) based on the retrospective verification by ward clinicians of weekly reports of positive bacteriologic results; and a reference standard (RS) consisting of the infection control team reviewing case records of patients with positive bacteriology results. Bacteremia, urinary tract infections, and catheter-related infections were recorded for all inpatients. The performances (sensitivity, specificity, and time consumption) of AS and LBWS were compared with those of RS.

RESULTS

Of 548 positive bacteriology samples included during the study period, 229 (42%) were classified as nosocomial infections. The overall sensitivity was 91% and 59% for AS and LBWS, respectively. The two methods had the same overall specificity value (91%). Kappa measures of agreement were 0.81 and 0.54 for AS and LBWS, respectively. AS required less time to collect data (54 seconds per week per unit) compared with LBWS (7 minutes and 43 seconds per week per unit) and RS (37 minutes and 15 seconds per week per unit).

CONCLUSION

Our results confirm that the retrospective review of charts and laboratory data by physicians lacks sensitivity for the surveillance of nosocomial infections. The intranet-based automated method developed for this purpose was more accurate and less time-consuming than the weekly, retrospective LBWS method.