How long do nosocomial pathogens persist on inanimate surfaces? A scoping review

Healthcare hygiene plays a crucial role in the prevention of healthcare-associated infections. Patients admitted to a room where the previous occupant had a multi-drug-resistant bacterial infection are at an increased risk of colonization and infection with the same organism. A 2006 systematic review by Kramer et al. found that certain pathogens can survive for months on dry surfaces. The aim of this review is to update Kramer et al.'s previous review and provide contemporary data on the survival of pathogens relevant to the healthcare environment. We systematically searched Ovid MEDLINE, CINAHL and Scopus databases for studies that described the survival time of common nosocomial pathogens in the environment. Pathogens included in the review were bacterial, viral, and fungal. Studies were independently screened against predetermined inclusion/exclusion criteria by two researchers. Conflicts were resolved by one of two senior researchers. A spreadsheet was developed for the data extraction. The search identified 1736 studies. Following removal of duplicates and application of the search criteria, the synthesis of results from 62 included studies were included. 117 organisms were reported. The longest surviving organism reported was Klebsiella pneumoniae which was found to have persisted for 600 days. Common pathogens of concern to infection prevention and control, can survive or persist on inanimate surfaces for months. This data supports the need for a risk-based approach to cleaning and disinfection practices, accompanied by appropriate training, audit and feedback which are proven to be effective when adopted in a 'bundle' approach.

Comparison of an algorithm, and coding data, with traditional surveillance to identify surgical site infections in Australia: a retrospective multi-centred cohort study

BACKGROUND

Surveillance of healthcare-associated infections (HAIs) in Australia is disparate, resource intensive, unsustainable, and provides limited information. Traditional HAI surveillance is time intensive and agreement levels between clinicians have been shown to be variable.

AIM

To compare two methods: a semi-automated algorithm, and coding data, against traditional surgical site infection (SSI) surveillance methods.

METHODS

This retrospective multi-centre cohort study included all patients undergoing a hip (HPRO) or knee (KPRO) prosthesis and coronary artery bypass graft (CABG) surgery during a two-year period at two large metropolitan hospitals. Routine SSI data were obtained via the infection prevention and control (IPC) team, a previously developed algorithm was applied to all patient records, and the ICD-10-AM data were searched for those categorized as having an SSI.

FINDINGS

Overall, 1447, 1416, and 1026 patients who underwent HPRO, KPRO, and CABG, respectively, were included. The highest sensitivity values were generated by the algorithm: HPRO deep or organ-space (D/O) 0.87 (95% confidence interval: 0.66-0.96), CABG 0.86 (0.64-0.96), and HPRO all SSI 0.77 (0.57-89); the lowest sensitivity was Code CABG D/O 0.03 (0.00-0.21). The highest PPV values were generated by the algorithm: HPRO D/O 0.97 (0.77-0.99), CABG D/O 0.97 (0.76-0.99), and the Code HPRO D/O 0.9 (0.66-0.99). Both the algorithm and coding data resulted in a substantial reduction in the number of medical records required to review.

CONCLUSION

The application of algorithms to enhance SSI surveillance demonstrates high accuracy in identifying patient records that require review by IPC teams to determine the presence of an SSI. Coding data alone should not be used to identify SSIs.

Psychosocial Interventions at the End-of-Life: A Scoping Review

BACKGROUND

The integration of holistic and effective end-of-life (EOL) care into cancer management has increasingly become a recognized field. People living with terminal cancer and their caregivers face a unique set of emotional, spiritual, and social stressors, which may be managed by psychosocial interventions.

OBJECTIVES

This study aimed to explore the types and characteristics of psychosocial interventions at the EOL for adult cancer patients and their caregivers and to identify gaps in the current literature.

METHODS

A systematic search was conducted through MEDLINE (Ovid) and CINAHL from January 1, 2011, to January 31, 2021, retrieving 2453 results. A final 15 articles fulfilled the inclusion criteria, reviewed by 2 independent reviewers. Ten percent of the original articles were cross-checked against study eligibility at every stage by 2 experienced researchers.

RESULTS

Most interventions reported were psychotherapies, with a predominance of meaning or legacy-related psychotherapies. Most interventions were brief, with significant caregiver involvement. Most studies were conducted in high-income, English-speaking populations.

CONCLUSION

There is robust, although heterogeneous, literature on a range of psychosocial interventions at the EOL. However, inconsistencies in the terminology used surrounding EOL and means of outcome assessment made the comparison of interventions challenging.

IMPLICATION FOR PRACTICE

Future studies will benefit from increased standardization of study design, EOL terminology, and outcome assessment to allow for a better comparison of intervention efficacy. There is a need for increased research in psychosocial interventions among middle- to low-income populations exploring social aspects, intimacy, and the impact of COVID-19.

Risk of organism acquisition from prior room occupants: An updated systematic review

BACKGROUND

Evidence from a previous systematic review indicates that patients admitted to a room where the previous occupant had a multidrug-resistant bacterial infection resulted in an increased risk of subsequent colonisation and infection with the same organism for the next room occupant. In this paper, we have sought to expand and update this review.

METHODS

A systematic review and meta-analysis was undertaken. A search using Medline/PubMed, Cochrane and CINHAL databases was conducted. Risk of bias was assessed by the ROB-2 tool for randomised control studies and ROBIN-I for non-randomised studies.

RESULTS

From 5175 identified, 12 papers from 11 studies were included in the review for analysis. From 28,299 patients who were admitted into a room where the prior room occupant had any of the organisms of interest, 651 (2.3%) were shown to acquire the same species of organism. In contrast, 981,865 patients were admitted to a room where the prior occupant did not have an organism of interest, 3818 (0.39%) acquired an organism(s). The pooled acquisition odds ratio (OR) for all the organisms across all studies was 2.45 (95% CI: 1.53-3.93]. There was heterogeneity between the studies (I2 89%, P < 0.001).

CONCLUSION

The pooled OR for all the pathogens in this latest review has increased since the original review. Findings from our review provide some evidence to help inform a risk management approach when determining patient room allocation. The risk of pathogen acquisition appears to remain high, supporting the need for continued investment in this area.

The incidence of nosocomial bloodstream infection and urinary tract infection in Australian hospitals before and during the COVID-19 pandemic: an interrupted time series study

BACKGROUND

The COVID-19 pandemic has had a significant impact on healthcare including increased awareness of infection prevention and control (IPC). The aim of this study was to explore if the heightened awareness of IPC measures implemented in response to the pandemic influenced the rates of healthcare associated infections (HAI) using positive bloodstream and urine cultures as a proxy measure.

METHODS

A 3 year retrospective review of laboratory data from 5 hospitals (4 acute public, 1 private) from two states in Australia was undertaken. Monthly positive bloodstream culture data and urinary culture data were collected from January 2017 to March 2021. Occupied bed days (OBDs) were used to generate monthly HAI incidence per 10,000 OBDs. An interrupted time series analysis was undertaken to compare incidence pre and post February 2020 (the pre COVID-19 cohort and the COVID-19 cohort respectively). A HAI was assumed if positive cultures were obtained 48 h after admission and met other criteria.

RESULTS

A total of 1,988 bloodstream and 7,697 urine positive cultures were identified. The unadjusted incident rate was 25.5 /10,000 OBDs in the pre-COVID-19 cohort, and 25.1/10,000 OBDs in the COVID-19 cohort. The overall rate of HAI aggregated for all sites did not differ significantly between the two periods. The two hospitals in one state which experienced an earlier and larger outbreak demonstrated a significant downward trend in the COVID-19 cohort (p = 0.011).

CONCLUSION

These mixed findings reflect the uncertainty of the effect the pandemic has had on HAI's. Factors to consider in this analysis include local epidemiology, differences between public and private sector facilities, changes in patient populations and profiles between hospitals, and timing of enhanced IPC interventions. Future studies which factor in these differences may provide further insight on the effect of COVID-19 on HAIs.

Mental health and wellbeing of health and aged care workers in Australia, May 2021 - June 2022: a longitudinal cohort study

OBJECTIVES

To assess the mental health and wellbeing of health and aged care workers in Australia during the second and third years of the coronavirus disease 2019 (COVID-19) pandemic, overall and by occupation group.

DESIGN, SETTING, PARTICIPANTS

Longitudinal cohort study of health and aged care workers (ambulance, hospitals, primary care, residential aged care) in Victoria: May-July 2021 (survey 1), October-December 2021 (survey 2), and May-June 2022 (survey 3).

MAIN OUTCOME MEASURES

Proportions of respondents (adjusted for age, gender, socio-economic status) reporting moderate to severe symptoms of depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder scale, GAD-7), or post-traumatic stress (Impact of Event Scale-6, IES-6), burnout (abbreviated Maslach Burnout Inventory, aMBI), or high optimism (10-point visual analogue scale); mean scores (adjusted for age, gender, socio-economic status) for wellbeing (Personal Wellbeing Index-Adult, PWI-A) and resilience (Connor Davidson Resilience Scale 2, CD-RISC-2).

RESULTS

A total of 1667 people responded to at least one survey (survey 1, 989; survey 2, 1153; survey 3, 993; response rate, 3.3%). Overall, 1211 survey responses were from women (72.6%); most respondents were hospital workers (1289, 77.3%) or ambulance staff (315, 18.9%). The adjusted proportions of respondents who reported moderate to severe symptoms of depression (survey 1, 16.4%; survey 2, 22.6%; survey 3, 19.2%), anxiety (survey 1, 8.8%; survey 2, 16.0%; survey 3, 11.0%), or post-traumatic stress (survey 1, 14.6%; survey 2, 35.1%; survey 3, 14.9%) were each largest for survey 2. The adjusted proportions of participants who reported moderate to severe symptoms of burnout were higher in surveys 2 and 3 than in survey 1, and the proportions who reported high optimism were smaller in surveys 2 and 3 than in survey 1. Adjusted mean scores for wellbeing and resilience were similar at surveys 2 and 3 and lower than at survey 1. The magnitude but not the patterns of change differed by occupation group.

CONCLUSION

Burnout was more frequently reported and mean wellbeing and resilience scores were lower in mid-2022 than in mid-2021 for Victorian health and aged care workers who participated in our study. Evidence-based mental health and wellbeing programs for workers in health care organisations are needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12621000533897 (observational study; retrospective).

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

BACKGROUND

Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices.

METHODS

The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention.

DISCUSSION

Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Experience and perspectives of infection prevention staff of the COVID-19 response in Australian hospitals

Background

Hospital infection prevention and control (IPC) staff have played a key role in adapting and implementing jurisdictional COVID-19 policy during the current pandemic. We aimed to describe the experiences of IPC staff in Australian hospitals during the COVID-19 pandemic to inform future pandemic preparedness plans.

Methods

A cross-sectional study involving an online survey distributed to IPC practitioners employed in Australian hospitals. Survey content was informed by in-depth interviews, and addressed work conditions, redeployed workforce, personal protective equipment, communication, and guidelines. Participants were recruited through the mailing lists of Australasian College of Infection Prevention and Control and the Australasian Society of Infectious Diseases.

Results

We received fully or partially completed responses from 160 participants, including 38 (24%) and 122 (76%) with nursing and medical backgrounds, respectively. Respondents reported access to sufficient information about PPE (75%, 114/152), PPE was of sufficient quantity (77%, 117/152) and was of sufficient quality (70%, 106/152). Barriers to infection prevention guideline implementation included frequently changing guidelines (57%, 84/148), timing of updates (65%, 96/148) and contradictory sources of information (64%, 95/148). Respondents described a need for better communication channels from government authorities to hospital IPC teams. All respondents described an increase in workload leading to difficulty completing work (63%, 97/154) and feeling burnt out (48%, 74/154).

Conclusions

These data identify avoidable barriers to implementation of COVID-19 infection prevention guidance in Australian hospitals. These findings can inform future national preparedness strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01116-9.

Mental Health Outcomes in Australian Healthcare and Aged-Care Workers during the Second Year of the COVID-19 Pandemic

Objective: the COVID-19 pandemic has incurred psychological risks for healthcare workers (HCWs). We established a Victorian HCW cohort (the Coronavirus in Victorian Healthcare and Aged-Care Workers (COVIC-HA) cohort study) to examine COVID-19 impacts on HCWs and assess organisational responses over time. Methods: mixed-methods cohort study, with baseline data collected via an online survey (7 May–18 July 2021) across four healthcare settings: ambulance, hospitals, primary care, and residential aged-care. Outcomes included self-reported symptoms of depression, anxiety, post-traumatic stress (PTS), wellbeing, burnout, and resilience, measured using validated tools. Work and home-related COVID-19 impacts and perceptions of workplace responses were also captured. Results: among 984 HCWs, symptoms of clinically significant depression, anxiety, and PTS were reported by 22.5%, 14.0%, and 20.4%, respectively, highest among paramedics and nurses. Emotional exhaustion reflecting moderate–severe burnout was reported by 65.1%. Concerns about contracting COVID-19 at work and transmitting COVID-19 were common, but 91.2% felt well-informed on workplace changes and 78.3% reported that support services were available. Conclusions: Australian HCWs employed during 2021 experienced adverse mental health outcomes, with prevalence differences observed according to occupation. Longitudinal evidence is needed to inform workplace strategies that support the physical and mental wellbeing of HCWs at organisational and state policy levels.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review

BACKGROUND

This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria.

METHODS

A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes.

RESULTS

Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult.

CONCLUSIONS

A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

The utility of frailty indices in predicting the risk of health care associated infections: A systematic review

BACKGROUND

Health care associated infections (HAIs) are a major health concern associated with significant morbidity and mortality. The relationship between frailty, a syndrome often associated with older individuals, and HAIs has not been investigated.

AIM

To determine if frailty scoring systems can assist in predicting the risk of developing HAIs in health care settings.

METHODS

A directed search was conducted across 4 databases (MEDLINE, Cochrane, Scopus, and CINAHL) for articles published between 1 January 1990 and 31 December 2019. All articles were screened for relevance to the research aims. The Newcastle-Ottawa Scale was utilised to assess the study quality and risk of bias.

FINDINGS

The literature search yielded 290 results, with 14 articles meeting the inclusion criteria. Significant heterogeneity was present across the studies with regards to the frailty index employed and HAI definitions. Most studies were conducted in an acute health care setting (n = 12), while 2 studies were conducted in nursing homes. Eight studies demonstrated that frail individuals were at an increased risk of developing HAIs, in both surgical (n = 5) and medical patient populations (n = 2). Two of the 3 validated frailty scoring systems employed across the studies, the Clinical Frailty Scale and the Frailty Index demonstrated this relationship.

CONCLUSIONS

The results of this review demonstrate a potential association between frailty and the development of HAIs.

Infection control professionals' and infectious diseases physicians' knowledge, preparedness, and experiences of managing COVID-19 in Australian healthcare settings

BACKGROUND

COVID-19 has placed unprecedented demands on infection control professionals (ICPs) and infectious disease (ID) physicians. This study examined their knowledge, preparedness, and experiences managing COVID-19 in the Australian healthcare settings.

METHODS

A cross-sectional study of ICPs and ID physician members of the Australasian College for Infection Prevention and Control (ACIPC) and the Australasian Society for Infectious Diseases (ASID) was conducted using an online survey. Descriptive statistics were used to summarise and report data.

RESULTS

A total of 103 survey responses were included in the analysis for ICPs and 45 for ID physicians. A majority of ICPs (78.7%) and ID physicians (77.8%) indicated having 'very good' or 'good' level of knowledge of COVID-19. Almost all ICPs (94.2%) relied on state or territory's department of health websites to source up-to-date information While most ID physicians (84.4%) used scientific literature and journals. A majority of ICPs (96%) and ID physicians (73.3%) reported feeling 'moderately prepared' or 'extremely prepared' for managing COVID-19. Most respondents had received specific training about COVID-19 within their workplace (ICPs: 75%; ID physicians: 66.7%), particularly training/certification in PPE use, which made them feel 'mostly or entirely confident' in using it. Most ICPs (84.5%) and ID physicians (76.2%) reported having 'considerably' or 'moderately more' work added to their daily duties. Their biggest concerns included the uncertainties under a rapidly changing landscape, PPE availability, and the community's compliance.

CONCLUSION

Harmonised information, specific COVID-19 training and education, and adequate support for front-line workers are key to successfully managing COVID-19 and other future outbreaks.

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia-Pacific Region

INTRODUCTION

Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia-Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country's healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30-31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

METHODS

The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

RESULTS

The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

CONCLUSIONS

Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Enteral nutrition feeding practices by intensive care nurses: A retrospective evaluation

BACKGROUND

Enteral nutrition (EN) is an integral component of standard management of critically ill patients in intensive care. However, achieving adequate nutrition in this environment continues to present many challenges.

DESIGN

A descriptive exploratory design using a retrospective review of medical records.

AIMS AND OBJECTIVES

The aims of this study were to describe nursing practice associated with EN feeding and identify barriers to optimal nutritional delivery in the intensive care unit (ICU).

METHODS

Patients admitted to a major Australian metropolitan health service ICU during a 6-month period, and who received EN for at least 72 hours, were eligible for inclusion. Documented text from patient medical records was analysed using content analysis. Numerical data were analysed using SPSS software (version 25.0). Descriptive and inferential statistics were calculated.

RESULTS

A total of 150 patients were included in the study. The mean time from admission to EN commencement was 12.6 hours, with 59.3% commenced within 12 hours of admission. Only 9.3% of patients commenced EN at the target rate. Of the 150 patients, 24 (16%) received 80% of nutrition targets within 72 hours of admission. Patients who had EN commenced within 12 hours of admission and at the target rate were significantly more likely to achieve nutritional requirements (P = <.01). Patients who received an initial dietitian review within 24 hours of admission were more likely to achieve nutrition requirements (P = <.01).

CONCLUSIONS

Commencing EN on time and meeting target volumes remains challenging in the ICU patient. Airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation provide barriers to optimal nutrition delivery to critically ill patients. Tackling these barriers may require interdisciplinary interventions.

RELEVANCE TO CLINICAL PRACTICE

Providing adequate nutrition to critically ill patients is challenging. This study provides evidence that day's one and two are problematic to EN delivery; particularly concerning airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation. Highlighting the need for further research into these aspects of nutrition management.

Budget impact analysis of routinely using whole-genomic sequencing of six multidrug-resistant bacterial pathogens in Queensland, Australia

OBJECTIVE

To predict the cost and health effects of routine use of whole-genome sequencing (WGS) of bacterial pathogens compared with those of standard of care.

DESIGN

Budget impact analysis was performed over the following 5 years. Data were primarily from sequencing results on clusters of multidrug-resistant organisms across 27 hospitals. Model inputs were derived from hospitalisation and sequencing data, and epidemiological and costing reports, and included multidrug resistance rates and their trends.

SETTING

Queensland, Australia.

PARTICIPANTS

Hospitalised patients.

INTERVENTIONS

WGS surveillance of six common multidrug-resistant organisms (Staphylococcus aureus, Escherichia coli, Enterococcus faecium, Klebsiella pneumoniae, Enterobacter sp and Acinetobacter baumannii) compared with standard of care or routine microbiology testing.

PRIMARY AND SECONDARY OUTCOMES

Expected hospital costs, counts of patient infections and colonisations, and deaths from bloodstream infections.

RESULTS

In 2021, 97 539 patients in Queensland are expected to be infected or colonised with one of six multidrug-resistant organisms with standard of care testing. WGS surveillance strategy and earlier infection control measures could avoid 36 726 infected or colonised patients and avoid 650 deaths. The total cost under standard of care was $A170.8 million in 2021. WGS surveillance costs an additional $A26.8 million but was offset by fewer costs for cleaning, nursing, personal protective equipment, shorter hospital stays and antimicrobials to produce an overall cost savings of $30.9 million in 2021. Sensitivity analyses showed cost savings remained when input values were varied at 95% confidence limits.

CONCLUSIONS

Compared with standard of care, WGS surveillance at a state-wide level could prevent a substantial number of hospital patients infected with multidrug-resistant organisms and related deaths and save healthcare costs. Primary prevention through routine use of WGS is an investment priority for the control of serious hospital-associated infections.

Nurses' and midwives' cleaning knowledge, attitudes and practices: An Australian study

Background

As frontline providers of care, nurses and midwives play a critical role in controlling infections such as COVID-19, influenza, multi-drug resistant organisms and health care associated infections. Improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. As nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives’ knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments.

Methods

Cross-sectional online survey of 96 nurses (RN/EN) and midwives (RW) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in Australia.

Results

Nurses and midwives broadly stated that they understood the importance of cleaning. However, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. Most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism.

Conclusion

Greater organisational support and improving applied knowledge about infection control procedures is needed. This includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

•

Improved cleaning reduces incidence of healthcare associated infection but relies on correct application.

•

Nurses and midwives expressed confusion regarding disinfectant use and cleaning responsibility.

•

Most would not be confident being placed in a room where a previous patient had a diagnosed infection.

The nurses' role in antimicrobial stewardship: A scoping review

BACKGROUND

The role of nurses in antimicrobial stewardship is understated and not well understood. Nurses can have a significant impact on the development of antimicrobial resistant bacteria in hospitals and the wider community through their management of intravenous antibiotics.

OBJECTIVE

To investigate the nurse's role in antimicrobial stewardship and examine best practice for preparing, administering and disposing of intravenous antibiotics.

METHODS

A systematically conducted scoping review was used. Seven databases were searched for published articles. Retrieved articles were screened for eligibility against pre-set inclusion and exclusion criteria with eligible full-text articles included in the synthesis. Reference lists of eligible articles and social media were reviewed to identify further sources of literature.

RESULTS

Forty-three sources of evidence were included. The extracted data indicate that a part of the nurse's role in antimicrobial stewardship is to monitor judicious antibiotic prescribing practices. Other than literature related to medication errors, there was limited research describing best practice when preparing, administering and disposing of intravenous antibiotics. There was also little evidence of consistent policy, guidelines and education for nurses' practice related to antimicrobial stewardship.

CONCLUSIONS

The evidence for best practice when nurses prepare, administer and dispose of intravenous antibiotics in hospitals is scarce. When nurses use best practice to manage intravenous antibiotics, the risk of antimicrobial resistant bacteria developing is minimised. The role of nurses in antimicrobial stewardship needs to be supported through education and evidence-based guidelines. Tweetable abstract: Nurse work practices may prevent the development and spread of antimicrobial resistant bacteria.

Prevalence of healthcare-associated infections and antimicrobial use among inpatients in a tertiary hospital in Fiji: a point prevalence survey

Background

Healthcare-associated infections (HAIs) and antimicrobial use (AMU) are important drivers of antimicrobial resistance, yet there is minimal data from the Pacific region. We sought to determine the point prevalence of HAIs and AMU at Fiji’s largest hospital, the Colonial War Memorial Hospital (CWMH) in Suva. A secondary aim was to evaluate the performance of European Centre for Diseases Prevention and Control (ECDC) HAI criteria in a resource-limited setting.

Methods

We conducted a point prevalence survey of HAIs and AMU at CWMH in October 2019. Survey methodology was adapted from the ECDC protocol. To evaluate the suitability of ECDC HAI criteria in our setting, we augmented the survey to identify patients with a clinician diagnosis of a HAI where diagnostic testing criteria were not met. We also assessed infection prevention and control (IPC) infrastructure on each ward.

Results

We surveyed 343 patients, with median (interquartile range) age 30 years (16–53), predominantly admitted under obstetrics/gynaecology (94, 27.4%) or paediatrics (83, 24.2%). Thirty patients had one or more HAIs, a point prevalence of 8.7% (95% CI 6.0% to 12.3%). The most common HAIs were surgical site infections (n = 13), skin and soft tissue infections (7) and neonatal clinical sepsis (6). Two additional patients were identified with physician-diagnosed HAIs that failed to meet ECDC criteria due to insufficient investigations. 206 (60.1%) patients were receiving at least one antimicrobial. Of the 325 antimicrobial prescriptions, the most common agents were ampicillin (58/325, 17.8%), cloxacillin (55/325, 16.9%) and metronidazole (53/325, 16.3%). Use of broad-spectrum agents such as piperacillin/tazobactam (n = 6) and meropenem (1) was low. The majority of prescriptions for surgical prophylaxis were for more than 1 day (45/76, 59.2%). Although the number of handwashing basins throughout the hospital exceeded World Health Organization recommendations, availability of alcohol-based handrub was limited and most concentrated within high-risk wards.

Conclusions

The prevalence of HAIs in Fiji was similar to neighbouring high-income countries, but may have been reduced by the high proportion of paediatric and obstetrics patients, or by lower rates of inpatient investigations. AMU was very high, with duration of surgical prophylaxis an important target for future antimicrobial stewardship initiatives.

Scope of practice and educational needs of infection prevention and control professionals in Australian residential aged care facilities

BACKGROUND

Healthcare-associated infections are serious and significant complications present across healthcare services, including residential aged care facilities. Although ensuring high quality personal and clinical care delivered to older people residing in these facilities is a high national priority, there is a paucity of evidence published about outbreaks, governance and education programs held for healthcare workers within Australian residential aged care facilities. The aim of this study is to examine the scope of practice of Infection Prevention and Control professionals within Australian residential aged care facilities and the types of infection prevention and control education and training delivered.

METHODS

A cross-sectional study was conducted inviting all Australian residential aged care facilities to participate in an online survey.

RESULTS

A total of 134 residential aged care facilities completed the survey. The majority (88.1%) reported having a designated Infection Prevention and Control professional responsible for surveillance and educational activities. Hand hygiene (94%), personal protective equipment (PPE) (79.9%) and environmental cleaning (70.1%) were some of the available Infection Prevention and Control programs. The lack of access to Infection Prevention and Control education (69.5%) and lack of Infection Prevention and Control expert advice (67.2%) were also reported by some Residential aged care facilities.

CONCLUSION

Australian residential aged care facilities recognise the importance of Infection Prevention and Control training programs to manage infection surveillance and outbreaks. Considerable activities are carried out to increase knowledge on breaking the chain of infection. Yet, more support and resources are needed to assist these efforts.

Prevalence of device use and transmission based precautions in nineteen large Australian acute care public hospitals: Secondary outcomes from a national healthcare associated infection point prevalence survey

BACKGROUND

The use of invasive devices increases the risk of healthcare associated infections (HAI). The recent national HAI point prevalence survey secondary outcomes aimed to estimate the prevalence of patients with an indwelling urinary catheter device and vascular access devices; and also identify prevalence of those managed under transmission based precautions (TBP); and those colonised or infected with a multi drug resistant organism (MDRO).

METHODS

A point prevalence study was conducted in large acute care Australian public hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control PPS Protocol. Data was also collected on prevalence of TBPs and MDROs.

RESULTS

A total of 2767 acute adult inpatients were sampled across 19 hospitals. The prevalence of peripheral vascular, central vascular and urinary catheters devices was 55.2% (95%CI: 53.3%-57.1%), 14.8% (95%CI: 13.5%-16.1%) and 20.7% (95%CI: 19.2%-22.3%) respectively. Of the 2767 patients sampled 285 (10.3%, 95%CI: 9.2%-11.5%) were documented as either being infected or colonised with a MDRO, and 781 (11.8%) patients were being managed under the hospital TBP policy.

CONCLUSION

This is the first national study to describe the prevalence of devices, TBPs and MDROs in Australian healthcare settings. In an era where device use should be constantly reviewed to minimise risk of HAI, and the increasing challenges of managing patients with MDROs, this data can serve as a benchmark for future studies.

Healthcare-associated infections in Australia: tackling the 'known unknowns'

Australia does not have a national healthcare-associated infection (HAI) surveillance program. Without national surveillance, we do not understand the burden of HAIs, nor can we accurately assess the effects of national infection prevention initiatives. Recent research has demonstrated disparity between existing jurisdictional-based HAI surveillance activity while also identifying broad key stakeholder support for the establishment of a national program. A uniform surveillance program will also address growing concerns about hospital performance measurements and enable public reporting of hospital data.

The prevalence of healthcare associated infections among adult inpatients at nineteen large Australian acute-care public hospitals: a point prevalence survey

Background

Australia does not have a national healthcare associated infection (HAI) surveillance program. Only one HAI point prevalence study has been undertaken in 1984. The objective of this study was to estimate the burden of healthcare associated infection (HAI) in acute adult inpatients in Australia.

Methods

A cross sectional point prevalence study (PPS) was conducted in a sample of large acute care hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control (ECDC) PPS Protocol with variation in the sampling method in that only acute inpatients ≥ 18 years old were included. ECDC HAI definitions were applied.

Results

Data was collected between August and November 2018. A total of 2767 patients from 19 hospitals were included in the study. The median age of patients was 67, and 52.9% of the sample were male. Presence of a multi-drug resistant organism was documented for 10.3% of the patients. There were 363 HAIs present in 273 patients. The prevalence of patients with a HAI was 9.9% (95%CI: 8.8-11.0). Hospital prevalence rates ranged from 5.7% (95%CI:2.9-11.0) to 17.0% (95%CI:10.7-26.1). The most common HAIs were surgical site infection, pneumonia and urinary tract infection, comprising 64% of all HAIs identified.

Conclusion

This is the first HAI PPS to be conducted in Australia in 34 years. The prevalence rate is higher than the previous Australian study and that reported by the ECDC, however differences in methodology limit comparison. Regular, large scale HAI PPS should be undertaken to generate national HAI data to inform and drive national interventions.

Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: A systematic review

BACKGROUND

Point prevalence studies identify that pneumonia is the most common healthcare associated infection. However, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to date, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used.

METHODS

We performed a systematic search to identify research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st January 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle-Ottawa Scale.

RESULTS

The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The majority of strategies for NV-HAP prevention focussed on oral care (n = 9). Three studies evaluated a form of physical activity, such as passive movements, two studies used dysphagia screening and management; and another study evaluated prophylactic antibiotics. Most studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials.

CONCLUSION

There was considerable heterogeneity in the included studies, including the type of intervention, study design, methods and definitions used to diagnose the NV-HAP. To date, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or movement and dysphagia management.

Clinician perspectives of policy implementation: A qualitative study of the implementation of a national infection prevention policy in Australian hospitals

BACKGROUND

Clinicians play an essential role in the implementation of infection prevention policy. Despite this, little is known about how infection control policy is implemented at an organizational level or what factors influence this process. In this study, we explore these factors and the policy implementation process in the context of the introduction of a national large-scale, government-directed infection prevention policy in Australia.

METHODS

Focus groups with infection control professionals were held in 3 states to investigate the perspectives of infection control professionals involved in the implementation of aseptic technique policy requirements in Australian hospitals. Data were analyzed using an interpretive description approach, with themes mapped to the Consolidated Framework for Implementation Research.

RESULTS

Common contextual factors were identified across all levels of the healthcare system that influenced implementation of the infection control policy, including external factors associated with the policy itself and the regulatory nature of government-directed policy.

CONCLUSIONS

This study suggests that there may be particular constructs and contextual factors that are specific to policy implementation in the hospital setting. A better understanding of these factors and their influence on policy implementation would present an opportunity for improved implementation planning, resource allocation, and more effective policy development.

Establishing the prevalence of healthcare-associated infections in Australian hospitals: protocol for the Comprehensive Healthcare Associated Infection National Surveillance (CHAINS) study

INTRODUCTION

A healthcare-associated infection (HAI) data point prevalence study (PPS) conducted in 1984 in Australian hospitals estimated the prevalence of HAI to be 6.3%. Since this time, there have been no further national estimates undertaken. In the absence of a coordinated national surveillance programme or regular PPS, there is a dearth of national HAI data to inform policy and practice priorities.

METHODS AND ANALYSIS

A national HAI PPS study will be undertaken based on the European Centres for Disease Control method. Nineteen public acute hospitals will participate. A standardised algorithm will be used to detect HAIs in a two-stage cluster design, random sample of adult inpatients in acute wards and all intensive care unit patients. Data from each hospital will be collected by two trained members of the research team. We will estimate the prevalence of HAIs, invasive device use, single room placement and deployment of transmission-based precautions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Alfred Health Human Research Ethics Committee (HREC/17/Alfred/203) via the National Mutual Assessment. A separate approval was obtained from the Tasmanian Health and Medical Human Research Committee (H0016978) for participating Tasmanian hospitals. Findings will be disseminated in individualised participating hospital reports, peer-reviewed publications and conference presentations.

Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study

BACKGROUND

The National Hand Hygiene Initiative (NHHI) is a standardised culture-change programme based on the WHO My 5 Moments for Hand Hygiene approach to improve hand hygiene compliance among Australian health-care workers and reduce the risk of health-care-associated infections. We analysed its effectiveness.

METHODS

In this longitudinal study, we assessed outcomes of the NHHI for the 8 years after implementation (between Jan 1, 2009, and June 30, 2017), including hospital participation, hand hygiene compliance (measured as the proportion of observed Moments) three times per year, educational engagement, cost, and association with the incidence of health-care-associated Staphylococcus aureus bacteraemia (HA-SAB).

FINDINGS

Between 2009 and 2017, increases were observed in national health-care facility participation (105 hospitals [103 public and two private] in 2009 vs 937 hospitals [598 public and 339 private] in 2017) and overall hand hygiene compliance (36 213 [63·6%] of 56 978 Moments [95% CI 63·2-63·9] in 2009 vs 494 673 [84·3%] of 586 559 Moments [84·2-84·4] in 2017; p<0·0001). Compliance also increased for each Moment type and for each health-care worker occupational group, including for medical staff (4377 [50·5%] of 8669 Moments [95% CI 49·4-51·5] in 2009 vs 53 620 [71·7%] of 74 788 Moments [71·4-72·0]; p<0·0001). 1 989 713 NHHI online learning credential programmes were completed. The 2016 NHHI budget was equivalent to AUD$0·06 per inpatient admission nationally. Among Australia's major public hospitals (n=132), improved hand hygiene compliance was associated with declines in the incidence of HA-SAB (incidence rate ratio 0·85; 95% CI 0·79-0·93; p≤0·0001): for every 10% increase in hand hygiene compliance, the incidence of HA-SAB decreased by 15%.

INTERPRETATION

The NHHI has been associated with significant sustained improvement in hand hygiene compliance and a decline in the incidence of HA-SAB. Key features include sustained central coordination of a standardised approach and incorporation into hospital accreditation standards. The NHHI could be emulated in other national culture-change programmes.

FUNDING

Australian Commission on Safety and Quality in Health Care.

Reducing urinary catheter use: a protocol for a mixed methods evaluation of an electronic reminder system in hospitalised patients in Australia

INTRODUCTION

Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. Prolonged urinary catheterisation is the main risk factor for development of CAUTIs; hence, interventions that target early catheter removal warrant investigation. The study's objectives are to examine the efficacy of an electronic reminder system, the CATH TAG, in reducing urinary catheter use (device utilisation ratio) and to determine the effect of the CATH TAG on nurses' ability to deliver patient care.

METHODS AND ANALYSIS

This study uses a mixed methods approach in which both quantitative and qualitative data will be collected. A stepped wedge randomised controlled design in which wards provide before and after observations will be undertaken in one large Australian hospital over 24 weeks. The intervention is the use of the CATH TAG. Eligible hospital wards will receive the intervention and act as their own control, with analysis undertaken of the change within each ward using data collected in control and intervention periods. An online survey will be administered to nurses on study completion, and a focus group for nurses will be conducted 2 months after study completion. The primary outcomes are the urinary catheter device utilisation ratio and perceptions of nurses about ease of use of the CATH TAG. Secondary outcomes include a reduced number of cases of catheter-associated asymptomatic bacteriuria, a reduced number of urinary catheters inserted per 100 patient admissions, perceptions of nurses regarding effectiveness of the CATH TAG, changes in ownership/interest by patients in catheter management, as well as possible barriers to successful implementation of the CATH TAG.

ETHICS AND DISSEMINATION

Approval has been obtained from the Human Research Ethics Committees of Avondale College of Higher Education (2017:15) and Queensland Health (HREC17QTHS19). Results will be disseminated via peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617001191381 (Pre-results).

Preventing healthcare-associated infections: the role of surveillance

Surveillance of healthcare-associated infections is central to healthcare epidemiology and infection control programmes and a critical factor in the prevention of these infections. By definition, the term 'infection prevention' implies that healthcare-associated infections may be preventable. The purpose of surveillance is to provide quality data that can be used in an effective monitoring and alert system and to reduce the incidence of preventable healthcare-associated infections. This article examines the purpose of surveillance, explains key epidemiological terms, provides an overview of approaches to surveillance and discusses the importance of validation.

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.

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.

Healthcare-associated infections in Australia: time for national surveillance

OBJECTIVE

Healthcare-associated infection (HAI) surveillance programs are critical for infection prevention. Australia does not have a comprehensive national HAI surveillance program. The purpose of this paper is to provide an overview of established international and Australian statewide HAI surveillance programs and recommend a pathway for the development of a national HAI surveillance program in Australia.

METHODS

This study examined existing HAI surveillance programs through a literature review, a review of HAI surveillance program documentation, such as websites, surveillance manuals and data reports and direct contact with program representatives.

RESULTS

Evidence from international programs demonstrates national HAI surveillance reduces the incidence of HAIs. However, the current status of HAI surveillance activity in Australian states is disparate, variation between programs is not well understood, and the quality of data currently used to compose national HAI rates is uncertain.

CONCLUSIONS

There is a need to develop a well-structured, evidence-based national HAI program in Australia to meet the increasing demand for validated reliable national HAI data. Such a program could be leveraged off the work of existing Australian and international programs.

Differences in identifying healthcare associated infections using clinical vignettes and the influence of respondent characteristics: a cross-sectional survey of Australian infection prevention staff

Background

Australia has commenced public reporting and benchmarking of healthcare associated infections (HAIs), despite not having a standardised national HAI surveillance program. Annual hospital Staphylococcus aureus bloodstream (SAB) infection rates are released online, with other HAIs likely to be reported in the future. Although there are known differences between hospitals in Australian HAI surveillance programs, the effect of these differences on reported HAI rates is not known.

Objective

To measure the agreement in HAI identification, classification, and calculation of HAI rates, and investigate the influence of differences amongst those undertaking surveillance on these outcomes.

Methods

A cross-sectional online survey exploring HAI surveillance practices was administered to infection prevention nurses who undertake HAI surveillance. Seven clinical vignettes describing HAI scenarios were included to measure agreement in HAI identification, classification, and calculation of HAI rates. Data on characteristics of respondents was also collected. Three of the vignettes were related to surgical site infection and four to bloodstream infection. Agreement levels for each of the vignettes were calculated. Using the Australian SAB definition, and the National Health and Safety Network definitions for other HAIs, we looked for an association between the proportion of correct answers and the respondents’ characteristics.

Results

Ninety-two infection prevention nurses responded to the vignettes. One vignette demonstrated 100 % agreement from responders, whilst agreement for the other vignettes varied from 53 to 75 %. Working in a hospital with more than 400 beds, working in a team, and State or Territory was associated with a correct response for two of the vignettes. Those trained in surveillance were more commonly associated with a correct response, whilst those working part-time were less likely to respond correctly.

Conclusion

These findings reveal the need for further HAI surveillance support for those working part-time and in smaller facilities. It also confirms the need to improve uniformity of HAI surveillance across Australian hospitals, and raises questions on the validity of the current comparing of national HAI SAB rates.

Variation in health care-associated infection surveillance practices in Australia

In the absence of a national health care-associated infection surveillance program in Australia, differences between existing state-based programs were explored using an online survey. Only 51% of respondents who undertake surveillance have been trained, fewer than half perform surgical site infection surveillance prospectively, and only 41% indicated they risk adjust surgical site infection data. Widespread variation of surveillance methods highlights future challenges when considering the development and implementation of a national program in Australia.

Validation of Coronary Artery Bypass Graft Surgical Site Infection Surveillance Data From a Statewide Surveillance System in Australia

Objective.

To measure the accuracy and determine the positive predictive value (PPV) and negative predictive value (NPV) of data submitted to a statewide surveillance system for identifying surgical site infection (SSI) complicating coronary artery bypass graft (CABG) surgery.

Design.

Retrospective review of hospital medical records comparing SSI data with surveillance data submitted by infection control consultants (ICCs).

Setting.

Victorian Hospital Acquired Infection Surveillance System (VICNISS) Coordinating Centre in Victoria, Australia.

Patients.

All patients reported to have an SSI following CABG surgery and a random sample of approximately 10% of patients reported not to have an SSI following CABG surgery.

Results.

The VICNISS ascertainment rate for CABG procedures in Victoria was 95%. One hundred sixty-nine medical records were reviewed, and reviewers agreed with ICCs about 46 (96%) of the patients reported as infected by the ICCs and 31 (91%) of the patients identified with a sternal SSI by the ICCs. In one-third of SSIs, the depth of SSI documented by ICCs was discordant with that documented by the reviewers. Disagreement about patients with donor site SSI was frequent. When the review findings were used as the reference standard, the PPV for ICC-reported SSI was 96% (95% confidence interval [CI], 86%-99%), and the NPV was 97% (95% CI, 92%-99%). For ICC-reported sternal SSI, the PPV was 91% (95% CI, 76%-98%) and the NPV was 98% (95% CI, 94%-100%).

Conclusions.

There was broad agreement on the number of infected patients and the number of patients with sternal SSI. However, discordance was frequent with respect to the depth of sternal SSI and the identification of donor site SSI. We recommend modifications to the methodology for National Noscomial Infection Surveillance System-based surveillance for SSI following CABG surgery.

Using Samples to Estimate the Sensitivity and Specificity of a Surveillance Process

Determining sensitivity and specificity of a postoperative infection surveillance process is a difficult undertaking. Because postoperative infections are rare, vast numbers of negative results exist, and it is often not reasonable to assess them all. This study gives a methodological framework for estimating sensitivity and specificity by taking only a small sample of the number of patients who test negative and comparing their findings to the reference or “gold standard” rather than comparing the findings of all patients to the gold standard. It provides a formula for deriving confidence intervals for these estimates and a guide to minimum requirements for sampling results.

Interhospital Comparisons of Coronary Artery Bypass Graft Surgical Site Infection Rates Differ if Donor Sites Are Excluded

The advent of public reporting of hospital-acquired infection rates has sparked ongoing discussion about the most appropriate surveillance data to present. When we used different numerators to calculate rates of surgical site infection following coronary artery bypass graft surgery, we found that some hospitals' rates and their rankings were notably affected.

Performance of the National Nosocomial Infections Surveillance Risk Index in Predicting Surgical Site Infection in Australia

Background.

The Victorian Hospital Acquired Infection Surveillance System (VICNISS) hospital-acquired infection surveillance system was established in 2002 in Victoria, Australia, and collates surgical site infection (SSI) surveillance data from public hospitals in Australia.

Objective.

To evaluate the association between the US National Nosocomial Infections Surveillance (NNIS) system's risk index and SSI rates for 7 surgical procedures.

Methods.

SSI surveillance was performed with NNIS definitions and methods for surgical procedures performed between November 2002 and September 2004. Correlations were assessed using the Goodman-Kruskal γ statistic.

Results.

Data were submitted for the following numbers of procedures: appendectomy, 545; coronary artery bypass graft (CABG), 4,632; cholecystectomy, 1,001; colon surgery, 623; cesarean section, 4,857; hip arthroplasty, 3,825; and knee arthroplasty, 2,416. NNIS risk index and increasing SSI rate were moderately well correlated for appendectomy (γ = 0.55), colon surgery (γ = 0.48), and cesarean section (γ = 0.42). A fairly positive correlation was found for cholecystectomy (γ = 0.17), hip arthroplasty (γ = 0.2), and knee arthroplasty (γ = 0.16). However, for CABG surgery, a poor association was found (γ = 0.02).

Conclusions.

The NNIS risk index was positively correlated with an increasing SSI rate for all 7 procedures; the strongest correlation was found for appendectomy, cesarean section, and colon surgery, and the poorest correlation was found for CABG surgery. We believe that risk stratification with the NNIS risk index is appropriate for comparison of data for most procedures and superior to use of no risk adjustment. However, for some procedures, particularly CABG, further studies of alternative risk indexes are needed to better stratify patients.

New magnetic phase diagram of (Sr,Ca)2RuO4

High-T(c) cuprates, iron pnictides, organic BEDT and TMTSF, alkali-doped C(60), and heavy-fermion systems have superconducting states adjacent to competing states exhibiting static antiferromagnetic or spin density wave order. This feature has promoted pictures for their superconducting pairing mediated by spin fluctuations. Sr(2)RuO(4) is another unconventional superconductor which almost certainly has a p-wave pairing. The absence of known signatures of static magnetism in the Sr-rich side of the (Ca, Sr) substitution space, however, has led to a prevailing view that the superconducting state in Sr(2)RuO(4) emerges from a surrounding Fermi-liquid metallic state. Using muon spin relaxation and magnetic susceptibility measurements, we demonstrate here that (Sr,Ca)(2)RuO(4) has a ground state with static magnetic order over nearly the entire range of (Ca, Sr) substitution, with spin-glass behaviour in Sr(1.5)Ca(0.5)RuO(4) and Ca(1.5)Sr(0.5)RuO(4). The resulting new magnetic phase diagram establishes the proximity of superconductivity in Sr(2)RuO(4) to competing static magnetic order.