Validation of the Korean National Healthcare-associated Infections Surveillance System (KONIS): an intensive care unit module report

External and internal validation of healthcare-associated infection data collected by the Korean National healthcare-associated Infections Surveillance System (KONIS)

BACKGROUND

This study analyzed the validity of healthcare-associated infection (HAI) data of the Korean National healthcare-associated Infections Surveillance System.

METHODS

The validation process consisted of external (EV) and internal (IV) validation phases. Of the 193 hospitals that participated from July 2016 through June 2017, EV was performed for 10 hospitals that were selected based on the HAI rate percentile. The EV team reviewed 295 medical records for 60 HAIs and 235 non-HAI control patients. IV was performed for both the 10 EV hospitals and 11 other participating hospitals that did not report any HAIs.

RESULTS

In the EV, the diagnosis of urinary tract infections had a sensitivity of 72.0% and a specificity of 99.3%. The respective sensitivities of bloodstream infection and pneumonia were 63.2% and 70.6%; the respective specificities were 98.8% and 99.6%. The agreement (ĸ) between the EV and IV for 10 hospitals was 0.754 for urinary tract infections and 0.674 for bloodstream infections (P < .001, respectively). Additionally, IV found additional cases among 11 zero-report hospitals.

DISCUSSION

This study demonstrates the need for ongoing validation and continuous training to maintain the accuracy of nationwide surveillance data.

CONCLUSIONS

IV should be considered a validation method to supplement EV.

Real-world experience of how chlorhexidine bathing affects the acquisition and incidence of vancomycin-resistant enterococci (VRE) in a medical intensive care unit with VRE endemicity: a prospective interrupted time-series study

BACKGROUND

Critically ill patients in intensive care units (ICUs) often acquire opportunistic infections or are colonized by vancomycin-resistant enterococci (VRE), which limits therapeutic options and results in high case-fatality rates. In clinical practice, the beneficial effects of universal chlorhexidine gluconate (CHG) bathing on the control of VRE remain unclear. This study aimed to investigate whether 2% CHG daily bathing reduced the acquisition of VRE in the setting of a medical ICU (MICU) with VRE endemicity.

METHODS

This quasi-experimental intervention study was conducted in a 23-bed MICU of a tertiary care hospital in Korea from September 2016 to December 2017. In a prospective, interrupted time-series analysis (ITS) with a 6-month CHG bathing intervention, we compared the acquisition and incidence of VRE and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Acinetobacter baumannii (CRAB) between the pre-intervention and intervention periods. The primary and secondary outcomes were a change in the acquisition of VRE and incidence of VRE, MRSA, or CRAB between the two periods, respectively.

RESULTS

All the adult patients admitted to the MICU were enrolled in the pre-intervention (n = 259) and intervention (n = 242). The overall CHG daily bathing compliance rate was 72.5%. In the ITS, there was a significant intervention effect with a 58% decrease in VRE acquisition (95% CI 7.1-82.1%, p = 0.038) following the intervention. However, there was no significant intervention effects on the incidence trend of VRE, MRSA, and CRAB determined by clinical culture between the pre-intervention and intervention periods.

CONCLUSION

In this real-world study, we concluded that daily bathing with CHG may be an effective measure to reduce VRE cross-transmission among patients in MICU with a high VRE endemicity.

A scoping review of registry captured indicators for evaluating quality of critical care in ICU

BACKGROUND

Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation.

METHOD

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance.

RESULTS

The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).

CONCLUSIONS

Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Prediction of the Risk of Hospital Deaths in Patients with Hospital-Acquired Pneumonia Caused by Multidrug-Resistant Acinetobacter baumannii Infection: A Multi-Center Study

Purpose

To predict the risk of hospital deaths in patients with hospital-acquired pneumonia (HAP) caused by multidrug-resistant Acinetobacter baumannii (MDR-AB) infection.

Patients and Methods

A total of 366 patients who were diagnosed with HAP caused by MDR-AB infection were enrolled between January 2013 and December 2016. The sociological characteristics and clinical data of these cases were collected. Univariate and multivariate logistic analyses were used to explore the risk factors of hospital deaths before medication and after drug withdrawal. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were utilized to assess the predictive effectiveness of the models with or without the adjustment.

Results

Hospital deaths occurred in 142 cases (38.80%). The results showed that acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores before medication and after drug withdrawal were associated with the risk of hospital deaths. Adjusting the covariants including the age, autoimmune disease, venous cannula, transfer of patients from other hospitals, and APACHE II score at admission, then no differences were discovered in predicting the hospital deaths between adjusted APACHE II and adjusted SOFA scores before medication (AUC: 0.808 vs 0.803, P =0.614) and after drug withdrawal (AUC: 0.876 vs 0.878, P =0.789).

Conclusion

Before medication or after drug withdrawal, the adjusted APACHE II and adjusted SOFA scores all performed well in determining the predictive effectiveness of the hospital deaths in patients with HAP caused by MDR-AB infection, indicating that the appropriate infection control may reduce the occurrence of nosocomial deaths and improve the prognosis.

Ten-year surveillance of central line-associated bloodstream infections in South Korea: Surveillance not enough, action needed

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are preventable health care-associated infections that can lead to increased mortality. Therefore, we investigated trends in CLABSI rates, and the factors associated with changing trends over a 10-year period using the Korean National Healthcare-associated Infections Surveillance System (KONIS).

METHODS

We investigated annual CLABSI rates from 2006 to 2015 in 190 KONIS-participating intensive care units (ICUs) from 107 participating hospitals. We collected data associated with hospital and ICU characteristics and analyzed trends using generalized autoregressive moving average models.

RESULTS

The CLABSI pooled mean rate decreased from 3.40 in 2006 to 2.20 in 2015 (per 1,000 catheter-days). The trend analysis also showed a significant decreasing trend in CLABSI rates in unadjusted models (annual increase, -0.137; P < .001). After adjusting for hospital and ICU characteristics, significant decreasing trends were identified (annual increase, -0.109; P < .001). However, there were no significant changes in subgroups with non-university-affiliated hospitals, hospitals in metropolitan areas near Seoul, small hospitals (300-699 beds), or surgical ICUs.

CONCLUSIONS

In South Korea, CLABSI rates have shown significant reductions in the past 10 years with participation in the KONIS. However, CLABSI rates may be reduced by encouraging more hospitals to participate in the KONIS and by improved policy support for hospitals lacking infection control resources.

A systematic review of central-line-associated bloodstream infection (CLABSI) diagnostic reliability and error

OBJECTIVE

To establish the reliability of the application of National Health and Safety Network (NHSN) central-line-associated bloodstream infection (CLABSI) criteria within established reporting systems internationally.

DESIGN

Diagnostic-test accuracy systematic review.

METHODS

We conducted a search of Medline, SCOPUS, the Cochrane Library, CINAHL (EbscoHost), and PubMed (NCBI). Cohort studies were eligible for inclusion if they compared publicly reported CLABSI rates and were conducted by independent and expertly trained reviewers using NHSN/Centers for Disease Control (or equivalent) criteria. Two independent reviewers screened, extracted data, and assessed risk of bias using the QUADAS 2 tool. Sensitivity, specificity, negative and positive predictive values were analyzed.

RESULTS

A systematic search identified 1,259 publications; 9 studies were eligible for inclusion (n = 7,160 central lines). Publicly reported CLABSI rates were more likely to be underestimated (7 studies) than overestimated (2 studies). Specificity ranged from 0.70 (95% confidence interval [CI], 0.58-0.81) to 0.99 (95% CI, 0.99-1.00) and sensitivity ranged from 0.42 (95% CI, 0.15-0.72) to 0.88 (95% CI, 0.77-0.95). Four studies, which included a consecutive series of patients (whole cohort), reported CLABSI incidence between 9.8% and 20.9%, and absolute CLABSI rates were underestimated by 3.3%-4.4%. The risk of bias was low to moderate in most included studies.

CONCLUSIONS

Our findings suggest consistent underestimation of true CLABSI incidence within publicly reported rates, weakening the validity and reliability of surveillance measures. Auditing, education, and adequate resource allocation is necessary to ensure that surveillance data are accurate and suitable for benchmarking and quality improvement measures over time.

REGISTRATION

Prospectively registered with International prospective register of systematic reviews (PROSPERO ID CRD42015021989; June 7, 2015). https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID%3dCRD42015021989.

Trends in device utilization ratios in intensive care units over 10-year period in South Korea: device utilization ratio as a new aspect of surveillance

BACKGROUND

Device-associated infection (DAI) is an important issue related to patient safety. It is important to reduce unnecessary device utilization in order to decrease DAI rates.

AIM

To investigate the time trend of device utilization ratios (DURs) of voluntarily participating hospitals, collected over a 10-year period through the Korean National Healthcare-associated Infections Surveillance System (KONIS).

METHODS

DURs from 2006 to 2015 in 190 intensive care units (ICUs) participating in KONIS were included in this study. DURs were calculated as the ratio of device-days to patient-days. The pooled incidences of DAIs and DURs were calculated for each year of participation, and the year-wise trends were analysed.

FINDINGS

Year-wise ventilator utilization ratio (V-DUR) increased significantly from 0.40 to 0.41 (F = 6.27, P < 0.01), urinary catheter utilization ratio (U-DUR) increased non-significantly from 0.83 to 0.84 (F = 1.66, P = 0.10), and C-line utilization ratio (CL-DUR) decreased non-significantly from 0.55 to 0.51 (F = 1.62, P = 0.11). In the subgroup analysis, 'medical ICU' (F = 2.79, P < 0.01) and 'hospital with >900 beds' (F = 3.07, P < 0.01) were associated with the significant increase in V-DUR.

CONCLUSION

In Korea, V-DUR showed a significant, year-wise increasing trend. The trends for U-DUR and CL-DUR showed no significant decrease. Efforts are required to ensure the reduction of DURs.