Infection control in long-term care: news from the front

Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities

Objectives:

To measure infection rates in a regional cohort of long-term-care facilities (LTCFs) using standard surveillance methods and to analyze different methods for interfacility comparisons.

Setting:

Seventeen LTCFs in Idaho.

Design:

Prospective, active surveillance for LTCF-acquired infections using standard definitions and case-finding methods was conducted from July 2001 to June 2002. All surveillance data were combined and individual facility performance was compared with the aggregate employing a variety of statistical and graphic methods.

Results:

The surveillance data set consisted of 472,019 resident-days of care with 1,717 total infections for a pooled mean rate of 3.64 infections per 1,000 resident-days. Specific infections included respiratory (828; rate, 1.75), skin and soft tissue (520; rate, 1.10), urinary tract (282; rate, 0.60), gastrointestinal (77; rate, 0.16), unexplained febrile illnesses (6; rate, 0.01), and bloodstream (4; rate, 0.01). Initially, methods adopted from the National Nosocomial Infections Surveillance System were used comparing individual rates with pooled means and percentiles of distribution. A more sensitive method appeared to be detecting statistically significant deviations (based on chi-square analysis) of the individual facility rates from the aggregate of all other facilities. One promising method employed statistical process control charts (U charts) adjusted to compare individual rates with aggregate monthly rates, providing simultaneous visual and statistical comparisons. Small multiples graphs were useful in providing images valid for rapid concurrent comparison of all facilities.

Conclusion:

Interfacility comparisons have been demonstrated to be valuable for hospital infection control programs, but have not been studied extensively in LTCFs.

Infection prevention disaster preparedness planning for long-term care facilities

BACKGROUND

Long-term care facilities (LTCFs) are defined as residential institutions that provide care to people who are unable to live independently. Planning for infection prevention in disaster situations is essential for LTCFs because of the increased risk inherent in their patient population. Experiences with past disasters, such as pandemic influenza and Hurricane Katrina, have demonstrated where LTCFs are lacking in preparedness and opportunities for improvement. Little guidance is currently available to assist these facilities in creating an infection prevention component for their disaster plans. This paper is intended to guide the development of an infection prevention component of the LTCF disaster plan.

METHODS

A literature review and Internet search were conducted in September 2010. A spreadsheet was created with infection prevention topics for disaster plans that were identified. Recommendations were divided into themes/domains for simplification and clarity.

RESULTS

Fifty-eight articles, planning documents/reports, and Web-based training programs were identified and screened. Of the sources screened, 33 publications were determined to be relevant; 22 of which were peer-reviewed journal articles, and 11 were state, federal, or regulatory agency publications.

CONCLUSION

Whereas there were multiple publications related to the difficulties and risk factors LTCFs face in disasters, there were no publications that specifically addressed infection prevention in disasters or planning specific to infection prevention concerns in disasters in long-term care. LTCF administrators or others responsible for disaster planning in LTCFs are encouraged to use this article as a guide to developing comprehensive infection prevention policies and protocols for their emergency operations plan.

Management of adverse clinical events by duty physicians in a nursing home

BACKGROUND AND AIMS

The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study.

METHODS

Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH.

RESULTS

Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever.

CONCLUSIONS

Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals

BACKGROUND/PURPOSE

To improve clinical results and resource utilization in the care of appendicitis in children, the authors examined the current practice and outcomes of 30 pediatric hospitals.

METHODS

The Pediatric Health Information System (PHIS) database consists of comparative data from 30 free-standing Children's hospitals. The study population of 3,393 children was derived from the database by selecting the "Diagnosis Related Group Code" for appendicitis (APRDRGv12 164), ages 0 to 17 years, using discharges between October 1, 1999 and September 30, 2000. Data are expressed as the range and median for individual hospital outcomes.

RESULTS

The nonpositive appendectomy rate ranged from 0 to 17% at the 30 hospitals (median, 2.6%). Ruptured appendicitis varied from 20% to 76% (median, 36.5%). The median length of stay (LOS) for nonruptured appendicitis was 2 days (range, 1.4 to 3.1 days), ruptured appendicitis varied from 4.4 to 11 days (median, 6 days). The median readmission rate within 14 days was 4.3% (0 to 10%). Laparoscopic appendectomy varied from 0 to 95% in the 30 hospitals (mean, 31%) The LOS did not vary significantly in laparoscopic versus open for nonruptured (2.3 v 2.0 days) or ruptured appendicitis (5.5 v 6.2 days). Days on antibiotics for ruptured appendicitis ranged from 4.6 to 7.9 days (median, 5.9 days) Children receiving any study varied from 18% to 89% (median, 69%). Ultrasound scan and computed tomography (CT) were comparable in both nonruptured (13% ultrasound scan v 14%) and ruptured appendicitis (14% ultrasound scan v 21% CT).

CONCLUSIONS

Significant variability in practice patterns and resource utilization exists in the management of acute appendicitis in pediatric hospitals. Clinical outcomes could be improved by collaborative initiatives to adopt evidence-based best practices.

[Incidence of infection acquired at a health center]

BACKGROUND

Nosocomial infections in geriatric patients have specific features in geriatric health care facilities and services. The incidence of nosocomial infection in a long-term care hospital is described.

PATIENTS AND METHOD

The study was carried in L'AlianCa from Barcelona, a long-term care hospital of 138 beds of geriatric rehabilitation or convalescence. All nosocomial infections occurred in 1999 were recorded. The criteria of nosocomial infection were those of McGeer, adapted to make them suitable to a long-term care hospital. The statistical methods employed were the Student'st test to compare means and chi2 to compare proportions.

RESULTS

The incidence of nosocomial infections was 2.8 per 1,000 resident care days, showing a statistically significant increase in the group aged over 75 (p = 0.009). Infected patients had longer hospital stay and greater physical dependence. Lower respiratory tract infections were the most common type of infection accounting for the 39.7% of the cases. The mortality rate was greater in the infected group (RR: 2.61; CI 95%, 1.60-4.25).

CONCLUSIONS

Elderly patients are at greater risk of contracting nosocomial infections. It is necessary to develop infection control programs useful for the long-term care hospital.

Reprocessing of single-use endoscopic biopsy forceps and snares. One hospital's study

Financial pressures imposed on hospitals by health maintenance organizations and insurers have prompted investigation into alternative procedures that reduce expenses while maintaining the high standards required for patient care. Although not necessarily mutually exclusive, these dual agendas pose a challenge for endoscopy managers charged with balancing the risks and benefits of reusable and disposable endoscopy instruments. Our endoscopy unit elected to evaluate the feasibility of reducing costs by using reprocessed single-use devices. Following the selection of a third party reprocessor and prior to using any reprocessed devices in the clinical setting, our facility decided to submit single use devices that had been used once for reprocessing and then have an independent laboratory test them for sterility. Although we followed a thorough, multi-disciplinary approach, our end result led us to conclude that the cleaning, reprocessing, and resterilization of single-use biopsy forceps and snares is a greater challenge than previously anticipated. Reprocessing of the single-use devices tested did not result in endoscopic instruments that met acceptable standards for sterility at our institution.

Variation in nosocomial infection prevalence according to patient care setting:a hospital-wide survey

A study was performed to estimate the prevalence of nosocomial infections (NI) and assess differences between medical care settings in one hospital complex. A seven-day period-prevalence survey was conducted in May 1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland, that included all patients in acute, sub-acute and chronic care settings. Variables included demography, exposure to invasive devices and antibiotics, surgical history, and patients' localization. Overall prevalence of NI was 11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928 patients studied, and ranged from 0% in ophthalmology to 23% in critical care units. Odds of infection in sub-acute and chronic care settings were significantly higher than in the acute care setting even after adjustment for case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34; Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric location (belonging to the sub-acute care setting) showed a significant proportion of urinary (39%) and respiratory (21%) tract infections, contrasting with a relatively low exposure to urinary catheters (6.1%) and orotracheal intubation (0%). In conclusion, sub-acute and chronic care settings are associated with high infection prevalence even after case-mix adjustment. Prevalence studies are an easy surveillance tool that can be exploited further by analysing data according to hospital care settings to identify high-risk areas.

Infection control programs in long-term-care facilities: structure and process

Due to the rapid transfer of patients from the acute-care setting, the intensity of nursing care among residents in long-term-care facilities (LTCFs) has increased, transforming today's LTCFs into subacute healthcare facilities. Given the increased risk of infection among residents in LTCFs and the associated morbidity and mortality, evaluation of infection control programs in skilled nursing LTCFs is warranted. This article addresses the current structure and process of infection control programs in skilled nursing LTCFs.