Impact of Device-Associated Infection on Trauma Patient Outcomes at a Major Trauma Center

Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US

BACKGROUND

Catheter associated urinary tract infections (CAUTIs) have become a focus for reducing healthcare costs. Reimbursement may be reduced to hospitals with higher rates. The implementation of bundles or other efforts to reduce infection numbers may not be as robust at hospitals caring for more diverse patient populations. This may lead to a disparity in hospital-associated infections rates that may lead to lower reimbursement and a downward spiral of quality of care and racial disparities.

METHODS

We analyzed patients in the National Trauma Data Bank from 2016 to 2017. The final analysis included patients 65 years or older with one or more day of mechanical ventilation. This was the population had the highest rate of CAUTI. We compared white patients to non-whites using students t test, Mann Whitney U test, or chi-square as appropriate. Logistic regression with odds ratios (ORs) and 95% confidence intervals (CI) was computed to identify risk factors for of CAUTI.

RESULTS

Risk factors for developing a CAUTI were race (OR 1.44, 95% confidence interval (95%CI) 1.23-1.71), injury severity score (OR 1.10 per increase of one, 95% CI 1.01-1.02), care at a teaching hospital (OR 1.17, 95%CI 1.02-1.35), private insurance (OR 1.28, 95%CI 1.09-1.51), hypertension (OR 1.18, 95%CI 1.02-1.37), female gender (OR 1.54, 95%CI 1.33-1.77). Non-white patients received care at teaching hospitals more often and had a higher rate of government insurance or no insurance.

DISCUSSION

The Center for Medicare and Medicaid Services (CMS) has put in place a reimbursement modification 87 plan based on the rates of hospital-associated infections including CAUTIs. We have demonstrated non-white 88 patients have higher odds for developing a CAUTI.

CONCLUSION

CMS may potentially worsen the racial disparity by further cutting reimbursement to hospitals who care for higher proportions of non-whites.

Journal club: "Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US"

In this article for Journal Club commentary entitled "Racial Disparities in Catheter Related Urinary Tract Infections Among Elderly Trauma Patients in the US", Keneally et al, conducted a study with the goal of assessing the role of social disparities in catheter associated urinary tract infections (CAUTIs). This cross-sectional study utilized secondary data to determine the possible CAUTI risk in ventilated, older (≥ 65 years of age) trauma patients exploring possible racial structural bias in healthcare. The analysis addressed the following questions in this specific population:While this study does consider race and discusses structural biases, which are important and sparsely researched in healthcare-associated infection (HAI) outcomes, the practice implementations are somewhat limited due to study design and analysis. Therefore, the focus of this Journal Club commentary will be reviewing basic steps Infection Preventionists (IPs) can take to critically appraise the literature for application in their facility's patient population.

Device associated infections at a trauma surgical center of India: Trend over eight years

BACKGROUND

Device-associated infections (DAIs) are an important cause of excessive stay and mortality in ICUs. Trauma patients are predisposed to acquire such infections due to various factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the rates and outcomes of DAIs at a dedicated Trauma Center in trauma patients and compares the rates with a previous pilot observation.

METHODS

The study reports the finding of ongoing surveillance and the use of an indigenous software at a level-1 trauma center in India. Surveillance for ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections was done based on standard definitions. The rates of HAIs and the profile of pathogens isolated from June 2010 to December 2018 were analyzed.

RESULTS

A total of 7485 patients were included in the analysis, amounting to 68,715 patient days. The rates of VAP, CLABSI, and CA-UTI were respectively 12, 9.8 1st 8.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Of the 1449 isolates recovered from cases of DAIs, Acinetobacter sp (28.2%) was the most common isolate, followed by Candida sp. A high rate of multi-resistance was observed.

CONCLUSION

Automated surveillance was easy and useful for data entry and analysis. Surveillance data should be used for implementing preventive programs.

Catheter-Associated Urinary Tract Infections among Trauma Patients: Poor Quality of Care or Marker of Effective Rescue?

Background: Catheter-associated urinary tract infection (CAUTI) is associated generally with worse outcomes among hospitalized patients, but the impact of CAUTI on clinical outcomes is poorly described in trauma patients. We hypothesized that trauma patients with CAUTI would have worse outcomes such as longer length of stay (LOS), fewer discharges to home, and higher outcome of death. Methods: Patients with LOS >2 d in the 2016 Trauma Quality Improvement Program (TQIP) database were included. Patients with and without CAUTI were matched 1:1 via a propensity score using patient, injury, and hospital factors as covariates. Matched pair analysis was performed to compare difference in clinical outcomes between patients with and without CAUTI. Results: There were 238,274 patients identified, of whom 0.7% had a diagnosis of CAUTI. Prior to matching, CAUTI patients had a higher mortality rate (6.6% vs. 3.4%, p < 0.01), but groups differed significantly. There were 1,492 matched pairs created, with effective reduction in bias; post-match propensity score covariates all had absolute standardized differences <0.1. In matched pair analysis, CAUTI patients had lower outcome of death compared with patients without CAUTI (6.7% vs. 10.1%, p < 0.01). The CAUTI was associated with longer length of stay, more intensive care unit and ventilator days, more unplanned events, and fewer discharges to home (all p < 0.01). Conclusions: Trauma patients with CAUTI had lower outcome of death compared with patients without CAUTI, despite worse clinical outcomes in all other aspects. This difference may be associated with "rescue" care in the form of unplanned events, and CAUTI may be an unintended consequence of this "rescue" care, rather than a marker of poor quality of care.

Risk factors for infection and evaluation of Sepsis-3 in patients with trauma

BACKGROUND

We aim to examine the risk factors associated with infection in trauma patients and the Sepsis-3 definition.

METHODS

This was a retrospective cohort study of adult trauma patients admitted to a Level I trauma center between January 2014 and January 2016.

RESULTS

A total of 1499 trauma patients met inclusion criteria and 15% (n = 232) had an infection. Only 19.8% (n = 46) of infected patients met criteria for Sepsis-3, with the majority (43%) of infected cases having a Sequential Organ Failure Assessment (SOFA) score greater on admission compared to the time of suspected infection. In-hospital death was 7% vs 9% (p = 0.65) between Sepsis-3 and infected patients, respectively. Risk factors associated with infection were female sex, admission SOFA score, Elixhauser score, and severe injury (P < 0.05).

CONCLUSION

Patients with trauma often arrive with organ dysfunction, which adds complexity and inaccuracy to the operational definition of Sepsis-3 using changes in SOFA scores. Injury severity score, comorbidities, SOFA score, and sex are risk factors associated with developing an infection after trauma.

Hand Hygiene Compliance in the Setting of Trauma Resuscitation

INTRODUCTION

Healthcare-associated infections are a significant health burden, and hand hygiene (HH) is an essential prevention strategy. World Health Organization (WHO) 2009 guidelines recommend washing hands during five moments of patient care; 1)before touching a patient; 2)before a clean procedure; 3)after body fluid exposure; and 4)after touching a patient or 5)patient surroundings. HH opportunities at these 5 moments are frequent and compliance is low (22-60%). Infection risk is particularly high in trauma patients, and HH compliance during active trauma resuscitation has yet to be evaluated.

MATERIALS AND METHODS

Using video surveillance, all healthcare worker (HCW)-patient interactions for 30 patients were retrospectively reviewed for HH compliance according to WHO guidelines and glove use during initial resuscitation at a level-1 trauma center.

RESULTS

342 HCW-patient interactions and 1034 HH opportunities were observed. HH compliance with the WHO moments was 7% (71/1034) overall; 3% (10/375) before patient contact, 0% (0/178) before a clean procedure, 11% (2/19) after body fluid contact, 15% (57/376) after patient contact and 2% (2/86) after contact with the environment. Glove use was more common, particularly before (69%) and after (47%) patient contact and after body fluid contact (58%). No HH was observed before clean procedures, but HCW donned new gloves 75% of the time before bedside procedures. If donning/removing gloves was included with HH as compliant, compliance was 57% overall.

CONCLUSION

HH opportunities are frequent and compliance with WHO HH guidelines may be infeasible, requiring significant amounts of time that may be better spent with the patient during the golden hour of trauma resuscitation. In an era where more scrutiny is being applied to patient safety, particularly the prevention of inpatient infections, more research is needed to identify alternative strategies (e.g. glove use, prioritizing moments) that may more effectively promote compliance in this setting.

Use of endotracheal tubes with subglottic secretion drainage reduces ventilator-associated pneumonia in trauma patients

BACKGROUND

Patients sustaining traumatic injuries have a higher incidence of ventilator-associated pneumonia (VAP) compared with other critically ill patient populations. Previous studies of patients with predominantly medical diagnoses and use of endotracheal tubes allowing subglottic secretion drainage (ETT-SSD) have shown significant reduction in VAP rates. We hypothesized that the use of ETT-SSD would reduce VAP in trauma patients.

METHODS

A retrospective review from 2010 to 2014 of adult trauma patients orotracheally intubated for more than 48 hours was performed at a Level 1 trauma center. Patients were compared based on standard endotracheal tube (ETT) versus ETT-SSD for the primary outcome VAP per 1,000 ventilator days. The diagnosis of VAP was made by quantitative bronchoalveolar lavage cultures as defined by Centers for Disease Control and Prevention criteria. Patients with ETT-SSD were matched to patients with ETT based on age group, sex, mechanism of injury, head and chest Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS).

RESULTS

Of 1,135 patients included in the study, 667 patients had ETT and 468 had ETT-SSD. Groups did not differ by demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, alcohol intoxication, or ISS. Patients with ETT-SSD had significantly higher head AIS score but lower chest AIS score. In matched cohorts, ETT-SSD had a lower VAP rate (5.7 vs. 9.3 for ETT, p = 0.03), decreased ventilator days (12 vs. 14, p = 0.04), and decreased intensive care unit length of stay (13 days vs. 16 days, p = 0.003).

CONCLUSION

After controlling for confounding factors, ETT-SSD decreased VAP rate, ventilator days, and intensive care unit length of stay in trauma patients. In this high-risk patient population, we recommend routine use of ETT-SSD to decrease VAP.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.