Nurse Staffing Level, Length of Work Experience, and Risk of Health Care-Associated Infections Among Hospital Patients: A Prospective Record Linkage Study

BACKGROUND

Nurse understaffing may have several adverse consequences for patients in hospitals, such as health care-associated infections (HAIs), but there is little longitudinal evidence available on staffing levels and HAIs with consideration of incubation times to confirm this. Using daily longitudinal data, we analyzed temporal associations between nurse understaffing and limited work experience, and the risk of HAIs.

METHODS

The study was based on administrative data of 40 units and 261,067 inpatient periods for a hospital district in Finland in 2013-2019. Survival analyses with moving time windows were used to examine the association of nurse understaffing and limited work experience with the risk of an HAI 2 days after exposure, adjusting for individual risk factors. We reported hazard ratios (HRs) with 95% CIs.

RESULTS

Neither nurse understaffing nor limited work experience were associated with the overall risk of HAIs. The results were inconsistent across staffing measures and types of HAIs, and many of the associations were weak. Regarding specific HAI types, 1-day exposure to low proportion of nurses with >3 years of in-hospital experience and low proportion of nurses more than 25 years old were associated with increased risk of bloodstream infections (HR=1.30; 95% CI: 1.04-1.62 and HR=1.40; 95% CI: 1.07-1.83). Two-day exposure to low nursing hours relative to target hours was associated with an increased risk of surgical-site infections (HR=2.64, 95% CI: 1.66-4.20).

CONCLUSIONS

Data from time-varying analyses suggest that nursing staff shortages and limited work experience do not always increase the risk of HAI among patients.

Building an Interactive Geospatial Visualization Application for National Health Care-Associated Infection Surveillance: Development Study

Background

The Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) is the most widely used health care–associated infection (HAI) and antimicrobial use and resistance surveillance program in the United States. Over 37,000 health care facilities participate in the program and submit a large volume of surveillance data. These data are used by the facilities themselves, the CDC, and other agencies and organizations for a variety of purposes, including infection prevention, antimicrobial stewardship, and clinical quality measurement. Among the summary metrics made available by the NHSN are standardized infection ratios, which are used to identify HAI prevention needs and measure progress at the national, regional, state, and local levels.

Objective

To extend the use of geospatial methods and tools to NHSN data, and in turn to promote and inspire new uses of the rendered data for analysis and prevention purposes, we developed a web-enabled system that enables integrated visualization of HAI metrics and supporting data.

Methods

We leveraged geocoding and visualization technologies that are readily available and in current use to develop a web-enabled system designed to support visualization and interpretation of data submitted to the NHSN from geographically dispersed sites. The server–client model–based system enables users to access the application via a web browser.

Results

We integrated multiple data sets into a single-page dashboard designed to enable users to navigate across different HAI event types, choose specific health care facility or geographic locations for data displays, and scale across time units within identified periods. We launched the system for internal CDC use in January 2019.

Conclusions

CDC NHSN statisticians, data analysts, and subject matter experts identified opportunities to extend the use of geospatial methods and tools to NHSN data and provided the impetus to develop NHSNViz. The development effort proceeded iteratively, with the developer adding or enhancing functionality and including additional data sets in a series of prototype versions, each of which incorporated user feedback. The initial production version of NHSNViz provides a new geospatial analytic resource built in accordance with CDC user requirements and extensible to additional users and uses in subsequent versions.

Characterization of Bacterial and Fungal Infections in Hospitalized Patients With Coronavirus Disease 2019 and Factors Associated With Health Care-Associated Infections

Background

Patients hospitalized with coronavirus disease 2019 (COVID-19) are at increased risk of health care–associated infections (HAIs), especially with prolonged hospital stays. We sought to identify incidence, antimicrobial susceptibilities, and outcomes associated with bacterial/fungal secondary infections in a large cohort of patients with COVID-19.

Methods

We evaluated adult patients diagnosed with COVID-19 between 2 March and 31 May 2020 and hospitalized >24 hours. Data extracted from medical records included diagnoses, vital signs, laboratory results, microbiological data, and antibiotic use. Microbiologically confirmed bacterial and fungal pathogens from clinical cultures were evaluated to characterize community- and health care–associated infections, including describing temporal changes in predominant organisms on presentation and throughout hospitalization. Univariable and multivariable logistic regression analyses were performed to investigate risk factors for HAIs.

Results

A total of 3028 patients were included and accounted for 899 positive clinical cultures. Overall, 516 (17%) patients with positive cultures met criteria for infection. Community-associated coinfections were identified in 183 (6%) patients, whereas HAIs occurred in 350 (12%) patients. Fifty-seven percent of HAIs were caused by gram-negative bacteria and 19% by fungi. Antibiotic resistance increased with longer hospital stays, with incremental increases in the proportion of vancomycin resistance among enterococci and ceftriaxone and carbapenem resistance among Enterobacterales. Intensive care unit stay, invasive mechanical ventilation, and steroids were associated with HAIs.

Conclusions

HAIs occur in a small proportion of patients hospitalized with COVID-19 and are most often caused by gram-negative and fungal pathogens. Antibiotic resistance is more prevalent with prolonged hospital stays. Antimicrobial stewardship is imperative in this population to minimize unnecessary broad-spectrum antibiotic use.

Automated Cluster Detection of Health Care-Associated Infection Based on the Multisource Surveillance of Process Data in the Area Network: Retrospective Study of Algorithm Development and Validation

BACKGROUND

The cluster detection of health care-associated infections (HAIs) is crucial for identifying HAI outbreaks in the early stages.

OBJECTIVE

We aimed to verify whether multisource surveillance based on the process data in an area network can be effective in detecting HAI clusters.

METHODS

We retrospectively analyzed the incidence of HAIs and 3 indicators of process data relative to infection, namely, antibiotic utilization rate in combination, inspection rate of bacterial specimens, and positive rate of bacterial specimens, from 4 independent high-risk units in a tertiary hospital in China. We utilized the Shewhart warning model to detect the peaks of the time-series data. Subsequently, we designed 5 surveillance strategies based on the process data for the HAI cluster detection: (1) antibiotic utilization rate in combination only, (2) inspection rate of bacterial specimens only, (3) positive rate of bacterial specimens only, (4) antibiotic utilization rate in combination + inspection rate of bacterial specimens + positive rate of bacterial specimens in parallel, and (5) antibiotic utilization rate in combination + inspection rate of bacterial specimens + positive rate of bacterial specimens in series. We used the receiver operating characteristic (ROC) curve and Youden index to evaluate the warning performance of these surveillance strategies for the detection of HAI clusters.

RESULTS

The ROC curves of the 5 surveillance strategies were located above the standard line, and the area under the curve of the ROC was larger in the parallel strategy than in the series strategy and the single-indicator strategies. The optimal Youden indexes were 0.48 (95% CI 0.29-0.67) at a threshold of 1.5 in the antibiotic utilization rate in combination-only strategy, 0.49 (95% CI 0.45-0.53) at a threshold of 0.5 in the inspection rate of bacterial specimens-only strategy, 0.50 (95% CI 0.28-0.71) at a threshold of 1.1 in the positive rate of bacterial specimens-only strategy, 0.63 (95% CI 0.49-0.77) at a threshold of 2.6 in the parallel strategy, and 0.32 (95% CI 0.00-0.65) at a threshold of 0.0 in the series strategy. The warning performance of the parallel strategy was greater than that of the single-indicator strategies when the threshold exceeded 1.5.

CONCLUSIONS

The multisource surveillance of process data in the area network is an effective method for the early detection of HAI clusters. The combination of multisource data and the threshold of the warning model are 2 important factors that influence the performance of the model.

Effectiveness of Copper-Impregnated Solid Surfaces on Lowering Microbial Bio-Burden Levels in an Acute Care Hospital

Background

Microbial bio-burden on high-touch surfaces in patient rooms may lead to acquisition of health care-associated infections in acute care hospitals. This study examined the effect of a novel copper-impregnated solid material (16%-20% copper oxide in a polymer-based resin) on bacterial contamination on high-touch surfaces in patient rooms in an acute care hospital.

Methods

Five high-touch surfaces were sampled for aerobic bacterial colonies (ABCs) 3 times per day over a 3-day period in 16 rooms with copper installed and 16 rooms with standard noncopper laminate installed on high-touch surfaces. A Bayesian multilevel negative binomial regression model was used to compare ABC plate counts from copper-impregnated surfaces with standard hospital laminate surfaces.

Results

The mean and median (interquartile range [IQR]) ABC counts from copper-impregnated surfaces were 25.5 and 11 (4-27), and for standard hospital laminate surfaces they were 60.5 and 29 (10-74.3). The negative binomial regression model-estimated incidence rate for ABC counts on plates taken from copper-impregnated surfaces was 0.40 (0.21-0.70) times the incidence rate of ABC counts on plates taken from standard hospital laminate surfaces.

Conclusions

Copper-impregnated solid surfaces may reduce the level of microbial contamination on high-touch surfaces in patient rooms in the acute care environment, as our study demonstrated a decline in microbial bio-burden on samples taken from copper-impregnated compared with standard hospital laminate high-touch surfaces.

Advances in Data-Driven Responses to Preventing Spread of Antibiotic Resistance Across Health-Care Settings

Among the most urgent and serious threats to public health are 7 antibiotic-resistant bacterial infections predominately acquired during health-care delivery. There is an emerging field of health-care epidemiology that is focused on preventing health care-associated infections with antibiotic-resistant bacteria and incorporates data from patient transfers or patient movements within and between facilities. This analytic field is being used to help public health professionals identify best opportunities for prevention. Different analytic approaches that draw on uses of big data are being explored to help target the use of limited public health resources, leverage expertise, and enact effective policy to maximize an impact on population-level health. Here, the following recent advances in data-driven responses to preventing spread of antibiotic resistance across health-care settings are summarized: leveraging big data for machine learning, integration or advances in tracking patient movement, and highlighting the value of coordinating response across institutions within a region.

Disparities in Health Care-Associated Infections in the NICU

OBJECTIVES

This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals.

STUDY DESIGN

This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative.

RESULTS

Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection.

CONCLUSION

Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.

Estimating the Direct Medical Economic Burden of Health Care-Associated Infections in Public Tertiary Hospitals in Hubei Province, China

This study estimated the attributable direct medical economic burden of health care-associated infections (HAIs) in China. Data were extracted from hospitals' information systems. Inpatient cases with HAIs and non-HAIs were grouped by the propensity score matching (PSM) method. Attributable hospitalization expenditures and length of hospital stay were measured to estimate the direct medical economic burden of HAIs. STATA 12.0 was used to conduct descriptive analysis, bivariate χ² test, paired Z test, PSM ( r = 0.25σ, nearest neighbor 1:1 matching), and logistic regress analysis. The statistically significant level was set at .05. The HAIs group had statistically significant higher expenditures and longer hospitalization stay than the non-HAIs group during 2013 to 2015 ( P < .001). The annual average HAI attributable total expenditure, medicines expenditure, out-of-pocket expenditure, and number of hospitalization days per inpatient were (2015 US$) 6173.02, 2257.98, and 1958.25 and 25 days during 2013 to 2015. The direct medical cost savings was estimated at more than 2015 US$12 billion per year in Chinese tertiary hospitals across the country. The significant attributable direct medical economic burden of HAIs calls for more effective HAI surveillance and better control with appropriate incentives.

Reduction of methicillin-resistant Staphylococcus aureus infection in long-term care is possible while maintaining patient socialization: A prospective randomized clinical trial

BACKGROUND

Antibiotic resistance is a challenge in long-term care facilities (LTCFs). The objective of this study was to demonstrate that a novel, minimally invasive program not interfering with activities of daily living or socialization could lower methicillin-resistant Staphylococcus aureus (MRSA) disease.

METHODS

This was a prospective, cluster-randomized, nonblinded trial initiated at 3 LTCFs. During year 1, units were stratified by type of care and randomized to intervention or control. In year 2, all units were converted to intervention consisting of universal decolonization using intranasal mupirocin and a chlorhexidine bath performed twice (2 decolonization-bathing cycles 1 month apart) at the start of the intervention period. Subsequently, after initial decolonization, all admissions were screened on site using real-time polymerase chain reaction, and those MRSA positive were decolonized, but not isolated. Units received annual instruction on hand hygiene. Enhanced bleach wipe cleaning of flat surfaces was done every 4 months.

RESULTS

There were 16,773 tests performed. The MRSA infection rate decreased 65% between baseline (44 infections during 365,809 patient days) and year 2 (12 infections during 287,847 patient days; P <.001); a significant reduction was observed at each of the LTCFs (P <.03).

CONCLUSIONS

On-site MRSA surveillance with targeted decolonization resulted in a significant decrease in clinical MRSA infection among LTCF residents.

Cleaning practices in the hospital setting: Are high-touch surfaces in isolation and standard precaution patient rooms cleaned to the same standard?

The purpose of this quality improvement project was to identify differences in cleaning practices between isolation rooms and standard precaution rooms in the hospital setting. An ultravoilet marking system was used to evaluate high-touch surfaces throughout the patient environment. Results reveal the importance of refining training systems to reflect staff perceptions and improve evaluation processes across systems in an effort to reduce health care-associated infections.

Active surveillance and safety organizational goals to reduce central line-associated bloodstream infections outside the intensive care unit: 9 years of experience

We performed a quasi-experimental, cohort study in the medical-surgical inpatient wards comparing central line-associated bloodstream infection (CLABSI) rates and microbiologic characteristics in 3 phases. The CLABSI rates decreased 60% from phase 1 to 2 and 61.5% from phase 2 to 3. Gram-positive organisms were most frequently isolated in phases 1 and 3, and gram-negative bacilli were most frequently isolated in phase 2. The CLABSI surveillance and prevention program focusing on patient safety had a significant impact on CLABSI rates.

Transmission of blood-borne pathogens in US dental health care settings: 2016 update

BACKGROUND

During the past decade, investigators have reported transmissions of blood-borne pathogens (BBPs) in dental settings. In this article, the authors describe these transmissions and examine the lapses in infection prevention on the basis of available information.

METHODS

The authors reviewed the literature from 2003 through 2015 to identify reports of the transmission of BBPs in dental settings and related lapses in infection prevention efforts, as well as to identify reports of known or suspected health care-associated BBP infections submitted by state health departments to the Centers for Disease Control and Prevention.

RESULTS

The authors identified 3 published reports whose investigators described the transmission of hepatitis B virus and hepatitis C virus. In 2 of these reports, the investigators described single-transmission events (from 1 patient to another) in outpatient oral surgery practices. The authors of the third report described the possible transmission of hepatitis B virus to 3 patients and 2 dental health care personnel in a large temporary dental clinic. The authors identified lapses in infection prevention practices that occurred during 2 of the investigations; however, the investigators were not always able to link a specific lapse to a transmission event. Examples of lapses included the failure to heat-sterilize handpieces between patients, a lack of training for volunteers on BBPs, and the use of a combination of unsafe injection practices.

CONCLUSIONS

The authors found that reports describing the transmission of BBPs in dental settings since 2003 were rare. Failure to adhere to Centers for Disease Control and Prevention recommendations for infection control in dental settings likely led to disease transmission in these cases.

PRACTICAL IMPLICATIONS

The existence of these reports emphasizes the need to improve dental health care personnel's understanding of the basic principles and implementation of standard precautions through the use of checklists, policies, and practices.

Hospital Clostridium difficile infection (CDI) incidence as a risk factor for hospital-associated CDI

BACKGROUND

Environmental risk factors for Clostridium difficile infections (CDIs) have been described at the room or unit level but not the hospital level. To understand the environmental risk factors for CDI, we investigated the association between institutional- and individual-level CDI.

METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project state inpatient databases for California (2005-2011). For each patient's hospital stay, we calculated the hospital CDI incidence rate corresponding to the patient's quarter of discharge, while excluding each patient's own CDI status. Adjusting for patient and hospital characteristics, we ran a pooled logistic regression to determine individual CDI risk attributable to the hospital's CDI rate.

RESULTS

There were 10,329,988 patients (26,086 cases and 10,303,902 noncases) who were analyzed. We found that a percentage point increase in the CDI incidence rate a patient encountered increased the odds of CDI by a factor of 1.182.

CONCLUSIONS

As a point of comparison, a 1-percentage point increase in the CDI incidence rate that the patient encountered had roughly the same impact on their odds of acquiring CDI as a 55.8-day increase in their length of stay or a 60-year increase in age. Patients treated in hospitals with a higher CDI rate are more likely to acquire CDI.

The first point prevalence survey of health care-associated infection and antimicrobial use in a Japanese university hospital: A pilot study

BACKGROUND

Point prevalence surveys (PPSs) in Japanese hospitals have not yet been reported. The purpose of this pilot PPS study was to evaluate the epidemiology of health care-associated infections (HAIs) and antimicrobial use in a Japanese tertiary university hospital.

METHODS

A 1-day, cross-sectional PPS was performed at a Japanese university hospital. Data on demographics, active HAIs, and antimicrobial use of all inpatients were collected using a data collection form.

RESULTS

Of 841 patients, 85 (10.1%) had 90 active HAIs, and 308 patients (36.6%) were administered 494 antimicrobials. Among the 90 HAIs and 58 pathogens, the most frequent infection and isolated pathogen were pneumonia (20.0%) and Enterobacteriaceae (27.6%), respectively. Of the 118 antimicrobials used for treatment of HAIs, carbapenems were the most frequently administered category of antimicrobials (22.9%). In regard to antimicrobials for surgical prophylaxis, 37 of 119 (31.1%) were administered to patients on postoperative day 3 or later, and 48 of 119 (40.3%) were administered orally.

CONCLUSIONS

The incidence of HAIs is higher than in other developed countries. The social and medical situation in Japan may affect patient demographics, active HAIs, and antimicrobial use. Multicenter PPSs are necessary to uncover the real epidemiology of HAIs and antimicrobial use in Japan.

International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system

BACKGROUND

The International Nosocomial Infection Control Consortium (INICC) is an international, nonprofit, multicentric health care-associated infection (HAI) cohort surveillance network with a methodology based on the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN). The INICC was founded in 1998 to promote evidence-based infection control in limited-resource countries through the analysis of surveillance data collected by their affiliated hospitals. The INICC is comprised of >3,000-affiliated infection control professionals from 1,000 hospitals in 67 countries and is the only source of aggregate standardized international data on HAI epidemiology. Having published reports on device-associated (DA) HAI (HAI) and surgical site infections (SSIs) from 43 countries and several reports per individual country, the INICC showed DA HAI and SSI rates in limited-resources countries are 3-5 times higher than in high-income countries.

METHODS

The INICC developed the INICC Multidimensional Approach (IMA) for HAI prevention with 6 components, bundles with 7-13 elements, and the INICC Surveillance Online System (ISOS) with 15 modules.

RESOURCES

In this article the IMA, the ISOS for outcome surveillance of HAIs and process surveillance of bundles to prevent HAIs, and the use of surveillance data feedback are described.

COMMENTS

Remarkable features of the IMA and ISOS are INICC's applying of the latest published CDC-NHSN HAI definitions, including their updates and revisions in 2008, 2013, 2015 and 2016; INICC's informatics system to check accuracy of fulfillment of CDC-NHSN HAI criteria; and INICC's system to check compliance with each bundle element.

Emerging Infections Program as Surveillance for Antimicrobial Drug Resistance

Across the United States, antimicrobial drug-resistant infections affect a diverse population, and effective interventions require concerted efforts across various public health and clinical programs. Since its onset in 1994, the Centers for Disease Control and Prevention Emerging Infections Program has provided robust and timely data on antimicrobial drug-resistant infections that have been used to inform public health action across a spectrum of partners with regard to many highly visible antimicrobial drug-resistance threats. These data span several activities within the Program, including respiratory bacterial infections, health care-associated infections, and some aspects of foodborne diseases. These data have contributed to estimates of national burden, identified populations at risk, and determined microbiological causes of infection and their outcomes, all of which have been used to inform national policy and guidelines to prevent antimicrobial drug-resistant infections.

Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings

BACKGROUND

To report the results of the International Infection Control Consortium (INICC) study conducted in Kuwait from November 2013-March 2015.

METHODS

A device-associated health care-acquired infection (DA-HAI) prospective surveillance study in 7 adult, pediatric, and neonatal intensive care units (ICUs) using the U.S. Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) definitions and INICC methods.

RESULTS

We followed 3,732 adult and pediatric patients for 21,611 bed days and 671 neonatal patients for 4,515 bed days. In the medical-surgical ICUs, the central line-associated bloodstream infection (CLABSI) rate was 3.5 per 1,000 central line days, the ventilator-associated pneumonia (VAP) rate was 4.0 per 1,000 mechanical ventilator days, and the catheter-associated urinary tract infection (CAUTI) rate was 3.3 per 1,000 urinary catheter days; all of them were lower than INICC rates (CLABSI: 4.9; VAP: 16.5; and CAUTI: 5.3) and higher than NHSN rates (CLABSI: 0.9; VAP: 1.1; and CAUTI: 1.2). Resistance of Staphylococcus aureus to oxacillin was 100%, resistance of Acinetobacter baumannii to imipenem and meropenem was 77.6%, and resistance of Klebsiella pneumoniae to imipenem and meropenem was 29.4%. Extra length of stay was 27.1 days for CLABSI, 22.2 days for VAP, and 19.2 days for CAUTI in adult and pediatric ICUs. Extra crude mortality was 19.9% for CLABSI, 30.9% for VAP, and 11.1% for CAUTI in adult and pediatric ICUs.

CONCLUSIONS

DA-HAI rates in our ICUs are higher than the CDC-NSHN rates and lower than the INICC international rates.

Costs associated with health care-associated infections in cardiac surgery

BACKGROUND

Health care-associated infections (HAIs) are the most common noncardiac complications after cardiac surgery and are associated with increased morbidity and mortality. Current information about their economic burden is limited.

OBJECTIVES

This research was designed to determine the cost associated with major types of HAIs during the first 2 months after cardiac surgery.

METHODS

Prospectively collected data from a multicenter, observational study of the Cardiothoracic Surgery Clinical Trials Network, in which patients were monitored for infections for 65 days after surgery, were merged with related financial data routinely collected by the University HealthSystem Consortium. Incremental length of stay (LOS) and cost associated with HAIs were estimated using generalized linear models, with adjustments for patient demographics, clinical history, baseline laboratory values, and surgery type.

RESULTS

Among 4,320 cardiac surgery patients (mean age: 64 ± 13 years), 119 (2.8%) experienced a major HAI during the index hospitalization. The most common HAIs were pneumonia (48%), sepsis (20%), and Clostridium difficile colitis (18%). On average, the estimated incremental cost associated with a major HAI was nearly $38,000, of which 47% was related to intensive care unit services. The incremental LOS was 14 days. Overall, there were 849 readmissions; among these, 8.7% were attributed to major HAIs. The cost of readmissions due to major HAIs was, on average, nearly threefold that of readmissions not related to HAIs.

CONCLUSIONS

Hospital cost, LOS, and readmissions are strongly associated with HAIs. These associations suggest the potential for large reductions in costs if HAIs following cardiac surgery can be reduced. (Management Practices and the Risk of Infections Following Cardiac Surgery; NCT01089712).

Costs associated with health care-associated infections in cardiac surgery

BACKGROUND

Health care-associated infections (HAIs) are the most common noncardiac complications after cardiac surgery and are associated with increased morbidity and mortality. Current information about their economic burden is limited.

OBJECTIVES

This research was designed to determine the cost associated with major types of HAIs during the first 2 months after cardiac surgery.

METHODS

Prospectively collected data from a multicenter, observational study of the Cardiothoracic Surgery Clinical Trials Network, in which patients were monitored for infections for 65 days after surgery, were merged with related financial data routinely collected by the University HealthSystem Consortium. Incremental length of stay (LOS) and cost associated with HAIs were estimated using generalized linear models, with adjustments for patient demographics, clinical history, baseline laboratory values, and surgery type.

RESULTS

Among 4,320 cardiac surgery patients (mean age: 64 ± 13 years), 119 (2.8%) experienced a major HAI during the index hospitalization. The most common HAIs were pneumonia (48%), sepsis (20%), and Clostridium difficile colitis (18%). On average, the estimated incremental cost associated with a major HAI was nearly $38,000, of which 47% was related to intensive care unit services. The incremental LOS was 14 days. Overall, there were 849 readmissions; among these, 8.7% were attributed to major HAIs. The cost of readmissions due to major HAIs was, on average, nearly threefold that of readmissions not related to HAIs.

CONCLUSIONS

Hospital cost, LOS, and readmissions are strongly associated with HAIs. These associations suggest the potential for large reductions in costs if HAIs following cardiac surgery can be reduced. (Management Practices and the Risk of Infections Following Cardiac Surgery; NCT01089712).

Reducing catheter-associated urinary tract infections: a quality-improvement initiative

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States, yet little is known about the prevention and epidemiology of pediatric CAUTIs.

METHODS

An observational study was conducted to assess the impact of a CAUTI quality improvement prevention bundle that included institution-wide standardization of and training on urinary catheter insertion and maintenance practices, daily review of catheter necessity, and rapid review of all CAUTIs. Poisson regression was used to determine the impact of the bundle on CAUTI rates. A retrospective cohort study was performed to describe the epidemiology of incident pediatric CAUTIs at a tertiary care children's hospital over a 3-year period (June 2009 to June 2012).

RESULTS

Implementation of the CAUTI prevention bundle was associated with a 50% reduction in the mean monthly CAUTI rate (95% confidence interval: -1.28 to -0.12; P = .02) from 5.41 to 2.49 per 1000 catheter-days. The median monthly catheter utilization ratio remained unchanged; ∼90% of patients had an indication for urinary catheterization. Forty-four patients experienced 57 CAUTIs over the study period. Most patients with CAUTIs were female (75%), received care in the pediatric or cardiac ICUs (70%), and had at least 1 complex chronic condition (98%). Nearly 90% of patients who developed a CAUTI had a recognized indication for initial catheter placement.

CONCLUSIONS

CAUTI is a common pediatric health care-associated infection. Implementation of a prevention bundle can significantly reduce CAUTI rates in children.

Back to basics: hand hygiene and surgical hand antisepsis

Health care-associated infections (HAIs) are a significant issue in the United States and throughout the world, but following proper hand hygiene practices is the most effective and least expensive way to prevent HAIs. Hand hygiene is inexpensive and protects patients and health care personnel alike. The four general types of hand hygiene that should be performed in the perioperative environment are washing hands that are visibly soiled, hand hygiene using alcohol-based products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based surgical hand rub product. Barriers to proper hand hygiene may include not thinking about it, forgetting, skin irritation, a lack of role models, or a lack of a safety culture. One strategy for improving hand hygiene practices is monitoring hand hygiene as part of a quality improvement project, but the most important aspect for perioperative team members is to set an example for other team members by following proper hand hygiene practices and reminding each other to perform hand hygiene.

Infection prevention and control standards in assisted living facilities: are residents' needs being met?

BACKGROUND

Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities.

OBJECTIVES

Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training.

METHODS

We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities.

RESULTS

Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating.

CONCLUSIONS

There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.