Barbara I. Braun

Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections Results From the Trial to Reduce Antimicrobial Prophylaxis Errors

Objective:The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP). Summary Background Data:National AMP guidelines should be supported by evidence from large contemporary data sets. Methods:Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac, hip/knee arthroplasty, and hysterectomy cases. Surgical site infections (SSIs) were ascertained through routine surveillance, using National Nosocomial Infections Surveillance system methodology. The association between the prophylaxis timing and the occurrence of SSI was assessed using conditional logistic regression (conditioning on hospital). Results:One-hundred thirteen SSI were detected in 109 patients. SSI risk increased incrementally as the interval of time between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 0.04). When antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded, the infection risk following administration of antibiotic within 30 minutes prior to incision was 1.6% compared with 2.4% associated with administration of antibiotic between 31 to 60 minutes prior to surgery (OR: 1.74; 95% confidence interval, 0.98–3.04). The infection risk increased as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision. Intraoperative redosing (performed in only 21% of long operations) appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 3.08 with no redosing; 95% confidence interval 0.74–12.90), but only when the preoperative dose was given correctly. Conclusions:These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.

Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery

IMPORTANCE Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations. OBJECTIVE To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties. DESIGN, SETTING, AND PARTICIPANTS Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014). INTERVENTIONS Patients whose preoperative nares screens were positive for methicillin-resistant S. aureus (MRSA) or methicillin-susceptible S. aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. MAIN OUTCOMES AND MEASURES The primary outcome was complex (deep incisional or organ space) S. aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis. RESULTS After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S. aureus SSIs occurred after 28,218 operations during the preintervention period and 29 occurred after 14,316 operations during the intervention period (mean rate per 10,000 operations, 36 for preintervention period vs 21 for intervention period, difference, -15 [95% CI, -35 to -2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S. aureus SSIs decreased for hip or knee arthroplasties (difference per 10,000 operations, -17 [95% CI, -39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10,000 operations, -6 [95% CI, -48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]). CONCLUSIONS AND RELEVANCE In this multicenter study, a bundle comprising S. aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S. aureus SSIs.

Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis

Objective To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures. Design Systematic review and meta-analysis. Data sources PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed. Eligibility criteria Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care. Participants Patients undergoing cardiac operations or total joint replacement procedures. Data extraction and study appraisal Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I2 statistics. Results 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56). Conclusions Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.

Hospital Financial Condition and Operational Decisions Related to the Quality of Hospital Care

Financial pressure mounted for hospitals nationwide during the late 1990s. Our study examines how this affected the quality of their operations in terms of organizational infrastructure and processes that support the delivery of care. Our sample consisted of community hospitals operating between 1995 and 2000. Financial pressure was measured based on changes in net patient revenues per adjusted patient day and the ratio of cash flow to total revenues. The authors examined effects on hospital investments in plant and equipment and on hospital standards compliance with selected Joint Commission on Accreditation of Healthcare Organization performance areas. The results suggest that increasing financial pressures did lead to cutbacks in these areas. These findings suggest the importance of looking broadly across hospital operations to identify factors that may contribute to poor patient outcomes. Given the findings of earlier studies, these results suggest that poor outcomes may in part result from deterioration in supporting infrastructure and organizational processes.

Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention

BACKGROUND The Cleaning and Disinfecting in Healthcare Working Group of the National Institute for Occupational Safety and Health, National Occupational Research Agenda, is a collaboration of infection prevention and occupational health researchers and practitioners with the objective of providing a more integrated approach to effective environmental surface cleaning and disinfection (C&D) while protecting the respiratory health of health care personnel. METHODS The Working Group, comprised of >40 members from 4 countries, reviewed current knowledge and identified knowledge gaps and future needs for research and practice. RESULTS An integrated framework was developed to guide more comprehensive efforts to minimize harmful C&D exposures without reducing the effectiveness of infection prevention. Gaps in basic knowledge and practice that are barriers to an integrated approach were grouped in 2 broad areas related to the need for improved understanding of the (1) effectiveness of environmental surface C&D to reduce the incidence of infectious diseases and colonization in health care workers and patients and (2) adverse health impacts of C&D on health care workers and patients. Specific needs identified within each area relate to basic knowledge, improved selection and use of products and practices, effective hazard communication and training, and safer alternatives. CONCLUSION A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.

The Effect of a Quality Improvement Collaborative to Improve Antimicrobial Prophylaxis in Surgical Patients: A Randomized Trial

BACKGROUND Quality improvement collaboratives are used to improve health care quality, but their efficacy remains controversial. OBJECTIVE To assess the effects of a quality improvement collaborative on preoperative antimicrobial prophylaxis. DESIGN Longitudinal cluster randomized trial, with the quality improvement collaborative as the intervention. SETTING United States. PARTICIPANTS 44 acute care hospitals, each of which randomly sampled approximately 100 selected surgical cases (cardiac, hip or knee replacement, and hysterectomy) at both the baseline and remeasurement phases. INTERVENTION All hospitals received a comparative feedback report. Hospitals randomly assigned to the intervention group (n = 22) participated in a quality improvement collaborative comprising 2 in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over 9 months. MEASUREMENTS Change in the proportion of patients receiving at least 1 antibiotic dose within 60 minutes of surgery (primary outcome) and change in the proportions of patients given any antibiotics, given antibiotics for 24 hours or less, given an appropriate drug, and given a single preoperative dose and receipt of any of the 5 measures (secondary outcome). RESULTS The groups did not differ in the change in proportion of patients who received a properly timed antimicrobial prophylaxis dose (-3.8 percentage points [95% CI, -13.9 to 6.2 percentage points]) after adjustment for region, hospital size, and surgery type. Similarly, the groups did not differ in individual measures of antibiotic duration; use of appropriate drug; receipt of a single preoperative dose; or an all-or-none measure combining timing, duration, and selection. LIMITATIONS Hospitals volunteered for the effort, thereby resulting in selection for participants who were motivated to change. Implementation of the surgical infection prevention measure reporting requirements by the Centers for Medicare & Medicaid Services and The Joint Commission may have motivated improvement in prophylaxis performance. CONCLUSION At a time of heightened national attention toward measures of antimicrobial prophylaxis performance, the trial did not demonstrate a benefit of participation in a quality improvement collaborative over performance feedback for improvement of these measures.

Preventing central venous catheter-associated primary bloodstream infections: characteristics of practices among hospitals participating in the Evaluation of Processes and Indicators in Infection Control (EPIC) study.

OBJECTIVES To describe the conceptual framework and methodology of the Evaluation of Processes and Indicators in Infection Control (EPIC) study and present results of CVC insertion characteristics and organizational practices for preventing BSIs. The goal of the EPIC study was to evaluate relationships among processes of care, organizational characteristics, and the outcome of BSI. DESIGN This was a multicenter prospective observational study of variation in hospital practices related to preventing CVC-associated BSIs. Process of care information (eg, barrier use during insertions and experience of the inserting practitioner) was collected for a random sample of approximately 5 CVC insertions per month per hospital during November 1998 to December 1999. Organization demographic and practice information (eg, surveillance activities and staff and ICU nurse staffing levels) was also collected. SETTING Medical, surgical, or medical-surgical ICUs from 55 hospitals (41 U.S. and 14 international sites). PARTICIPANTS Process information was obtained for 3,320 CVC insertions with an average of 58.2 (+/- 16.1) insertions per hospital. Fifty-four hospitals provided policy and practice information. RESULTS Staff spent an average of 13 hours per week in study ICU surveillance. Most patients received nontunneled, multiple lumen CVCs, of which fewer than 25% were coated with antimicrobial material. Regarding barriers, most clinicians wore masks (81.5%) and gowns (76.8%); 58.1% used large drapes. Few hospitals (18.1%) used an intravenous team to manage ICU CVCs. CONCLUSIONS Substantial variation exists in CVC insertion practice and BSI prevention activities. Understanding which practices have the greatest impact on BSI rates can help hospitals better target improvement interventions.

Integrating performance measure data into the Joint Commission accreditation process

This article describes the Joint Commission’s implementation plans, experience, and results to date of incorporating performance measurement data into the accreditation process. These plans have evolved in response to changes in the health care environment, feedback from accredited organizations, and both technical and political obstacles encountered. During the late 1980s, the Joint Commission developed a national performance measurement system, the IMSystem, to incorporate information about the process and outcomes of care into the accreditation process. In 1995, the ORYX initiative was introduced to offer health care organizations significant flexibility in selecting a measurement system and measures while promoting organizational self-improvement and accountability. Recently, the plans have evolved to incorporate standardized core measures that are known to be valid and reliable. These initiatives have moved the field much closer to the day when quality assessment will reflect a comprehensive view of organizational performance, based, in part, on performance measurement data.

The impact of hospital practice on central venous catheter associated bloodstream infection rates at the patient and unit level: a multicenter study.

Objective : Little is known about factors driving variation in bloodstream infection (BSI) rates between institutions. The objectives of this study are to (1) identify patient, process of care, and hospital factors that influence intensive care unit (ICU)-level BSI rates and (2) compare those factors to individual risk factors identified in a cohort analysis. Design: In this multicenter prospective observational study, the authors measured the process of care for 2970 randomly sampled central venous catheter insertions over 13 months. Setting: Medical, surgical, and medical/surgical ICUs of 37 domestic and 13 international hospitals. Results: Significant correlates of unit-level BSI rates were percentage of female patients, patients on dialysis, ICU bed size, percentage of practitioners with low numbers of previous insertions, and percentage inserted by nurses. Patient-level analysis identified gender, age, posttransplant, postsurgery, and use of the line for parenteral nutrition. Conclusions: Factors that influence unit-to-unit variation may differ from factors identified in studies of individual patient risk. (Am J Med Qual 2008;23:24-38)

Measuring adherence to hand hygiene guidelines: A field survey for examples of effective practices

BACKGROUND Measuring adherence to hand hygiene guidelines is resource intensive and complicated by lack of standardized methodology. The multiplicity of approaches in use makes it difficult to meaningfully compare performance across health care organizations. The goal of this project was to identify promising and effective practices for measuring adherence with hand hygiene guidelines across a variety of settings. METHODS A cross-sectional survey was conducted electronically in February 2007 to collect information on aspects of hand hygiene measured (eg, frequency, thoroughness of technique, glove use, product consumption), data collection approaches, training and resources, reports, and others. Invitations to respond were widely distributed through Web site announcements and list-serve messages of The Joint Commission and collaborating organizations. A panel of national experts developed and applied criteria for evaluating the methods. RESULTS Two hundred forty-two responses were submitted from a variety of settings and countries. Most (approximately 75%) measured frequency of hand hygiene; approximately 50% measured thoroughness, glove use, product usage, patient and provider satisfaction, or other aspects. Seventy-two percent relied exclusively on manual data collection, and most methods (80%) had been in use for less than 3 years. Most (65%) spent less than 1 hour in training data collectors, and few had evidence of reliability or validity. Forty submissions met most criteria for inclusion in an educational monograph. CONCLUSION Among respondents who considered their approach to be an example of an effective practice, there was substantial variation in methods and little evidence of reliability. Standardization of methods is needed to compare performance across organizations or within an organization over time.