Bryan P. Simmons

Enterobacter sakazakii infections in neonates associated with intrinsic contamination of a powdered infant formula.

We report an outbreak of Enterobacter sakazakii infection and colonization in neonates related to an infant formula contaminated during the manufacturing process. The outbreak occurred in a 20-bed neonatal intensive care unit during a six-week period in 1988, and involved a total of four infants. Three infants had sepsis and three had bloody diarrhea; all patients responded to intravenous antibiotics and recovered without complications. The E sakazakii isolated from the formula had the same plasmid and multilocus enzyme profile as those isolated from patients. This outbreak demonstrates the significance of commercially contaminated formulas and emphasizes the need to limit contamination and multiplication of bacteria in enteral formulas.

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.

The role of handwashing in prevention of endemic intensive care unit infections.

Handwashing is believed to be the most important means of preventing nosocomial infections. Previous studies of healthcare workers (HCWs) have shown that handwashing practices are poor. No one has shown that handwashing practices can be easily improved and that this prevents endemic (nonepidemic) nosocomial infection. Handwashing and infection rates were studied in two intensive care units (ICUs) of a community teaching hospital. Handwashing rates were monitored secretly throughout the study. After six months of observation, we started interventions to increase handwashing. Handwashing increased gradually, but overall rates before (22.0%) and after (29.9%) interventions were not significantly different (p = .071). Handwashing never occurred before intravenous care, whereas it occurred 67.5% for all other indications (p less than .0001). When questioned, nurses felt they were washing appropriately nearly 90% of the time. Infection rates seemed unrelated to handwashing throughout the study, and no clusters of infection were detected. We conclude that handwashing rates, when measured against arbitrary but reasonable standards, are suboptimal, difficult to change and not closely related to evidence of cross-infection. Further, nurses wash hands selectively, depending on the indication for handwashing, and generally believe they are washing much more frequently than an objective observer believes they are.

Guideline for Prevention of Surgical Wound Infections

Patients who undergo a surgical operation are at high risk of having one or more nosocomial infections. These infections develop in more surgical patients (8%) than in any other patient group, and about 70% of all nosocomial infections throughout the hospital develop in patients who have an operation. Most infections in surgical patients, however, are not related to the wound but to instrumentation of the urinary and respiratory tracts. Thus, personnel who take care of these patients should be aware of measures to prevent nosocomial infections at all sites. Moreover, to prevent surgical wound infections, personnel who perform the operation must take the lead in instituting prevention measures, because the most important measures involve use of good surgical technique and are not easily instituted simply by making changes in hospital policy.

Neurologic complications including paralysis after a medication error involving implanted intrathecal catheters

PURPOSE Long-term continuous intrathecal infusion of medications for chronic medical problems is common. We investigated the cause of a cluster of severe neurologic complications in patients with intrathecal catheters. METHODS We performed an epidemiologic cohort study of patients who had intrathecal catheters in place in one neurosurgical practice, to assess the presence of new neurologic complications and associated risk factors. RESULTS The practice included 61 patients who received pain medication through implanted intrathecal catheter pumps, 19 of whom were treated with morphine, either alone or in combination with other medications. None of the 42 patients whose drug regimen did not include morphine developed a complication, whereas 8 of 13 patients who received morphine in refills of their pumps during one 4-week period experienced neurologic complications. Three persons underwent laminectomy for sterile abscesses and were left with new paralysis or leg weakness. Testing of two stock bottles from the involved pharmacy, both labeled as containing pure morphine, revealed the presence of methadone in addition to morphine. One of these bottles also contained trace ethanol. A sample of medication aspirated from the pump of a patient prescribed morphine from the same pharmacy was also found to have contained methadone and methanol. CONCLUSIONS A variety of severe neurologic complications was associated with inadvertent administration of methadone, and perhaps other unintended substances, by means of implanted intrathecal catheters to a group of patients. Medical errors in an outpatient pharmacy led to this outbreak.

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.

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)

Comparison of clinical indicators for performance measurement of health care quality: a cautionary note

The use of clinical performance data is increasing rapidly. Yet, substantial variation exists across indicators designed to measure the same clinical event. We compared indicators from several indicator measurement systems to determine the consistency of results. Five measurement systems with well-defined indicators were selected. They were applied to 24 hospitals. Indicators for mortality from coronary artery bypass graft surgery and mortality in the perioperative period were chosen from these measurement systems. Analyses results and concludes that it is faulty to assume that clinical indicators derived from different measurement systems will give the same rank order. Widespread demand for external release of outcome data from hospitals must be balanced by an educational effort about the factors that influence and potentially confound reported rates.

Comparing Bloodstream Infection Rates: The Effect of Indicator Specifications in the Evaluation of Processes and Indicators in Infection Control (EPIC) Study

OBJECTIVE Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators. DESIGN Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications. SETTING A total of 28 hospitals participating in the EPIC study. PARTICIPANTS Hospitals submitted deidentified information about all patients with BSIs from January through September 1999. RESULTS Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs=0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83). CONCLUSIONS Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.