Charles Salemi

Hand washing and physicians: How to get them together

OBJECTIVE To determine the motivating and behavioral factors responsible for improving compliance with hand washing among physicians. DESIGN Five unobtrusive, observational studies recording hand washing after direct patient contact, with study results reported to physicians. SETTING A 450-bed hospital in a health maintenance organization with an 18-bed medical-surgical intensive care unit (ICU) and a 12-bed cardiac care unit. METHODS An infectious disease physician met individually with participants to report study results and obtain a commitment to hand washing guidelines. Follow-up interviews were conducted to evaluate behavioral factors and educational programs. Hand washing study results were presented to all staff physicians by live and videotaped inservice presentations and electronic mail (e-mail) newsletters. The importance of influencing factors and the educational effectiveness of the hand washing program were evaluated. RESULTS Five observational hand washing studies were conducted in the ICU between April 1999 and September 2000. Rates of physician compliance with hand washing were 19%, 85%, 76%, 74%, and 68%, respectively. There were 71 initial encounters and 55 follow-up interviews with the same physicians. Physician interviews revealed that 73% remembered the initial encounter, 70% remembered the hand washing inservice presentations, and 18% remembered the e-mail newsletters. Personal commitment and meeting with an infectious disease physician had the most influence on hand washing behavior. Direct inservice presentations (either live or videotaped) had more influence than did e-mail information. Rates of ventilator-associated pneumonia did not significantly change before and during the study periods. A decrease in the rate of central-line-related bloodstream infections from 3.2 to 1.4 per 1,000 central-line days was found, but could not be solely attributed to improved physician compliance with hand washing. CONCLUSIONS Physician compliance with hand washing can improve. Personal encounters, direct meetings with an infectious disease physician, and videotaped presentations had the greatest impact on physician compliance with hand washing at our medical center, compared with newsletters sent via e-mail. Local data on compliance with hand washing and physician involvement are factors to be considered for physician hand washing compliance programs in other medical centers.

Association between severity of illness and mortality from nosocomial infection

BACKGROUND For the years 1987 through 1992, a study was undertaken to analyze nosocomial infection mortality data and to stratify risk according to severity of underlying illness to compare with published data from the Centers for Disease Control and Prevention. METHODS Nosocomial infections that contributed to or caused death were identified. In addition, during 1990 through 1992, severity of illness was determined as the subjective estimate of the risk of death or lack of risk of death during the current hospital admission before the onset of the nosocomial infection. These groups were named +SIC and -SIC, respectively. RESULTS It was determined that the data from death certificates in cases of known nosocomial infection were not sufficient to determine whether nosocomial infection contributed to or caused death. There was a 24% increase in cases of nosocomial infection contributing to or causing death when a physician reviewed deaths in patients with nosocomial infections who did not have a diagnosis of nosocomial infection listed on the death certificate. The rates for nosocomial infections contributing to or causing death are as follows: nosocomial pneumonia, 20%; and bloodstream infections, 19%. In patients who died and had severity of illness determination, there was a statistically significant difference in the rates of nosocomial infections contributing to or causing death between -SIC and +SIC groups for both nosocomial pneumonia and bloodstream infections. The rates for bloodstream infections were as follows: -SIC, 5%; and +SIC, 21%. For nosocomial pneumonia, the rates were as follows: -SIC, 13%; and +SIC, 23%. CONCLUSION In published reports from the Centers for Disease Control and Prevention, a rate of 13% is given for nosocomial pneumonia and bloodstream infections contributing to or causing death; however, there is no stratification for severity of illness in these reports. The presence of life-threatening illness before the onset of nosocomial pneumonia or bloodstream infection accounts for most deaths among our patients. For valid comparisons, mortality outcome data for nosocomial infections should be stratified for risk according to severity of underlying illness.

American society of anesthesiology scoring discrepancies affecting the National Nosocomial Infection Surveillance System : Surgical-site-infection risk index rates

The American Society of Anesthesiology (ASA) scoring was performed for the National Nosocomial Infection Surveillance (NNIS) System surgical-site-infection (SSI) risk indexing in 250 prosthetic-joint surgeries. There were ASA scoring discrepancies in 59% of 116 ASA-3 surgeries and 2 out of 10 ASA-3 SSI. The original ASA scoring led to an uncorrected SSI rate of 5.8 per 100 surgeries in the NNIS risk group 0; with corrected ASA scores, the rate was 4.5 per 100 surgeries.

Severity of illness classification for infection control departments: A study in nosocomial pneumonia

BACKGROUND A subjective severity of illness classification was evaluated in a study of nosocomial pneumonia. This is a 5-category system based on the determination of the control of underlying illness and the risk of death during current hospital admission. METHODS A case-control study was performed with 128 cases of nosocomial pneumonia and 252 control patients. An additional 60 case and 90 control patients were used to compare this classification with APACHE II scoring in intensive care unit patients. RESULTS In univariate analysis, the severity illness classification was significantly associated with nosocomial pneumonia risk (p < 0.01). APACHE II adequately predicted mortality rate but was not statistically significantly associated with nosocomial pneumonia risk among intensive care unit patients. In logistic regression analysis, the severity of illness classification, surgery, age, nasogastric tube placement, and histamine blockers each showed significant independent association with nosocomial pneumonia. CONCLUSIONS The role of the severity of illness classification for risk stratification in nosocomial pneumonia is valid. Its roles in the evaluation of surgical wound infection, nosocomial bacteremia, and quality of care remain to be determined in subsequent studies.

Heat-and-Moisture Exchangers Used With Biweekly Circuit Tubing Changes: Effect on Costs and Pneumonia Rates

In 1991, heat-and-moisture exchangers were introduced with biweekly ventilator circuit tubing changes, resulting in elimination of multiple pieces of respiratory equipment and reduced labor costs. The annual savings were

Clostridium difficile Colitis: Reduced Time to Diagnosis in a Community-Based Outpatient Setting Between 1997 and 2004

157,000, totalling

An enhanced benchmark for prosthetic joint replacement infection rates

1.5 million since the onset of the program. There have been no increases in rates of ventilator-associated pneumonia.

Decreasing medication discrepancies between outpatient and inpatient care through the use of computerized pharmacy data.

OBJECTIVE We studied antibiotic use prior to the onset of Clostridium difficile colitis (CDC) and time interval between onset of gastrointestinal symptoms and diagnosis for two historical time periods with separate comparisons for inpatients and outpatients to determine whether time to diagnosis had decreased and whether previous metronidazole use is associated with CDC. METHOD We performed a retrospective chart review of adult patients (those 18 years or older) with positive findings on Clostridium difficile (CD) stool toxin tests performed at a Kaiser Permanente Southern California medical center. Independent assessments were compared for 1997-1998 and for 2004 time periods. These assessments used similar enrollment and exclusion criterion. Study populations were evaluated for previous antibiotic use and to determine time from clinical presentation of symptoms to diagnosis of CDC during each of the time periods, with assessments made separately for inpatients and outpatients. RESULTS Findings showed a reduction in the average time from symptom presentation to diagnosis among outpatients with CDC from 17 days in the first time period (1997-1998) to ten days during the second time period (2004). No significant difference in the average time from symptom presentation to diagnosis of CDC was evident among inpatients (5.33 days for 1997-1998 and 6.00 days for 2004). Multiple antibiotic use prior to diagnosis of CDC was evident among both outpatients and inpatients in this study. Metronidazole had been used prior to the onset of CDC in approximately 15% of cases. CONCLUSION The time from symptom onset to a CDC diagnosis decreased by seven days between the 1997-1998 and 2004 time periods among outpatients in this health care setting. Previous metronidazole use appeared to be associated with some cases of CDC.