David Birnbaum

Epidemiologic typing systems for coagulase-negative staphylococci.

An adverse consequence of advances in invasive therapeutic procedures and prosthetic surgical implants has been an increasing incidence of serious nosocomial infections with coagulase-negative staphylococci (CNS). Many of these infections are preventable; however, prevention requires an understanding of the important reservoirs and means of transmission. This has been hampered by lack of an adequate typing system for both prospective epidemiologic studies and outbreak investigations. Powerful techniques, some not previously used for typing CNS, might be useful in future efforts to better understand the hospital epidemiology of these important pathogens. However, further research is required to validate new typing systems.

SIR, you've led me astray!

BACKGROUND The standardized infection ratio (SIR) is an indirectly standardized morbidity ratio that has been used to compare the infection rate in a hospital with an expected number of infections from a national standard and is being increasingly promoted as a metric for the public reporting of healthcare-associated infections (HAIs). OBJECTIVE To identify potential discrepancies between SIR and other measures of risk. METHODS Hypothetical and real data were compared using relative risk, a directly standardized morbidity ratio, and SIR values across a range of varying hospital population compositions. RESULTS In real and hypothetical data, other summary statistics were consistent with each other and with underlying HAI incidence density rates. However, use of the SIR frequently led to conclusions inconsistent with these other inherently unbiased estimators. CONCLUSION Because of a recognized type of distortion inherent in the calculation of indirectly standardized ratios, use of the SIR can lead to conclusions that differ from those reached when using other traditional measures of risk and to incorrect assessments of conclusions about the performance of hospitals or states. In addition, the tendency to inappropriately arrange SIR values in rank order for comparison makes SIR unsuitable as a statewide metric for monitoring HAIs.

Adoption of guidelines for Universal Precautions and Body Substance Isolation in Canadian acute-care hospitals.

The impact of recently recommended hospital infection control guidelines on Canadian acute-care hospitals is unknown. A confidential cross-sectional mailed survey of all acute-care Canadian hospitals was conducted to determine rates of receipt and adoption of published guidelines for Universal Precautions (UP) or Body Substance Isolation (BSI), rationale for adoption and knowledge of costs and benefits. Five hundred and seventy-nine of 943 sites (61%) responded (exceeding 80% in urban centers); 94% among hospitals with at least 300 beds and 57% among those under 300 beds. Seventy-four percent of responders claimed adoption of UP (65%) or BSI (9%), staff protection being their primary motivation. Adoption of either UP or BSI was associated with size (p less than .001), increasing progressively from 45% in the smallest group (less than 25 beds) to 84% in the largest (greater than or equal to 500 beds). Many hospitals introduced modifications and some substituted names other than UP or BSI in adopting a new strategy. In practice, UP and BSI now mean different things in different hospitals, and the distinction between them has become blurred. Furthermore, only 5% claiming adoption of a new strategy adopted all of the fundamental policies expected under UP or BSI. Receipt of guidelines was also correlated with size: one-third of hospitals under 200 beds had not received key publications defining UP and BSI. Only 19% claiming adoption of a new strategy indicated knowledge of cost implications. These results suggest a need for closer collaboration among hospitals and government agencies in developing uniform infection control policies, and for systematic evaluation of the cost and effectiveness of new strategies.

Hidden in plain view: the importance of professional nursing care

Examines health‐care restructuring activities undertaken across North American hospitals over the past decade related to hospital care by nursing professionals (i.e. hospital nurses versus practical nurses or aides). Identifies fundamental lessons learned and highlights important priority research areas that must be undertaken to ensure that future initiatives achieve the intended effect of improving patient outcomes.

Postdischarge surgical site infection surveillance practices in Washington acute care hospitals.

Little is known about postdischarge surveillance practices currently in place among American hospitals. This survey describes practices used by acute care hospitals covered by Washington States legislated mandate for public reporting of surgical site infections. While the vast majority of facilities use multiple techniques, wide variation in practices was discovered.

who is at risk of what

If you have calculated the sample size required for an employee survey or an observational study of departmental practices but found that the number of observations required is larger than the number of employees, chances are the error is due to use of approximation formulae. Many of us unknowingly were taught to use approximations that fail to include the finite population correction factor. Depending on the objective of a study and the proportion of a population sampled, it may be necessary to consider this correction factor in order to estimate standard error and sample size accurately.

Mandatory public reporting

Purpose – The purpose of this paper is to discuss early experience with American state laws that are starting to mandate public disclosure of adverse outcome event rates from surveillance programs which previously were regarded as a solely confidential activity of internal quality review committees.Design/methodology/approach – The paper is a literature review of sources identified from the PARADIGM database.Findings – Responding to public concerns prompted by the Institute of Medicines widely read report on medical error, a growing number of states have legislated mandatory public reporting of adverse event rates. This change from an era of data held confidential by each accreditation‐compliant hospital or shared by voluntary participation in regional or national programs heralds dissatisfaction that cannot be ignored and a political response that cannot be impeded. However, to avoid repeating mistakes of early efforts, it is essential to recognize that meaningful mandatory public reporting will require...

Addressing Public Health informatics patient privacy concerns

Purpose – The purpose of this paper is to review stakeholder perspectives and provide a framework for improving governance in health data stewardship. Patients may wish to view their own lab results or clinical records, but others (notably academics, journalists and lawyers) tend to want scores of patient records in their search for patterns or trends. Public Health informatics capabilities are growing in scope and speed as clinical information systems, health information exchange networks and other potential database linkages enable more access to healthcare data. This change facilitates novel service improvements, but also raises new personal privacy protection issues. Design/methodology/approach – This paper summarizes a panel session discussion from the 2015 Information Technology and Communication in Health biennial international conference. The perspectives of health service research, journalism, Public Health informatics and privacy protection were represented. Findings – In North America, an expec...

The Denver Connection (Porter‐Swedish) experiment revisited

The so‐called Denver connection should be today’s shining example of how to achieve health care quality and safety improvement through lasting evidence‐based collaborations led by health professionals. Instead, this 30 year old experiment is all but forgotten and the story of its demise is a tale of destructive corporate growth. Unfortunately, it bears prescient similarity to problems in health care restructuring today. We should question whether today’s business models, management performance, and accreditation mandates have set the right stage before we venture forth to act again. Unless we ensure a better environment in which to operate, today’s “new” approaches for improving quality and safety may be doomed to the same sad fate.

Beware of the patient safety juggernauts

Patient safety and medical error have become prominent issues following publication of Institute of Medicine reports in the USA. The USA, Australia, and now Canada have followed a national “medical error” studies path that uses language rejected by the interdisciplinary group of experts described previously in this column, and continues using methods considered seriously flawed as well as incomplete by noteworthy hospital epidemiologists. Preliminary review of British hospitals by similar methods also has been published. Proven and more cost‐effective surveillance methods are pertinent methods developed over the past several decades by hospital epidemiology and infection control professionals who have more experience, but this heritage has been ignored in recent patient safety juggernauts. It is time to question why retrospective physician chart review approaches remain in vogue with national bodies to enumerate adverse patient outcomes and attribute them with “medical error” when better alternatives exist.