Jackson Musuuza

Analyzing excess mortality from cancer among individuals with mental illness

The objective was to compare patterns of site‐specific cancer mortality in a population of individuals with and without mental illness.

Status of the Prevention of Multidrug-Resistant Organisms in International Settings: A Survey of the Society for Healthcare Epidemiology of America Research Network.

OBJECTIVE To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States. DESIGN Cross-sectional survey. PARTICIPANTS International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. METHODS Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their countrys economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income. RESULTS A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior. CONCLUSIONS In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed. Infect Control Hosp Epidemiol. 2016:1-8.

Incidence and risk factors for surgical site infection post-hysterectomy in a tertiary care center

Background: Preoperative antibiotic prophylaxis and surgical technological advances have greatly reduced, but not totally eliminated surgical site infection (SSI) posthysterectomy. We aimed to identify risk factors for SSI posthysterectomy among women with a high prevalence of gynecologic malignancies, in a tertiary care setting where compliance with the Joint Commissions Surgical Care Improvement Project core measures is excellent. Methods: The study was a matched case–control, 2 controls per case, matched on date of surgery. Study time was January 2, 2012‐December 31, 2015. Procedures included abdominal and vaginal hysterectomies (open, laparoscopic, and robotic). SSI (superficial incisional or deep/organ/space) was defined as within 30 days postoperatively, per Centers for Disease Control and Prevention criteria. Statistical analysis included bivariate analysis and conditional logistic regression controlling for demographic and clinical variables, both patient‐related and surgery‐related, including detailed prophylactic antibiotic exposure. Results: Of the total 1,531 hysterectomies performed, we identified 52 SSIs (3%), with 60% being deep incisional or organ/space infections. All case patients received appropriate preoperative antibiotics (timing, choice, and weight‐based dosing). Bivariate analysis showed that higher median weight, higher median Charlson comorbidity index, immune suppressed state, American Society of Anesthesiologists score ≥ 3, prior surgery within 60 days, clindamycin/gentamicin prophylaxis, surgery involving the omentum or gastrointestinal tract, longer surgery duration, ≥4 surgeons present in the operating room, higher median blood loss, ≥7 catheters or invasive devices in the operating room, and higher median length of hospital stay increased SSI risk (P < .05 for all). Cefazolin preoperative prophylaxis, robot‐assisted surgery, and laparoscopic surgery were protective (P < .05 for all). Duration of surgery was the only independent risk factor for SSI identified on multivariate analysis (odds ratio, 3.45; 95% confidence interval, 1.21‐9.76; P = .02). Conclusions: In our population of women with multimorbidity and hysterectomies largely due to underlying gynecologic malignancies, duration of surgery, presumed a marker of surgical complexity, is a significant SSI risk factor. The choice of preoperative antibiotic did not alter SSI risk in our study.

Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review

OBJECTIVE Compliance with hand hygiene in healthcare workers is fundamental to infection prevention yet remains a challenge to sustain. We examined fidelity reporting in interventions to improve hand hygiene compliance, and we assessed 5 measures of intervention fidelity: (1) adherence, (2) exposure or dose, (3) quality of intervention delivery, (4) participant responsiveness, and (5) program differentiation. DESIGN Systematic review METHODS A librarian performed searches of the literature in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and Web of Science of material published prior to June 19, 2015. The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews, and assessment of study quality was conducted for each study reviewed. RESULTS A total of 100 studies met the inclusion criteria. Only 8 of these 100 studies reported all 5 measures of intervention fidelity. In addition, 39 of 100 (39%) failed to include at least 3 fidelity measures; 20 of 100 (20%) failed to include 4 measures; 17 of 100 (17%) failed to include 2 measures, while 16 of 100 (16%) of the studies failed to include at least 1 measure of fidelity. Participant responsiveness and adherence to the intervention were the most frequently unreported fidelity measures, while quality of the delivery was the most frequently reported measure. CONCLUSIONS Almost all hand hygiene intervention studies failed to report at least 1 fidelity measurement. To facilitate replication and effective implementation, reporting fidelity should be standard practice when describing results of complex behavioral interventions such as hand hygiene.

Using a Systems Engineering Initiative for Patient Safety to Evaluate a Hospital-wide Daily Chlorhexidine Bathing Intervention.

We undertook a systems engineering approach to evaluate housewide implementation of daily chlorhexidine bathing. We performed direct observations of the bathing process and conducted provider and patient surveys. The main outcome was compliance with bathing using a checklist. Fifty-seven percent of baths had full compliance with the chlorhexidine bathing protocol. Additional time was the main barrier. Institutions undertaking daily chlorhexidine bathing should perform a rigorous assessment of implementation to optimize the benefits of this intervention.

Risk of Clostridium difficile Infection in Hematology-Oncology Patients Colonized With Toxigenic C. difficile

The prevalence of colonization with toxigenic Clostridium difficile among patients with hematological malignancies and/or bone marrow transplant at admission to a 566-bed academic medical care center was 9.3%, and 13.3% of colonized patients developed symptomatic disease during hospitalization. This population may benefit from targeted C. difficile infection control interventions. Infect Control Hosp Epidemiol 2017;38:718-720.

Challenges to Safe Injection Practices in Ambulatory Care.

Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices. Infect Control Hosp Epidemiol 2017;38:614-616.

Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles

BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.

Leadership rounds to reduce health care–associated infections

Background: Evidence‐based guidelines exist to reduce health care–associated infections (HAIs). Leadership rounds are one tool leaders can use to ensure compliance with guidelines, but have not been studied specifically for the reduction of HAIs. This study examines HAI leadership rounds at one facility. Methods: We explored unit‐based HAI leadership rounds led by 2 hospital leaders at a large academic hospital. Leadership rounds were observed on 19 units, recorded, and coded to identify themes. Themes were linked to the Consolidated Framework for Implementation Research and used to guide interviews with frontline staff members. Results: Staff members disclosed unit‐specific problems and readily engaged in problem‐solving with top hospital leaders. These themes appeared over 350 times within 22 rounds. Findings revealed that leaders used words that demonstrated fallibility and modeled curiosity, 2 factors associated with learning climate and psychologic safety. These 2 themes appeared 115 and 142 times, respectively. The flexible nature of the rounds appeared to be conducive for reflection and evaluation, which was coded 161 times. Conclusions: Each interaction between leaders and frontline staff can foster psychologic safety, which can lead to open problem‐solving to reduce barriers to implementation. Discovering specific communication and structural factors that contribute to psychologic safety may be powerful in reducing HAIs.

Key actors’ perspectives on cost-effectiveness analysis in Uganda: a cross-sectional survey

BackgroundCost effectiveness analysis (CEA) is a useful tool for allocation of constrained resources, yet CEA methodologies are rarely taught or implemented in developing nations. We aimed to assess exposure to, and interest in CEA, and identify barriers to implementation in Uganda.MethodsA cross-sectional survey was carried out in Uganda using a newly developed self-administered questionnaire (via online and paper based approaches), targeting the main health care actors as identified by a previous study.ResultsOverall, there was a 68% response rate, with a 92% (69/75) response rate among the paper-based respondents compared to a 40% (26/65) rate with the online respondents. Seventy eight percent (74/95) of the respondents had no exposure to CEA. None of those with a master of medicine degree had any CEA exposure, and 80% of technical officers, who are directly involved in policy formulation, had no CEA exposure. Barriers to CEA identified by more than 50% of the participants were: lack of information technology (IT) infrastructure (hardware and software); lack of local experts in the field of CEA; lack of or limited local data; limited CEA training in schools; equity or ethical issues; and lack of training grants incorporating CEA. 93% reported a lot of interest in learning to conduct CEA, and over 95% felt CEA was important for clinical decision making and policy formulation.ConclusionsAmong health care actors in Uganda, there is very limited exposure to, but substantial interest in conducting CEA and including it in clinical decision making and health care policy formation. Capacity to undertake CEA needs to be built through incorporation into medical training and use of regional approaches.