Jane Banaszak-Holl

Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study

BACKGROUND Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

The role of the “champion” in infection prevention: results from a multisite qualitative study

Background: Although 20% or more of healthcare-associated infections can be prevented, many hospitals have not implemented practices known to reduce infections. We explored the types and numbers of champions who lead efforts to implement best practices to prevent hospital-acquired infection in US hospitals. Methods: Qualitative analyses were conducted within a multisite, sequential mixed methods study of infection prevention practices in Veteran Affairs and non-Veteran Affairs hospitals in the USA. The first phase included telephone interviews conducted in 2005–2006 with 38 individuals at 14 purposively selected hospitals. The second phase used findings from phase 1 to select six hospitals for site visits and interviews with another 48 individuals in 2006–2007. Results: It was possible for a single well-placed champion to implement a new technology, but more than one champion was needed when an improvement required people to change behaviours. Although the behavioural change itself may appear to be an inexpensive and simple solution, implementation was often more complicated than changing technology because behavioural changes required interprofessional coalitions working together. Champions in hospitals with low-quality working relationships across units or professions had a particularly challenging time implementing behavioural change. Merely appointing champions is ineffective; rather, successful champions tended to be intrinsically motivated and enthusiastic about the practices they promoted. Even when broad implementation is stymied, champions can implement change within their own sphere of influence. Conclusions: The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks.

Use of Central Venous Catheter-Related Bloodstream Infection Prevention Practices by US Hospitals

OBJECTIVE To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs). PARTICIPANTS AND METHODS Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs. RESULTS The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P=.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P<.001); and a composite approach (62% vs 44%; P=.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices. CONCLUSION Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.

The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study.

OBJECTIVE Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals. METHODS We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders. RESULTS We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospitals patient safety activities than did senior executives. CONCLUSIONS Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts

BACKGROUND As of October 2008, hospitals in the United States no longer receive Medicare reimbursement for certain types of health care-associated infection (HAI), thereby heightening the need for effective prevention efforts. The mere existence of evidence-based practices, however, does not always result in the use of such practices because of the complexities inherent in translating evidence into practice. A qualitative study was conducted to determine the barriers to implementing evidence-based practices to prevent HAI, with a specific focus on the role played by hospital personnel. METHODS In-depth phone and in-person interviews were conducted between October 2006 and September 2007 with 86 participants (31 physicians) including chief executive officers, chiefs of staff, hospital epidemiologists, infection control professionals, intensive care unit directors, nurse managers, and frontline physicians and nurses, in 14 hospitals. FINDINGS Active resistance to evidence-based practice change was pervasive. Successful efforts to overcome active resisters included benchmarking infection rates, identifying effective champions, and participating in collaborative efforts. Organizational constipators-mid- to high-level executives who act as insidious barriers to change-also increased the difficulty in implementing change. Recognizing the presence of constipators is often the first step in addressing the problem but can be followed with including the organizational constipator early in group discussions to improve communication and obtain buy-in, working around the individual, and terminating the constipators employment. DISCUSSION Two types of personnel-active resistors and organizational constipators-impeded HAI prevention activities, and several approaches were used to overcome those barriers. Hospital administrators and patient safety leaders can use the findings to more successfully structure activities that prevent HAI in their hospitals.

Nursing home-to-nursing home transfers: prevalence, time pattern, and resident correlates.

OBJECTIVES To characterize the time pattern of nursing home-to-nursing home transfers and assess which resident characteristics are associated with transfers. METHODS Minimum Data Set assessments of all Maine and New York nursing home residents were obtained for 1994-1996. The hazard rate for nursing home transfers was estimated by nonparametric statistical techniques, censored at loss to follow-up. Comparisons of resident characteristics were made between those who transferred and those who stayed at their initial facility. RESULTS Residents of Maine nursing homes were considerably more likely to transfer than were New York residents. Transfer rates declined during the first 2 years after admission and remained stable thereafter. Correlates of transfers were similar across states. Residents who transferred were more likely to be male, to be married, to be younger, to have better cognitive and physical health, to have Medicare or private payment sources (vs. Medicaid), and to have pressure ulcers. Rural location did not affect the likelihood of transfer. CONCLUSIONS This study provides the most detailed information to date on the prevalence, timing, and correlates of nursing home transfers. These transitions occur most frequently early in the stay but continue at a lower rate even among long stayers. This information is useful for understanding lifetime dynamics of long-term-care utilization. Several barriers to mobility appear to be present (eg, less generous payment source, health limitations, and absence of a spouse). The higher transfer rates observed in Maine might imply that institutional or other factors limit the mobility of New York residents.

Do Market-Level Hospital and Physician Resources Affect Small Area Variation in Hospital Use?

This study evaluates the effect of market-level physician and hospital resources on hospital use. It is anticipated that higher hospital discharges are associated with (1) greater hospital and physician resources, (2) more differentiated hospital and physician resources, and (3) higher levels of teaching intensity in the community. Data on 14 modified diagnostically related groups (DRGs) and 58 hospital market communities in Michigan are analyzed during a 7-year period. Findings indicate that physician resources, hospital resources, differentiation of hospital and physician resources, and teaching intensity contribute only modestly to discharges, holding constant the socioeconomic attributes of the community and adjusting for the variation in hospital use over time. With the inclusion of hospital and physician resource variables, socioeconomic factors remain important determinants of the variation across market communities. Findings are discussed in terms of their implications for health care organizations, managed care programs, and cost control efforts in general.

To Test or Not to Test? The Role of Attitudes, Knowledge, and Religious Involvement Among U.S. Adults on Intent-to-Obtain Adult Genetic Testing

Genetic testing can advance cancer prevention if current screening behaviors improve. Increased prevalence of high-risk genotypes within specific religious groups, use of religious venues for recruiting to genetic screening, and ethical–religious considerations argue for exploring the role of religiosity in forming genetic testing decisions. This study uses the theory of reasoned action and structural equation modeling to test the effects of religious involvement, attitudes, knowledge, and previous experience on intent-to-obtain genetic testing within a representative sample of 1,824 U.S. adults. A majority of respondents indicate willingness to test, especially for curable disorders. Attitudes, knowledge, and previous experience have significant direct effects, and religious involvement has an indirect effect, through its negative effect on attitudes, on intent-to-test. High religious involvement is associated with more negative attitudes toward genetic testing. The findings underscore the need to refine genetic testing outreach efforts to account for multiple influences on consumer intent-to-test.

The Effect of Administrative Resources on Care in Nursing Homes

This article evaluates whether the hours spent on the job by nursing home administration have an effect on the quality of care. Administration with more hours on the job were expected to be actively involved in developing market strategies, implementing continuous, quality improvement, and in developing stricter facility guidelines for care—all of which contribute to improved care processes. The proportion of residents who were restrained, catheterized, had pressure ulcers, or were given psychoactive drugs and the number of health-related deficiencies and nonhealth-related deficiencies were used as measures of quality in 15,834 nursing facilities. We examined effects separately for facilities that belong to a chain and those that are freestanding. Overall, the results indicate that the quality indicators are associated with the number of full-time equivalent hours of administration in both chain and freestanding facilities. This study provides preliminary evidence that the intensity of facility administration can have an important effect on the quality of care residents receive.

Using a standardized donor ratio to assess the performance of organ procurement organizations.

OBJECTIVE To develop a Standardized Donor Ratio (SDR) as an outcome measure for evaluating the effectiveness of organ procurement organizations (OPOs). DATA SOURCES/STUDY SETTING All deaths by cause in the United States during 1993-1994 as reported in the Vital Mortality Statistics, Multiple Cause of Death files. The OPO-specific data were provided by the United Network for Organ Sharing (UNOS). STUDY DESIGN Each OPOs expected number of donors was calculated by applying national donation rates to deaths with potential for donation in 24 age, sex, and race cells. The SDR was calculated by dividing the observed number of donors by the expected number. The chi2 tests of the hypothesis that the OPOs performance differed from the national norm of 1.0 were performed. The SDR was compared to the existing performance standard based on the unadjusted number of donors per million live population in the OPOs service area. An ordinary least squares (OLS) regression assessed predictors of the SDR. PRINCIPAL FINDINGS The SDRs ranged from 0.41 to 1.99. Twenty-nine of 64 OPOs had SDRs significantly different than 1.0. The SDRs were positively associated with the percent of white living population and the number of organ types transplanted per transplant center served by the OPO. CONCLUSIONS The SDRs can be used by Centers for Medicare and Medicaid Services (CMS), UNOS, and OPOs to target quality improvement initiatives, present more accurate comparisons of OPO performance, and develop public policy on the evaluation of the effectiveness of organ procurement efforts.