Jeanne E. Zack

Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit

Objective The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections. Design Pre- and postintervention observational study. Setting Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital. Patients A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000. Interventions A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. Measurements and Main Results Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between

An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center.

185,000 and

Nosocomial Primary Bloodstream Infections in Intensive Care Unit Patients in a Nonteaching Community Medical Center: A 21-Month Prospective Study

2.808 million. Conclusions A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.

Epidemiology of methicillin-resistant Staphylococcus aureus colonization in a surgical intensive care unit.

ObjectiveTo evaluate the effectiveness of an evidence-based intervention to prevent catheter-associated bloodstream infections among intensive care unit patients at a nonteaching, community hospital. DesignNonrandomized pre/post observational trial. SettingTwo intensive care units at Missouri Baptist Medical Center, Saint Louis, MO. ParticipantsNurses and critical care physicians. InterventionA ten-page, self-study module on the prevention of catheter-associated bloodstream infections, lectures, and posters given between July and September 1999. MeasurementsThe incidence of nosocomial catheter-associated bloodstream infection and patient demographics were measured for patients admitted between March 1998 and July 2000. Main ResultsThirty cases of catheter-associated bloodstream infections during 6110 catheter-days were noted in the preintervention period (4.9 cases/1000 catheter-days) vs. 11 cases during the 5210 catheter-days in the postintervention period (2.1 cases/1000 catheter-days). The relative risk for catheter-associated infection in the postintervention period was 0.43 (95% confidence interval, 0.22–0.84). Among catheterized patients, Acute Physiology and Chronic Health Evaluation II score (25.2 preintervention vs. 25.1 postintervention; p = .86), hemodialysis (91 of 647 [14%] patients vs. 69 of 541 [13%]; p = .70), and the mean number of catheter days per patient (9.1 vs. 9.6 days; p = .46) did not differ between the pre- and postintervention periods. ConclusionsA focused, educational intervention among nurses and physicians in a nonteaching community hospital resulted in a significant, sustained reduction in the incidence of catheter-associated bloodstream infection.

Effectiveness of an Educational Program to Reduce Ventilator-Associated Pneumonia in a Tertiary Care Center in Thailand: A 4-Year Study

All patients admitted to the medical and surgical intensive care units of a 500-bed nonteaching suburban hospital were followed prospectively for the occurrence of nosocomial primary bloodstream infections for 21 months. The incidence of primary bloodstream infection was 38 (1%) of 3163 patients; among patients with central venous catheters, it was 34 (4%) of 920 patients, or 4.0 infections per 1000 catheter-days. Ventilator-associated pneumonia, congestive heart failure, and each intravascular catheter inserted were independently associated with the development of a nosocomial primary bloodstream infection. Among infected patients, the crude mortality rate was 53%, and these patients had longer stays in intensive care units and the hospital than did uninfected patients. Bloodstream infection, however, was not an independent risk factor for death. The incidence, risk factors, and serious outcomes of bloodstream infections in a nonteaching community hospital were similar to those seen in tertiary-care teaching hospitals.

Use of Hypochlorite Solution to Decrease Rates of Clostridium difficile–Associated Diarrhea

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a cause of healthcare-associated infections among surgical intensive care unit (ICU) patients, though transmission dynamics are unclear. OBJECTIVE To determine the prevalence of MRSA nasal colonization at ICU admission, to identify associated independent risk factors, to determine the value of these factors in active surveillance, and to determine the incidence of and risk factors associated with MRSA acquisition. DESIGN Prospective cohort study. SETTING Surgical ICU at a teaching hospital. PATIENTS All patients admitted to the surgical ICU. RESULTS Active surveillance for MRSA by nasal culture was performed at ICU admission during a 15-month period. Patients who stayed in the ICU for more than 48 hours had nasal cultures performed weekly and at discharge from the ICU, and clinical data were collected prospectively. Of 1,469 patients, 122 (8%) were colonized with MRSA at admission; 75 (61%) were identified by surveillance alone. Among 775 patients who stayed in the ICU for more than 48 hours, risk factors for MRSA colonization at admission included the following: hospital admission in the past year (1-2 admissions: adjusted odds ratio [aOR], 2.60 [95% confidence interval {CI}, 1.47-4.60]; more than 2 admissions: aOR, 3.56 [95% CI, 1.72-7.40]), a hospital stay of 5 days or more prior to ICU admission (aOR, 2.54 [95% CI, 1.49-4.32]), chronic obstructive pulmonary disease (aOR, 2.16 [95% CI, 1.17-3.96]), diabetes mellitus (aOR, 1.87 [95% CI, 1.10-3.19]), and isolation of MRSA in the past 6 months (aOR, 8.18 [95% CI, 3.38-19.79]). Sixty-nine (10%) of 670 initially MRSA-negative patients acquired MRSA in the ICU (corresponding to 10.7 cases per 1,000 ICU-days at risk). Risk factors for MRSA acquisition included tracheostomy in the ICU (aOR, 2.18 [95% CI, 1.13-4.20]); decubitus ulcer (aOR, 1.72 [95% CI, 0.97-3.06]), and receipt of enteral nutrition via nasoenteric tube (aOR, 3.73 [95% CI, 1.86-7.51]), percutaneous tube (aOR, 2.35 [95% CI, 0.74-7.49]), or both (aOR, 3.33 [95% CI, 1.13-9.77]). CONCLUSIONS Active surveillance detected a sizable proportion of MRSA-colonized patients not identified by clinical culture. MRSA colonization on admission was associated with recent healthcare contact and underlying disease. Acquisition was associated with potentially modifiable processes of care.

Ventilator-associated pneumonia in a multi-hospital system: differences in microbiology by location.

BACKGROUND Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection-related death and morbidity in intensive care units (ICUs). We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU (MICU). METHODS A 4-year controlled, prospective, quasi-experimental study was conducted in an MICU, surgical ICU (SICU), and coronary care unit (CCU) for 1 year before the intervention (period 1), 1 year after the intervention (period 2), and 2 follow-up years (period 3). The SICU and CCU served as control ICUs. The educational program involved respiratory therapists and nurses and included a self-study module with preintervention and postintervention assessments, lectures, fact sheets, and posters. RESULTS Before the intervention, there were 45 episodes of VAP (20.6 cases per 1000 ventilator-days) in the MICU, 11 (5.4 cases per 1000 ventilator-days) in the SICU, and 9 (4.4 cases per 1000 ventilator-days) in the CCU. After the intervention, the rate of VAP in the MICU decreased by 59% (to 8.5 cases per 1000 ventilator-days; P=.001) and remained stable in the SICU (5.6 cases per 1000 ventilator-days; P=.22) and CCU (4.8 cases per 1000 ventilator-days; P=.48). The rate of VAP in the MICU continued to decrease in period 3 (to 4.2 cases per 1000 ventilator-days; P=.07), and rates in the SICU and CCU remained unchanged. Compared with period 1, the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 (P<.001) and by 8.9 days in period 3 (P<.001). The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50% (P<.001) and 37%-45% (P<.001), respectively. CONCLUSIONS A focused education intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and cost of hospitalization.

Impact of a methicillin-resistant Staphylococcus aureus active surveillance program on contact precaution utilization in a surgical intensive care unit.

An increased rate of Clostridium difficile-associated diarrhea (CDAD) was noted in 2 intensive care units of a university-affiliated tertiary care facility. One unit instituted enhanced environmental cleaning with a hypochlorite solution in all rooms, whereas the other unit used hypochlorite solution only in rooms of patients with CDAD. The CDAD rates decreased in both units.

Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia

OBJECTIVE To determine whether there were differences in the microbiologic etiologies of ventilator-associated pneumonia in different clinical settings. DESIGN Observational retrospective cohort study of microbiologic etiologies of ventilator-associated pneumonia from 1998 to 2001 in a multi-hospital system. Microbiologic results were compared between hospitals and between different intensive care units (ICUs) within hospitals. SETTING Three hospitals--one pediatric teaching hospital, one adult teaching hospital, and one community hospital--in one healthcare system in the midwestern United States. PATIENTS Patients at the target hospitals who developed ventilator-associated pneumonia and for whom microbiologic data were available. RESULTS Seven hundred fifty-three episodes of ventilator-associated pneumonia had culture data available for review. The most common organisms at all hospitals were Staphylococcus aureus (28.4%) and Pseudomonas aeruginosa (25.2%). The pediatric hospital had higher proportions of Escherichia coli (9.5% vs 2.3%; P < .001) and Klebsiella pneumoniae (13% vs 3.1%; P < .001) than did the adult hospitals. In the pediatric hospital, the pediatric ICU had higher P aeruginosa rates than did the neonatal ICU (33.3% vs 17%; P = .01). In the adult hospitals, the surgical ICU had higher Acinetobacter baumannii rates (10.2% vs. 1.7%; P < .001) than did the other ICUs. CONCLUSIONS Microbiologic etiologies of ventilator-associated pneumonia vary between and within hospitals. Knowledge of these differences can improve selection of initial antimicrobial regimens, which may decrease mortality.

An Educational Intervention to Reduce Ventilator-Associated Pneumonia in an Integrated Health System: A Comparison of Effects

Objective:To determine the impact of an active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) on contact precaution utilization, as measured by additional number of contact precaution days attributable to the active surveillance program. Design:Prospective cohort study. Setting:Twenty-four-bed surgical intensive care unit (ICU). Patients:All patients admitted to the surgical ICU. Interventions:Nasal cultures for MRSA were performed at admission to a surgical ICU for 19 months. Patients admitted >48 hrs also received weekly and discharge nasal cultures. Measurements and Main Results:Clinical data, including start date and initial indication for contact precautions, were prospectively collected. Of 1,893 admissions, 253 (13%) were found to be MRSA-positive during their ICU stay. One hundred forty-six (58%) were identified by nasal culture alone. Compared with the first 10 months of study, the prevalence of MRSA on admission to the ICU during the last 9 months of the study period significantly increased (7.2% vs. 11.4%, p < .001). Acquisition of MRSA by noncolonized patients remained constant between the first 10 months and last 9 months of study (7.0 vs. 5.5 cases per 1000 patient days, p = .29). Two hundred fourteen (6%) of 3461 total contact precaution days in the ICU were attributable to MRSA active surveillance. In sensitivity analyses, the implementation of rapid, same-day results for MRSA active surveillance would increase contact precaution days by 15% compared with no surveillance. If the total number of vancomycin-resistant enterococci patients in the ICU were reduced by 50%, the contact precaution days attributable to active surveillance would increase to 9%. Conclusions:MRSA active surveillance increased total contact precaution days in this ICU by 6% yet detected 58% of MRSA cases that would have been otherwise missed. Despite an increasing prevalence of MRSA on admission to the ICU, the acquisition rate has remained constant.