Kathleen Gase

Statewide NICU Central-Line-Associated Bloodstream Infection Rates Decline After Bundles and Checklists

OBJECTIVE: In 2008, all 18 regional referral NICUs in New York state adopted central-line insertion and maintenance bundles and agreed to use checklists to monitor maintenance-bundle adherence and report checklist use. We sought to confirm whether adopting standardized bundles and using central-line maintenance checklists reduced central-line–associated bloodstream infections (CLABSI). METHODS: This was a prospective cohort study that enrolled all neonates with a central line who were hospitalized in any of 18 NICUs. Each NICU reported CLABSI and central-line utilization data and checklist use. We used χ2 to compare CLABSI rates in the preintervention (January to December 2007) versus the postintervention (March to December 2009) periods and Poisson regression to model adjusted CLABSI rates. RESULTS: Each study period included more than 55 000 central-line days and more than 200 000 patient-days. CLABSI rates decreased 67% statewide (risk ratio: 0.33 [95% confidence interval: 0.27–0.41]; P < .0005); after adjusting for the altered central-line–associated bloodstream infection definition in 2008, by 40% (risk ratio: 0.60 [95% confidence interval: 0.48–0.75]; P < .0005). A total of 13 of 18 NICUs reported using maintenance checklists for 10% to 100% of central-line days. The checklist-use rate was associated with the CLABSI rate (coefficient: −0.57, P = .04). A total of 10 of 18 NICUs were independent CLABSI rate predictors, ranging from 1 site with greatly reduced risk (incidence rate ratio: 0.04, P < .0005) to 1 site with greatly increased risk (incidence rate ratio: 2.87, P < .0005). CONCLUSIONS: Although standardizing central-line care elements led to a significant statewide decline in NICU CLABSIs, site of care remains an independent risk factor. Using maintenance checklists reduced CLABSIs.

Risk factors for coronary artery bypass graft chest surgical site infections in New York State, 2008

BACKGROUND All hospitals in New York State (NYS) are required to report surgical site infections (SSIs) occurring after coronary artery bypass graft surgery. This report describes the risk adjustment method used by NYS for reporting hospital SSI rates, and additional methods used to explore remaining differences in infection rates. METHODS All patients undergoing coronary artery bypass graft surgery in NYS in 2008 were monitored for chest SSI following the National Healthcare Safety Network protocol. The NYS Cardiac Surgery Reporting System and a survey of hospital infection prevention practices provided additional risk information. Models were developed to standardize hospital-specific infection rates and to assess additional risk factors and practices. RESULTS The National Healthcare Safety Network risk score based on duration of surgery, American Society of Anesthesiologists score, and wound class were not highly predictive of chest SSIs. The addition of diabetes, obesity, end-stage renal disease, sex, chronic obstructive pulmonary disease, and Medicaid payer to the model improved the discrimination between procedures that resulted in SSI and those that did not by 25%. Hospital-reported infection prevention practices were not significantly related to SSI rates. CONCLUSIONS Additional risk factors collected using a secondary database improved the prediction of SSIs, however, there remained unexplained variation in rates between hospitals.

Prevention of Hospital‐Onset Clostridium difficile Infection in the New York Metropolitan Region Using a Collaborative Intervention Model

Abstract: The incidence, severity, and associated costs of Clostridium difficile (C. difficile) infection (CDI) have dramatically increased in hospitals over the past decade, indicating an urgent need for strategies to prevent transmission of C. difficile. This article describes a multifaceted collaborative approach to reduce hospital‐onset CDI rates in 35 acute care hospitals in the New York metropolitan region. Hospitals participated in a comprehensive CDI reduction intervention and formed interdisciplinary teams to coordinate their efforts. Standardized clinical infection prevention and environmental cleaning protocols were implemented and monitored using checklists. Monthly data reports were provided to hospitals for facility‐specific performance evaluation and comparison to aggregate data from all participants. Hospitals also participated in monthly teleconferences to review data and highlight successes, challenges, and strategies to reduce CDI. Incidence of hospital‐onset CDI per 10,000 patient days was the primary outcome measure. Additionally, the incidence of nonhospital‐associated, community‐onset, hospital‐associated, and recurrent CDIs were measured. The use of a collaborative model to implement a multifaceted infection prevention strategy was temporally associated with a significant reduction in hospital‐onset CDI rates in participating New York metropolitan regional hospitals.

Comparison of 2 Clostridium difficile surveillance methods: National Healthcare Safety Network's laboratory-identified event reporting module versus clinical infection surveillance.

OBJECTIVE To determine whether the Centers for Disease Control and Preventions National Healthcare Safety Network (NHSN) laboratory-identified (LabID) event reporting module for Clostridium difficile infection (CDI) is an adequate proxy measure of clinical CDI for public reporting purposes by comparing the 2 surveillance methods. DESIGN Validation study. SETTING Thirty New York State acute care hospitals. METHODS Six months of data were collected by 30 facilities using a clinical infection surveillance definition while also submitting the NHSN LabID event for CDI. The data sets were matched and compared to determine whether the assigned clinical case status matched the LabID case status. A subset of mismatches was evaluated further, and reasons for the mismatches were quantified. Infection rates determined using the 2 definitions were compared. RESULTS A total of 3,301 CDI cases were reported. Analysis of the original data yielded a 67.3% (2,223/3,301) overall case status match. After review and validation, there was 81.3% (2,683/3,301) agreement. The most common reason for disagreement (54.9%) occurred because the symptom onset was less than 48 hours after admission but the positive specimen was collected on hospital day 4 or later. The NHSN LabID hospital onset rate was 29% higher than the corresponding clinical rate and was generally consistent across all hospitals. CONCLUSIONS Use of the NHSN LabID event minimizes the burden of surveillance and standardizes the process. With a greater than 80% match between the NHSN LabID event data and the clinical infection surveillance data, the New York State Department of Health made the decision to use the NHSN LabID event CDI data for public reporting purposes.

Surgical site infection risk factors identified for patients undergoing colon procedures, New York State 2009-2010.

BACKGROUND Since 2007, New York State (NYS) hospitals have been required to report surgical site infections (SSIs) following colon procedures to the NYS Department of Health, using the National Healthcare Safety Network (NHSN). The purpose of this study was to identify risk factors for the development of SSIs in patients undergoing colon procedures. METHODS NYS has been conducting validation studies at hospitals to assess the accuracy of the surveillance data reported by the participating hospitals. A sample of patients undergoing colon procedures in NYS hospitals were included in hospital-acquired infection program validation studies in 2009 and 2010. Medical chart reviews and on-site visits were performed to verify patient information reported and to evaluate additional risk factors for SSI. Bivariable and multivariable logistic regressions were performed. RESULTS A total of 2,656 colon procedures were included in this analysis, including 698 SSI cases. Multivariable analysis indicated that SSI following colon procedure was associated with body mass index greater than 30 (odds ratio [OR], 1.48 [95% confidence interval (CI), 1.21-1.80]), male sex (OR, 1.34 [95% CI, 1.10-1.64]), American Society of Anesthesiologists physical classification score greater than 3 (OR, 1.33 [95% CI, 1.08-1.64]), procedure duration, transfusion (OR, 1.32 [95% CI, 1.05-1.66]), left-side colon surgical procedures, other gastroenterologic procedures, irrigation, hospital bed size greater than 500, and medical school affiliation. CONCLUSIONS Male sex, obesity, transfusion, type of procedure, and prolonged duration were significant factors associated with overall infection risk after adjusting other factors. Additional factors not collected in the NHSN slightly improved prediction of SSIs.

Trends in validity of central line–associated bloodstream infection surveillance data, New York State, 2007-2010

BACKGROUND In 2007, New York State (NYS) hospitals began mandatory public reporting of central line-associated bloodstream infection (CLABSI) data associated with intensive care units (ICUs) into the National Healthcare Safety Network (NHSN). Facilities were required to use the NHSN device-associated CLABSI criteria to identify laboratory-confirmed bloodstream infections. METHODS Onsite audits were conducted in ICUs by NYS hospital-acquired infection program staff using a standardized database. Hospitals provided ICU patient medical records with a positive blood culture during a selected time frame. RESULTS Between 2007 and 2010, an average of 79% of all reporting hospitals were audited annually. Of the 5,697 patients audited, 3,104 (54%) had a central line in place, and 650 of the patients with a central line (21%) were identified as having a CLABSI by the hospital-acquired infection program reviewer. Between 2007 and 2010, the specificity increased from 90% to 99%, whereas the sensitivity remained stable at approximately 71%. As a result of the audit process, the NYS 2010 CLABSI rate increased by 5.6%. CONCLUSIONS A standardized audit process has helped improve the accuracy of CLABSI reporting. Data validation provides consistent data for measuring the progress of infection prevention strategies and allows for relevant comparison of ICU data.

Response to Dr Horwitz, infection control IV: Moving forward—infection practitioners' scope of practice

When I read the title of Horowitz’s commentary,1 I was excited and hopeful he would identify some shortcomings of our profession and offer solutions to these issues. On reading the submission, however, I was disappointed. I agree with Horowitz’s assertion that states should modify their requirements to better align with the Centers for Disease Control and Prevention’s isolation guideline. But, focusing his call to action on a small aspect—the act of placing a patient on transmissionbased precautions—of an infection preventionist’s responsibilities is not the most effective use of his argument and influence. There are many opportunities to advance the infection prevention profession and further the work we do to keep patients safe. In no particular priority order, I would like to offer 4 changes in an infection preventionist’s scope of practice that would allow for more influence and better patient outcomes.

Inter-rater Reliability of Infection Preventionists’ Colon Surgical Site Infection Determination Utilizing a User Assisted Electronic Surveillance System

ISSUE: Our 28 bed Hematology Oncology (Heme-Onc) unit has had an unacceptably high central line assosciated bloodstream infection (CLABSI) rate. This patient population with various hematologic malignancies, including stem cell transplants, is at high risk for neutropenia, mucositis and graft-versus-host disease. Despite aggressive prevention efforts with implementation of multiple evidence-based CLABSI interventions over a 3 year period, no significant reduction in the CLABSI rate was achieved. PROJECT: Applying the new January 2013 National Healthcare Safety Network (NHSN) mucosal barrier injury laboratoryconfirmed bloodstream infection (MBI-LCBSI) definition, we identified that 80% of the CLABSIs on our Heme-Onc unit met the MBI-LCBSI definition for the first quarter of 2013. To determine if this finding was new, all CLABSIs from 2012 on this Heme-Onc unit were retrospectively reviewed applying the 2013 NSHN MBILCBI definition. Tracking of the CLABSI rate excluding the MBI-LCBSIs continued in 2013. Chi square tests were performed to determine if the overall CLABSI rate was significantly different than the CLABSI rate excluding MBI-LCBIs for both 2012 and 2013. RESULTS: The overall CLABSI rate in 2012 was 4.07 BSI/1,000 device days. 67.6% of the CLABSIs in 2012met the definition for MBI-LCBSI. The CLABSI rate, excluding MBI-LCBSIs, was 1.32 BSI/1,000 device days. For the first eleven months of 2013, the overall CLABSI rate was 3.6 BSI/1,000 device days. 77.8 % of the CLABSIs met the MBI-LCBSI definition in 2013. The CLABSI rate, excluding the MBI-LCBIs, was 0.8 BSI/1,000 device days. There was a significant difference between the rates in 2012, (c2 (1) 1⁄4 11.72, p < .01) as well as in 2013, (c2 (1) 1⁄4 13.33, p < .01).