Kathryn B. Kirkland

Variability in the Hawthorne Effect With Regard to Hand Hygiene Performance in High‐ and Low‐Performing Inpatient Care Units

UNLABELLEDnOBJECTIVE. To determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline levels of hand hygiene compliance.nnnDESIGNnObservational study.nnnSETTINGnThree inpatient care units, selected on the basis of past hand hygiene performance, in a hospital where hand hygiene observation and feedback are routine.nnnPARTICIPANTSnThree infection control practitioners (ICPs) and a student intern observed hospital staff.nnnMETHODSnBeginning in late 2005, the 3 ICPs, who were well known to the hospital staff, performed frequent, regular observations of hand hygiene in all 3 inpatient care units of the hospital, as part of routine surveillance. During the study period (January-May 2007), a student intern who was unknown to the hospital staff also performed observations of hand hygiene in the 3 inpatient care units. The rates of hand hygiene compliance observed by the 3 ICPs were compared with those observed by the student intern.nnnRESULTSnThe 3 ICPs observed 332 opportunities for hand hygiene during 15 observation periods, and the student intern observed 355 opportunities during 19 observation periods. The overall rate of hand hygiene compliance observed by the ICPs was 65% (ie, in 215 of the 332 opportunities, the performance of proper hand hygiene by hospital staff was observed), and the overall rate of hand hygiene compliance observed by the student intern was 58% (ie, in 207 of the 355 opportunities, the performance of proper hand hygiene by hospital staff was observed) (P=.1 ). Both the ICPs and the student intern were able to distinguish between inpatient care units with a high rate of hand hygiene compliance (hereafter referred to as high-performing units) and those with a low rate (hereafter referred to as low-performing units). However, in the 2 high-performing units, the ICPs observed significantly higher compliance rates than did the student intern, whereas in the low-performing unit, both the ICPs and the student intern measured similarly low rates of hand hygiene compliance.nnnCONCLUSIONSnRecognized observers are associated with higher rates of hand hygiene compliance, even in a healthcare setting where such observations have become routine. This effect (ie, the Hawthorne effect) is more pronounced in high-performing units and insignificant in low-performing units. The use of unrecognized observers may be important for verifying high performance but is probably unnecessary for documenting poor performance. Moreover, the Hawthorne effect may be a useful tool for sustaining and improving hand hygiene compliance.

Patient Attitudes Toward the Use of Fecal Microbiota Transplantation in the Treatment of Recurrent Clostridium difficile Infection

BACKGROUNDnFecal microbiota transplantation (FMT), a safe, effective alternative therapy for recurrent Clostridium difficile infection (CDI), is infrequently used, in part because of an assumption that patients are unwilling to consider FMT because of its unappealing nature.nnnMETHODSnThrough a structured survey, including hypothetical case scenarios, we assessed patient perceptions of the aesthetics of FMT and their willingness to consider it as a treatment option, when presented with scenarios involving recurrent CDI.nnnRESULTSnFour hundred surveys were distributed; 192 (48%) were returned complete. Seventy percent of respondents were female; 59% were >49 years of age. When provided efficacy data only, 162 respondents (85%) chose to receive FMT, and 29 (15%) chose antibiotics alone. When aware of the fecal nature of FMT, 16 respondents changed their choice from FMT to antibiotics alone, but there was no significant change in the total number choosing FMT (154 [81%]; P = .15). More respondents chose FMT if offered as a pill (90%; P = .002) or if their physician recommended it (94%; P < .001). Respondents rated all aspects of FMT at least somewhat unappealing, selecting the need to handle stool and receiving FMT by nasogastric tube as most unappealing. Women rated all aspects of FMT more unappealing; older respondents rated all aspects less unappealing. Most respondents preferred to receive FMT in the hospital (48%) or physicians office (39%); 77% were willing to pay out-of-pocket for FMT.nnnCONCLUSIONSnPatients recognize the inherently unappealing nature of FMT, but they are nonetheless open to considering it as a treatment alternative for recurrent CDI, especially when recommended by a physician.

Infectious diseases consultation lowers mortality from Staphylococcus aureus bacteremia.

Staphylococcus aureus bacteremia (SAB) is a lethal and increasingly common infection in hospitalized patients. We assessed the impact of infectious diseases consultation (IDC) on clinical management and hospital mortality of SAB in 240 hospitalized patients in a retrospective cohort study. Patients who received IDC were older than those who did not (57.9 vs. 51.7 yr; p = 0.05), and were more likely to have a health care-associated infection (63% vs. 45%; p < 0.01). In patients who received IDC, there was a higher prevalence of severe complications of SAB such as central nervous system involvement (5% vs. 0%, p = 0.01), endocarditis (20% vs. 2%; p < 0.01), or osteomyelitis (15.6% vs. 3.4%; p < 0.01). Patients who received IDC had closer blood culture follow-up and better antibiotic selection, and were more likely to have pus or prosthetic material removed. Hospital mortality from SAB was lower in patients who received IDC than in those who did not (13.9% vs. 23.7%; p = 0.05). In multivariate survival analysis, IDC was associated with substantially lower hazard of hospital mortality during SAB (hazard 0.46; p = 0.03). This mortality benefit accrued predominantly in patients with methicillin-resistant SAB (hazard 0.3; p < 0.01), and in patients who did not require ICU admission (hazard 0.15; p = 0.01). In conclusion, IDC is associated with reduced mortality in patients with staphylococcal bacteremia. Abbreviations: ICU = intensive care unit, IDC = infectious diseases consultation, MRSA = methicillin-resistant Staphylococcus aureus, SAB = Staphylococcus aureus bacteremia.

The safety of immunizing with tetanus-diphtheria-acellular pertussis vaccine (Tdap) less than 2 years following previous tetanus vaccination: experience during a mass vaccination campaign of healthcare personnel during a respiratory illness outbreak.

BACKGROUNDnTdap is recommended for health care personnel (HCP) aged <65 years who received tetanus diphtheria or tetanus toxoid immunization (Td/TT) ≥2 years earlier. During a medical center Tdap vaccination campaign, we assessed the safety of use of a Td/TT to Tdap interval <2 years in HCP. We also describe reactogenicity in HCP who were aged ≥65 years or pregnant.nnnMETHODSnHCP vaccinated with Tdap were surveyed to assess time since last Td/TT (≥2 years vs. <2 years), age, pregnancy status, and injection site adverse events (AEs) during the 2 weeks after Tdap. AE rates were calculated and compared by non-inferiority analysis using a predetermined margin of 10%. We searched clinic logbooks to assess for clinically important adverse events during the 2 months after Tdap.nnnRESULTSnOf the 4524 vaccinated HCP, 2221 (49.1%) completed a safety survey which met criteria for analysis. Non-inferiority analysis found that rates of moderate and/or severe injection site AEs were not significantly greater in those vaccinated <2 years than in those vaccinated ≥2 years after previous Td/TT. Three serious adverse events were reported during the 2 months after vaccination, none in persons who were ≥65 years, pregnant or received Td/TT <2 years before.nnnCONCLUSIONSnOur findings add to the body of evidence that a short interval between Td/TT and a single dose of Tdap is safe.

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series

Background Evidence that hand hygiene (HH) reduces healthcare-associated infections has been available for almost two centuries. Yet HH compliance among healthcare professionals continues to be low, and most efforts to improve it have failed. Objective To improve healthcare workers HH, and reduce healthcare-associated infections. Design 3-year interrupted time series with multiple sequential interventions and 1-year post-intervention follow-up. Setting Teaching hospital in rural New Hampshire. Interventions In five categories: (1) leadership/accountability; (2) measurement/feedback; (3) hand sanitiser availability; (4) education/training; and (5) marketing/communication. Measurement Monthly changes in observed HH compliance (%) and rates of healthcare-associated infection (including Staphylococcus aureus infections, Clostridium difficile infections and bloodstream infections) per 1000 inpatient days. The subset of S aureus infections attributable to the operating room served as a tracer condition. We used statistical process control charts to identify significant changes. Results HH compliance increased significantly from 41% to 87% (p<0.01) during the initiative, and improved further to 91% (p<0.01) the following year. Nurses achieved higher HH compliance (93%) than physicians (78%). There was a significant, sustained decline in the healthcare-associated infection rate from 4.8 to 3.3 (p<0.01) per 1000 inpatient days. The rate of S aureus infections attributable to the operating room rose, while the rate of other S aureus infections fell. Conclusions Our initiative was associated with a large and significant hospital-wide improvement in HH which was sustained through the following year and a significant, sustained reduction in the incidence of healthcare-associated infection. The observed increased incidence of the tracer condition supports the assertion that HH improvement contributed to infection reduction. Persistent variation in HH performance among different groups requires further study.

Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007

BACKGROUNDnDuring December 2006 to March 2007, a substantial increase in norovirus illnesses was noted in northern New England. We sought to identify institutional risk factors for norovirus outbreaks in northern New England long-term care facilities (LTCFs).nnnMETHODSnState health departments in Maine, New Hampshire, and Vermont distributed surveys to infection preventionists at all LTCFs in their respective states. We collected information regarding facility attributes, routine staff use of alcohol-based hand sanitizer (ABHS) versus soap and water, facility cleaning practices, and occurrence of any acute gastroenteritis outbreaks during December 2006 to March 2007. Norovirus confirmation was conducted in public health laboratories. Data were analyzed with univariate and logistic regression methods.nnnRESULTSnOf 160 facilities, 91 (60%) provided survey responses, with 61 facilities reporting 73 outbreaks; 29 were confirmed norovirus. Facilities reporting that staff were equally or more likely to use ABHS than soap and water for routine hand hygiene had higher odds of an outbreak than facilities with staff less likely to use ABHS (adjusted odds ratio, 6.06; 95% confidence interval: 1.44-33.99).nnnCONCLUSIONnThis study suggests that preferential use of ABHS over soap and water for routine hand hygiene might be associated with increased risk of norovirus outbreaks in LTCFs.

Physician Attitudes toward the Use of Fecal Microbiota Transplantation for the Treatment of Recurrent Clostridium difficile Infection

BACKGROUNDnFecal microbiota transplantation (FMT) is a safe and effective, yet infrequently used therapy for recurrent Clostridium difficile infection (CDI).nnnOBJECTIVEnTo characterize barriers to FMT adoption by surveying physicians about their experiences and attitudes toward the use of FMT.nnnMETHODSnAn electronic survey was distributed to physicians to assess their experience with CDI and attitudes toward FMT.nnnRESULTSnA total of 139 surveys were sent and 135 were completed, yielding a response rate of 97%. Twenty-five (20%) physicians had treated a patient with FMT, 10 (8%) offered to treat with FMT, nine (7%) referred a patient to receive FMT, and 83 (65%) had neither offered nor referred a patient for FMT. Physicians who had experience with FMT (performed, offered or referred) were more likely to be male, an infectious diseases specialist, >40 years of age, fellowship trained and practicing in an urban setting. The most common reasons for not offering or referring a patient for FMT were: not having the right clinical situation (33%); the belief that patients would find it too unappealing (24%); and institutional or logistical barriers (23%). Only 8% of physicians predicted that the majority of patients would opt for FMT if given the option. Physicians predicted that patients would find all aspects of the FMT process more unappealing than they would as providers.nnnCONCLUSIONSnPhysicians have limited experience with FMT despite having treated patients with multiple recurrent CDIs. There is a clear discordance between physician beliefs about FMT and patient willingness to accept FMT as a treatment for recurrent CDI.

Outbreak of Skin Infections in College Football Team Members Due to an Unusual Strain of Community-Acquired Methicillin-Susceptible Staphylococcus aureus

ABSTRACT We report a skin and soft-tissue infection outbreak among football team members due to a USA300 methicillin-susceptible Staphylococcus aureus (MRSA) strain with genes coding for Panton-Valentine leukocidin and the arginine catabolic mobile element. We postulate that the strain is a community-associated USA300 MRSA strain that lost methicillin resistance but retained important virulence factors.

Clinician Judgment as a Tool for Targeting HIV Counseling and Testing in North Carolina State Mental Hospitals, 1994

HIV infection increasingly affects populations that may not appear at high risk based on the use of some traditional targeting strategies. To shed some light on how to more sensitively/effectively identify people who need routine HIV testing and counseling, the objective of this study is to determine the prevalence of HIV infection in North Carolina state mental hospitals and to evaluate clinician judgment as a tool for targeting HIV counseling and testing. The design used is a blinded seroprevalence study. The study population includes all patients admitted to North Carolina state mental hospitals between March 1st and May 31st, 1994. The main outcome measures are the HIV seroprevalence, demographic and diagnostic features, and clinician assessment of the likelihood of HIV infection. The results of the study find that of 2159 study subjects, 35 persons (1.6%) were infected with HIV; of these, 14 (40%) were not previously known to be infected. All 35 HIV infections occurred in persons aged 13-59 years. Within this age group, infection rates were significantly higher for Blacks, males, persons who had a diagnosis of organic brain disease, and persons who had multiple psychiatric diagnoses. However, testing strategies that targeted any of the higher risk groups were insensitive. The rate of HIV infection for persons judged by the admitting clinician to have a high or intermediate likelihood of HIV infection was 26.4 times higher than the rate for those judged to have a low likelihood of infection (2.1 vs. 0.1%, 95% confidence intervals: 3.5-201.3). Of the 14 previously undiagnosed HIV-infected persons, 13 were judged by clinicians to have a high or intermediate likelihood of HIV infection. Moreover, 1258 persons were correctly assessed to have a low likelihood of infection. Conclusions from this study are that an HIV counseling and testing strategy targeting persons (in this setting aged 13-59 years) who were judged by clinicians to have a high or intermediate likelihood of infection, would have identified more than 90% of previously undetected infections while substantially reducing the number of negative HIV tests performed.

Serious Choices: A Protocol for an Environmental Scan of Patient Decision Aids for Seriously Ill People at Risk of Death Facing Choices about Life-Sustaining Treatments

BackgroundSeriously ill people at high risk of death face difficult decisions, especially concerning the extent of medical intervention. Given the inherent difficulty and complexity of these decisions, the care they receive often does not align with their preferences. Patient decision aids that educate individuals about options and help them construct preferences about life-sustaining care may reduce the mismatch between the care people say they want and the care they receive. The quantity and quality of patient decision aids for those at high risk of death, however, are unknown.ObjectiveThis protocol describes an approach for conducting an environmental scan of life-sustaining treatment patient decision aids for seriously ill patients, identified online and through informant analysis. We intend for the outcome to be an inventory of all life-sustaining treatment patient decision aids for seriously ill patients currently available (either publicly or proprietarily) along with information about their content, quality, and known use.MethodsWe will identify patient decision aids in a three-step approach (1) mining previously published systematic reviews; (2) systematically searching online and in two popular app stores; and (3) undertaking a key informant survey. We will screen and assess the quality of each patient decision aid identified using the latest published draft of the U.S. National Quality Forum National Standards for the Certification of Patient Decision Aids. Additionally, we will evaluate readability via readable.io and content via inductive content analysis. We will also use natural language processing to assess the content of the decision aids.DiscussionResearchers increasingly recognize the environmental scan as an optimal method for studying real-world interventions, such as patient decision aids. This study will advance our understanding of the availability, quality, and use of decision aids for life-sustaining interventions targeted at seriously ill patients. We also aim to provide patients, their families, and friends, along with their clinicians, a broad set of resources for making life-sustaining treatment decisions. Although we intend to capture all patient decision aids for the seriously ill in our review, we anticipate the possibility that we may miss some decision aids. In addition to publishing our findings in an academic journal, we plan to post our inventory online in an easy-to-read format for public and clinical consumption.