Laurie J. Conway

Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010

OBJECTIVES We set out to review and compare guidelines to prevent catheter-associated urinary tract infection (CAUTI), examine the association between recent federal initiatives and CAUTI guidelines, and recommend practices for preventing CAUTI that are associated with strong evidence and are consistent across guidelines. BACKGROUND Catheter-associated urinary tract infections are the most common healthcare-associated infection, and a cause of significant morbidity and mortality in critically ill patients. METHODS A search of the English-language literature for guidelines in the prevention of adult CAUTI, published between 1980 and 2010, was conducted in Medline and the National Guideline Clearinghouse. RESULTS Many recommendations were consistent across 8 guidelines, including limited use of urinary catheters, the insertion of catheters aseptically, and the maintenance of a closed drainage system. The weight of evidence for some endorsed practices was limited, and different grading systems made comparisons across recommendations difficult. Federal initiatives are closely aligned with the 4 most recent guidelines. CONCLUSION Additional research into the prevention of CAUTI is needed, as is a harmonization of guideline grading systems for recommendations.

Targeted Surveillance of Methicillin-Resistant Staphylococcus aureus and Its Potential Use To Guide Empiric Antibiotic Therapy

ABSTRACT The present study aimed to determine the frequency of methicillin-resistant Staphylococcus aureus (MRSA)-positive clinical culture among hospitalized adults in different risk categories of a targeted MRSA active surveillance screening program and to assess the utility of screening in guiding empiric antibiotic therapy. We completed a prospective cohort study in which all adults admitted to non-intensive-care-unit locations who had no history of MRSA colonization or infection received targeted screening for MRSA colonization upon hospital admission. Anterior nares swab specimens were obtained from all high-risk patients, defined as those who self-reported admission to a health care facility within the previous 12 months or who had an active skin infection on admission. Data were analyzed for the subcohort of patients in whom an infection was suspected, determined by (i) receipt of antibiotics within 48 h of admission and/or (ii) the result of culture of a sample for clinical analysis (clinical culture) obtained within 48 h of admission. Overall, 29,978 patients were screened and 12,080 patients had suspected infections. A total of 46.4% were deemed to be at high risk on the basis of the definition presented above, and 11.1% of these were MRSA screening positive (colonized). Among the screening-positive patients, 23.8% had a sample positive for MRSA by clinical culture. Only 2.4% of patients deemed to be at high risk but found to be screening negative had a sample positive for MRSA by clinical culture, and 1.6% of patients deemed to be at low risk had a sample positive for MRSA by clinical culture. The risk of MRSA infection was far higher in those who were deemed to be at high risk and who were surveillance culture positive. Targeted MRSA active surveillance may be beneficial in guiding empiric anti-MRSA therapy.

Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units

BACKGROUND Little is known about whether recommended strategies to prevent catheter-associated urinary tract infection (CAUTI) are being implemented in intensive care units (ICU) in the United States. OBJECTIVES Our objectives were to describe the presence of and adherence to CAUTI prevention policies in ICUs, to identify variations in policies based on organizational characteristics, and to determine whether a relationship exists between prevention policies and CAUTI incidence rates. METHODS Four hundred forty-one hospitals that participate in the National Healthcare Safety Network were surveyed in spring 2008. RESULTS Two hundred fifty hospitals provided information for 415 ICUs (response rate, 57%). A small proportion of ICUs surveyed had policies supporting bladder ultrasound (26%, n = 106), condom catheters (20%, n = 82), catheter removal reminders (12%, n = 51), or nurse-initiated catheter discontinuation (10%, n = 39). ICUs in hospitals with ≥ 500 beds were half as likely as those in smaller hospitals to have adopted at least 1 CAUTI prevention policy (odds ratio, 0.52; 95% confidence interval: 0.33-0.86), and ICUs in hospitals where the infection control director reported always having access to key decision makers for planning were more than twice as likely as those with less access to have adopted a policy (odds ratio, 2.41; 95% confidence interval: 1.56-3.72). CONCLUSION Little attention is currently placed on CAUTI prevention in ICUs in the United States. Further research is needed to elucidate relationships between adherence to CAUTI prevention recommendations and CAUTI incidence rates.

Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities

BACKGROUND The World Health Organization (WHO) launched a multimodal strategy and campaign in 2009 to improve hand hygiene practices worldwide. Our objective was to evaluate the implementation of the strategy in United States health care facilities. METHODS From July through December 2011, US facilities participating in the WHO global campaign were invited to complete the Hand Hygiene Self-Assessment Framework online, a validated tool based on the WHO multimodal strategy. RESULTS Of 2,238 invited facilities, 168 participated in the survey (7.5%). A detailed analysis of 129, mainly nonteaching public facilities (80.6%), showed that most had an advanced or intermediate level of hand hygiene implementation progress (48.9% and 45.0%, respectively). The total Hand Hygiene Self-Assessment Framework score was 36 points higher for facilities with staffing levels of infection preventionists > 0.75/100 beds than for those with lower ratios (P = .01) and 41 points higher for facilities participating in hand hygiene campaigns (P = .002). CONCLUSION Despite the low response rate, the survey results are unique and allow interesting reflections. Whereas the level of progress of most participating facilities was encouraging, this may reflect reporting bias, ie, better hospitals more likely to report. However, even in respondents, further improvement can be achieved, in particular by embedding hand hygiene in a stronger institutional safety climate and optimizing staffing levels dedicated to infection prevention. These results should encourage the launch of a coordinated national campaign and higher participation in the WHO global campaign.

Implementation and Impact of an Automated Group Monitoring and Feedback System to Promote Hand Hygiene Among Health Care Personnel

BACKGROUND Despite substantial evidence to support the effectiveness of hand hygiene for preventing health care-associated infections, hand hygiene practice is often inadequate. Hand hygiene product dispensers that can electronically capture hand hygiene events have the potential to improve hand hygiene performance. A study on an automated group monitoring and feedback system was implemented from January 2012 through March 2013 at a 140-bed community hospital. METHODS An electronic system that monitors the use of sanitizer and soap but does not identify individual health care personnel was used to calculate hand hygiene events per patient-hour for each of eight inpatient units and hand hygiene events per patient-visit for the six outpatient units. Hand hygiene was monitored but feedback was not provided during a six-month baseline period and three-month rollout period. During the rollout, focus groups were conducted to determine preferences for feedback frequency and format. During the six-month intervention period, graphical reports were e-mailed monthly to all managers and administrators, and focus groups were repeated. RESULTS After the feedback began, hand hygiene increased on average by 0.17 events/patient-hour in inpatient units (interquartile range = 0.14, p = .008). In outpatient units, hand hygiene performance did not change significantly. A variety of challenges were encountered, including obtaining accurate census and staffing data, engendering confidence in the system, disseminating information in the reports, and using the data to drive improvement. CONCLUSIONS Feedback via an automated system was associated with improved hand hygiene performance in the short-term.

Tensions inherent in the evolving role of the infection preventionist

BACKGROUND The role of infection preventionists (IPs) is expanding in response to demands for quality and transparency in health care. Practice analyses and survey research have demonstrated that IPs spend a majority of their time on surveillance and are increasingly responsible for prevention activities and management; however, deeper qualitative aspects of the IP role have rarely been explored. METHODS We conducted a qualitative content analysis of in-depth interviews with 19 IPs at hospitals throughout the United States to describe the current IP role, specifically the ways that IPs effect improvements and the facilitators and barriers they face. RESULTS The narratives document that the IP role is evolving in response to recent changes in the health care landscape and reveal that this progression is associated with friction and uncertainty. Tensions inherent in the evolving role of the IP emerged from the interviews as 4 broad themes: (1) expanding responsibilities outstrip resources, (2) shifting role boundaries create uncertainty, (3) evolving mechanisms of influence involve trade-offs, and (4) the stress of constant change is compounded by chronic recurring challenges. CONCLUSION Advances in implementation science, data standardization, and training in leadership skills are needed to support IPs in their evolving role.

Exploring Infection Prevention Policy Implications From a Qualitative Study

Health care–associated infections (HAIs) are common and costly patient safety problems that are largely preventable. As a result, numerous policy changes have recently taken place including mandatory reporting and lack of reimbursement for HAIs. A qualitative approach was used to obtain dense description and gain insights about the current practice of infection prevention in California. Twenty-three in-depth, semistructured interviews were conducted at six acute care hospitals. Content analysis revealed 4 major interconnected themes: (a) impacts of mandatory reporting; (b) impacts of technology on HAI surveillance; (c) infection preventionists’ role expansion; and (d) impacts of organizational climate. Personnel reported that interdisciplinary collaboration was a major facilitator for implementing effective infection prevention, and organizational climate promoting a shared accountability is urgently needed. Mandatory reporting requirements are having both intended and unintended consequences on HAI prevention. More research is needed to measure the long-term effects of these important changes in policy.

Risk Factors for Bacteremia in Patients With Urinary Catheter–Associated Bacteriuria

Background Catheter‐associated bacteriuria is complicated by secondary bacteremia in 0.4% to 4.0% of cases. The directly attributable mortality rate is 12.7%. Objective To identify risk factors for bacteremia associated with catheter‐associated bacteriuria. Methods Data were acquired from a large electronic clinical and administrative database of consecutive adult inpatient admissions to 2 acute care hospitals during a 7‐year period. Data on patients with catheter‐associated bacteriuria and bacteremia were compared with data on control patients with catheter‐associated bacteriuria and no bacteremia, matched for date of admission plus or minus 30 days. Urine and blood cultures positive for the same pathogen within 7 days were used to define catheter‐associated bacteriuria and bacteremia. Multivariable conditional logistic regression was used to determine independent risk factors for bacteremia. Results The sample consisted of 158 cases and 474 controls. Independent predictors of bacteremia were male sex (odds ratio, 2.76), treatment with immunosuppressants (odds ratio, 1.68), urinary tract procedure (odds ratio, 2.70), and catheter that remained in place after bacteriuria developed (odds ratio, 2.75). Patients with enterococcal bacteriuria were half as likely to become bacteremic as were patients with other urinary pathogens (odds ratio, 0.46). Odds of secondary bacteremia increased 2% per additional day of hospital stay (95% CI, 1.01‐1.04) and decreased 1% with each additional year of age (95% CI, 0.97‐0.99). Conclusions The results add new information about increased risk for bacteremia among patients with catheters remaining in place after catheter‐associated bacteriuria and confirm evidence for previously identified risk factors.

Translating Infection Control Guidelines Into Practice: Implementation Process Within a Health Care Institution

Health-care-associated infections (HAIs) remain a major patient safety problem even as policy and programmatic efforts designed to reduce HAIs have increased. Although information on implementing effective infection control (IC) efforts has steadily grown, knowledge gaps remain regarding the organizational elements that improve bedside practice and accommodate variations in clinical care settings. We conducted in-depth, semistructured interviews in 11 hospitals across the United States with a range of hospital personnel involved in IC (n = 116). We examined the collective nature of IC and the organizational elements that can enable disparate groups to work together to prevent HAIs. Our content analysis of participants’ narratives yielded a rich description of the organizational process of implementing adherence to IC. Findings document the dynamic, fluid, interactional, and reactive nature of this process. Three themes emerged: implementing adherence efforts institution-wide, promoting an institutional culture to sustain adherence, and contending with opposition to the IC mandate.

Surgical Site Infection Prevention Policies and Adherence in California Hospitals, 2010

Surgical site infections (SSIs) are common, costly, and preventable; 55% may be prevented with current evidence-based strategies.1 SSIs occur at a rate of more than 290,000 infections per year and cost approximately