Linda H. Danko

Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units

BACKGROUND The Department of Veterans Affairs (VA) is the largest single provider of long-term care in the United States. The prevalence of nursing home-associated infections (NHAIs) among residents of VA nursing home care units (NHCUs) is not known. METHODS A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted in the VAs 133 NHCUs on November 9, 2005. RESULTS From a total population of 11,475 NHCU residents, 591 had at least 1 NHAI for a point prevalence rate of 5.2%. Urinary tract infection, asymptomatic bacteriuria, pneumonia, skin infection, gastroenteritis, and soft tissue infection were most prevalent, constituting 72% of all NHAIs. A total of 2817 residents (24.5%) had 1 or more indwelling device. Of these 2817 residents with an indwelling device(s), 309 (11.0%) had 1 or more NHAI. In contrast, the prevalence of NHAIs in residents without an indwelling device was 3.3%. Indwelling urinary catheter, percutaneous gastrostomy tube, intravenous peripheral line, peripherally inserted central catheter, and suprapubic urinary catheter were most common, accounting for 79.3% of all devices used. CONCLUSION There are effective infection surveillance and control programs in VA NHCUs with a point prevalence of NHAIs of 5.2%.

Nursing home-associated infections in Department of Veterans Affairs community living centers

BACKGROUND Little is known about factors contributing to nursing home-associated infections (NHAIs). We conducted a survey of residents in 133 Department of Veterans Affairs community living centers to determine the roles of indwelling device use, bed locations, and treatment codes on NHAIs. METHODS A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted on November 14, 2007. RESULTS Among 10,939 residents, 575 had at least one NHAI, for a point prevalence rate of 5.3%. Urinary tract infection, skin infection, asymptomatic bacteriuria, and pneumonia were the most prevalent NHAIs. A total of 2687 residents had one or more indwelling devices; 290 of these also had an NHAI, for a prevalence of 10.8%. In contrast, the prevalence of NHAIs in residents without indwelling devices was 3.5% (P < .0001). Indwelling urinary catheters, percutaneous gastrostomy tubes, peripherally inserted central catheters, and suprapubic urinary catheters were the most commonly used devices. There were 4027 residents in designated units and 6912 residents in dispersed units. The rate of device use was 21.4% in the designated units and 26.4% in the dispersed units (P < .0001). The prevalence of NHAIs was 4.5% in the designated units and 5.7% in the dispersed units (P < .001). Rates of NHAIs and device use varied greatly among the various treatment codes; however, there was a positive correlation between the rates of NHAIs and device use. Stepwise logistic regression analysis of data from long-stay and short-stay skilled nursing care residents revealed that only the presence of an indwelling device, not length of stay or bed location, affected the rate of NHAIs. CONCLUSION Indwelling device use, but not bed location or treatment code, was found to be associated with increased rate of NHAIs.

Laboratory Reporting of Staphylococcus aureus with Reduced Susceptibility to Vancomycin in United States Department of Veterans Affairs Facilities

A national survey was sent to all appropriate Veterans Health Administration (VA) medical facilities asking abut the ability to test for Staphylococcus aureus with reduced susceptibility to vancomycin (SARV) (MICs >4 μg/mL). Also, a request was made for the number of patients having SARV isolated during a 1-year period. Nineteen patients from eight sites across the country had isolation of SARV. Of these, MicroScan (Dade Behring, Inc, MicroScan Division, West Sacramento, CA) technology was used for 17 patients, Vitek (Hazelwood, MO) was used for 1 of the remaining 2 patients, and E-test (AB Biiodisk North America, Inc, Piscataway, NJ) for the other. All patients with this organism had microbiology testing done onsite in the reporting VA facility’s College of American Pathologists-approved laboratory. For comparison, similar data were obtained for a 1-year period 2 years prior to the current survey; seven patients from four sites were verified to have a SARV. Between the two survey periods the reported cases of SARV increased 170%, indicating a need for continued surveillance and potentially a need to initiate a collection of isolates for further analysis.

Healthcare-Associated Myiasis: Prevention and Intervention

Healthcare-associated myiasis (maggot infestation) can have complications that go well beyond the medical consequences of the infestation for patients, their families, and facilities. Prevention of healthcare-associated myiasis requires effort on two fronts: minimizing patient risk factors and reducing fly populations in the healthcare environment. If myiasis occurs, intervention must be swift, thorough, and interdisciplinary. The first priority always is the well-being of the patient. Preservation and identification of the maggots can help determine the likely timing and circumstances that led to the infestation. Conditions favoring the infestation must be identified and then corrected. Free and rapid communication must be promoted. A single designated knowledgeable spokesperson to communicate with the patient, employees, and, as needed, the media will reduce miscommunication and hasten mitigation. Following the guidelines presented in this document, healthcare facilities should be able to reduce the likelihood of healthcare-associated myiasis and effectively intervene when such events occur.

Legionella in the veterans healthcare system: report of an eight-year survey.

The Veterans Health Administration (VHA) of the Department of Veterans Affairs tracks legionella disease in the system of 172 medical centres and additional outpatient clinics using an annual census for reporting. In fiscal year 1999, 3.62 million persons were served by the VHA. From fiscal year 1989-1999, multiple intense interventions were carried out to decrease the number of cases and case rates for legionella disease. From fiscal year 1992-1999, the number of community-acquired and healthcare-associated cases decreased in the VHA by 77 and 95.5% respectively (P = 0.005 and 0.01). Case rates also decreased significantly for community and healthcare-associated cases (P = 0.02 and 0.001, respectively), with the VHA healthcare-associated case rates decreasing at a greater rate than VHA community-acquired case rates (P = 0.02). Over the time of the review, the VHA case rates demonstrated a greater decrease compared to the case rates for the United States as a whole (P = 0.02). Continued surveillance, centrally defined strategies, and local implementation can have a positive outcome for prevention of disease in a large, decentralized healthcare system.

Tuberculosis in the veterans healthcare system: a six-year review and evaluation of programme effectiveness.

The Department of Veterans Affairs operates a large, centrally administered health care system consisting of 173 hospitals and 4 free standing outpatient clinics nationwide with approximately 945,115 hospital discharges, 24.2 million outpatient visits, and 2.86 million persons served annually over the time frame of the review. The purpose of the study was to define whether such a system could effect timely change in the incidence of tuberculosis (TB) using centralized programme planning and flexible field implementation. A retrospective review of the number of newly diagnosed cases of active TB treated at veterans health care facilities between 1 October 1990 and 30 September 1997 was determined by using a standardized annual case census. Intervention included implementation of the most current guidelines for the prevention of transmission of TB in the community and hospital setting, including administrative and engineering controls and a change in personal protective equipment. Centrally directed programme guidance, education, and funding were provided for field use in health care facilities of widely varying size and complexity. The numbers of total reported cases of TB decreased significantly (P < 0.001) throughout the veterans health care system (nationally and regionally), with the case rate decreasing at a rate significantly greater than that seen in the USA as a whole (P < 0.0001). TB associated with multi-drug resistance (isoniazid and rifampin) and HIV coinfection also significantly decreased over the study period. Therefore, a large, centrally administered health care system can effectively combat a re-emerging infectious disease and may also demonstrate a successful outcome greater than seen in other, perhaps less organized health care settings.