Monika Pogorzelska

Central line bundle implementation in US intensive care units and impact on bloodstream infections.

Background Central line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs. Methodology/Principal Findings In this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%. Conclusions/Significance In NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies.

Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit

OBJECTIVE The ventilator bundle is being promoted to prevent adverse events in ventilated patients including ventilator-associated pneumonia (VAP). We aimed to: (i) examine adoption of the ventilator bundle elements; (ii) determine effectiveness of individual elements and setting characteristics in reducing VAP; (iii) determine effectiveness of two infection-specific elements on reducing VAP; and, (iv) assess crossover effects of complying with VAP elements on central line-associated bloodstream infections. DESIGN Cross-sectional survey. SETTING Four hundred and fifteen ICUs from 250 US hospitals. PARTICIPANTS Managers/directors of infection prevention and control departments. INTERVENTIONS Adoption and compliance with ventilator bundle elements. MAIN OUTCOME MEASURES VAP rates. RESULTS The mean VAP rate was 2.7/1000 ventilator days. Two-thirds (n = 284) reported presence of the full ventilator bundle policy. However, only 66% (n = 188/284) monitored implementation; of those, 39% (n = 73/188) reported high compliance. Only when an intensive care unit (ICU) had a policy, monitored compliance and achieved high compliance were VAP rates lower. Compliance with individual elements or just one of two infection-related element had no impact on VAP (β = -0.79, P= 0.15). There was an association between complying with two infection elements and lower rates (β = -1.81, P< 0.01). There were no crossover effects. Presence of a full-time hospital epidemiologist (HE) was significantly associated with lower VAP rates (β = -3.62, P< 0.01). CONCLUSIONS The ventilator bundle was frequently present but not well implemented. Individual elements did not appear effective; strict compliance with infection elements was needed. Efforts to prevent VAP may be successful in settings of high levels of compliance with all infection-specific elements and in settings with full-time HEs.

Home health care registered nurses and the risk of percutaneous injuries: a pilot study.

BACKGROUND Home health care is the fastest-growing sector in the health care industry, expected to grow 66% over the next 10 years. Yet data on occupational health hazards, including the potential risk of exposure to blood and body fluids, associated with the home care setting remain very limited. As part of a larger study of bloodborne pathogen risk in non-hospital-based registered nurses (RNs), data from 72 home health care nurses were separately analyzed to identify risk of blood/body fluid exposure. METHODS A 152-item self-administered mailed risk assessment questionnaire was completed by RNs employed in home health care agencies in New York State. RESULTS Nine (13%) of the home health care nurses experienced 10 needlesticks in the 12-month period before the study. Only 4 of the needlesticks were formally reported to the nurses employer. The devices most frequently associated with needlesticks were hollow-bore and phlebotomy needles, and included 3 needles with safety features. Exposure was most commonly attributed to patient actions, followed by disposal-related activities. CONCLUSIONS These data suggest that home health care nurses may be at potential occupational risk for bloodborne pathogen exposure. Risk management strategies tailored to the home health care setting may be most effective in reducing this risk.

Certification in infection control matters: Impact of infection control department characteristics and policies on rates of multidrug-resistant infections.

BACKGROUND The study objective is to describe infection control policies aimed at multidrug-resistant organisms (MDRO) in California hospitals and assess the relationship among these policies, structural characteristics, and rates of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) bloodstream infections and Clostridium difficile infections. METHODS Data on infection control policies, structural characteristics, and MDRO rates were collected through a 2010 survey of California infection control departments. Bivariate and multivariable Poisson and negative binomial regressions were conducted. RESULTS One hundred eighty hospitals provided data (response rate, 54%). Targeted MRSA screening upon admission was reported by the majority of hospitals (87%). The majority of hospitals implemented contact precautions for confirmed MDRO and C difficile patients; presumptive isolation/contact precautions for patients with pending screens were less frequently implemented. Few infection control policies were associated with lower MDRO rates. Hospitals with a certified infection control director had significantly lower rates of MRSA bloodstream infections (P < .05). CONCLUSION Although most California hospitals are involved in activities to decrease MDRO, there is variation in specific activities utilized with the most focus placed on MRSA. This study highlights the importance of certification and its significant impact on infection rates. Additional research is needed to confirm these findings.

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.

Electronic surveillance systems in infection prevention: Organizational support, program characteristics, and user satisfaction

BACKGROUND The use of electronic surveillance systems (ESSs) is gradually increasing in infection prevention and control programs. Little is known about the characteristics of hospitals that have a ESS, user satisfaction with ESSs, and organizational support for implementation of ESSs. METHODS A total of 350 acute care hospitals in California were invited to participate in a Web-based survey; 207 hospitals (59%) agreed to participate. The survey included a description of infection prevention and control department staff, where and how they spent their time, a measure of organizational support for infection prevention and control, and reported experience with ESSs. RESULTS Only 23% (44/192) of responding infection prevention and control departments had an ESS. No statistically significant difference was seen in how and where infection preventionists (IPs) who used an ESS and those who did not spend their time. The 2 significant predictors of whether an ESS was present were score on the Organizational Support Scale (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.02-1.18) and hospital bed size (OR, 1.004; 95% CI, 1.00-1.007). Organizational support also was positively correlated with IP satisfaction with the ESS, as measured on the Computer Usability Scale (P = .02). CONCLUSION Despite evidence that such systems may improve efficiency of data collection and potentially improve patient outcomes, ESSs remain relatively uncommon in infection prevention and control programs. Based on our findings, organizational support appears to be a major predictor of the presence, use, and satisfaction with ESSs in infection prevention and control programs.

Wide variation in adoption of screening and infection control interventions for multidrug-resistant organisms: A national study

BACKGROUND We performed a survey of National Healthcare Safety Network hospitals in 2008 to describe adoption of screening and infection control policies aimed at multidrug-resistant organisms (MDRO) in intensive care units (ICUs) and identify predictors of their presence, monitoring, and implementation. METHODS Four hundred forty-one infection control directors were surveyed using a modified Dillman technique. To explore differences in screening and infection control policies by setting characteristics, bivariate and multivariable logistic regression models were constructed. RESULTS In total, 250 hospitals participated (57% response rate). Study ICUs (n = 413) routinely screened for methicillin-resistant Staphylococcus aureus (59%); vancomycin-resistant Enterococcus (22%); multidrug-resistant, gram-negative rods (12%); and Clostridium difficile (11%). Directors reported ICU policies to screen all admissions for any MDRO (40%), screen periodically (27%), utilize presumptive isolation/contact precautions pending a screen (31%), and cohort colonized patients (42%). Several independent predictors of the presence and implementation of different interventions including mandatory reporting and teaching status were identified. CONCLUSION This study found wide variation in adoption of MDRO screening and infection control interventions, which may reflect differences in published recommendations or their interpretation. Further research is needed to provide additional insight on effective strategies and how best to promote compliance.

Assessment of attitudes of intensive care unit staff toward clinical practice guidelines.

Although studies on the implementation and adherence to specific practice guidelines have been proliferating, research examining the attitude of healthcare workers toward practice guidelines in general has been lacking. This study is a secondary analysis of data collected from 39 volunteer hospitals participating in the National Nosocomial Infection Surveillance System on attitudes of intensive care unit staff regarding practice guidelines in general. Age, profession, type of intensive care unit, and race were identified as significant predictors of attitude scores in this study. Understanding the differences in perceived barriers is important for the adherence to practice guidelines.

California Hospitals' Response to State and Federal Policies Related to Health Care-Associated Infections

In October 2008, the Centers for Medicare and Medicaid Services (CMS) denied payment for ten selected health care–associated infections (HAI). In January 2009, California enacted mandatory reporting of infection prevention processes and HAI rates. This longitudinal mixed-methods study examined the impact of federal and state policy changes on California hospitals. Data on structures, processes, and outcomes of care were collected pre- and post-policy changes. In-depth interviews with hospital personnel were performed after policy implementation. More than 200 hospitals participated with 25 personnel interviewed. We found significant increases in adoption of and adherence to evidence-based practices and decreased HAI rates (p < .05). Infection preventionists (IP) spent more time on surveillance and in their offices and less time on education and in other locations (p < .05). Qualitative data confirmed mandatory reporting had intended and unintended consequences and highlighted the importance of technology and organizational climate in preventing infections and the changing IPs’ role. This is especially relevant because the California Department of Public Health has since mandated hospitals to report data on 29 different for surgical site infections and a lawsuit has been filed to delay the implementation of these requirements.

Home Health Care Challenges and Avian Influenza

Recent public health disasters, both nationally and internationally, have underscored the importance of preparedness in effectively responding to these events. Within the home health care sector, preparedness is especially critical, as home care patients may be at increased risk of disaster-related morbidity and mortality because of their age, disability, or other vulnerability. Importantly, the home health care population is growing, with an estimated 7 million patients currently receiving home health care services. Yet the degree of preparedness at all levels of the home care sector (agency, health care worker, and patient and/or family) is largely unknown. Without this knowledge, important first steps toward development and implementation designed to address barriers to preparedness cannot be taken. To help address some of these knowledge gaps, one aspect of preparedness, namely the willingness of home health care workers to respond during an avian influenza outbreak, was recently examined. Findings revealed very low levels of willingness. Preliminary recommendations designed to address this issue are presented following a general discussion of the issue.