Titus L. Daniels

Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives.

OBJECTIVE To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence. DESIGN Time-series design with correlation analysis. SETTING Tertiary care academic medical center, including outpatient clinics and procedural areas. PARTICIPANTS Medical center healthcare personnel. METHODS A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection. RESULTS A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P < .001) as well as from one phase to the next (P < .001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R(@) = 0.70). CONCLUSIONS Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.

Clinical Impact of Blood Cultures Contaminated with Coagulase- Negative Staphylococci at an Academic Medical Center

Of all blood cultures positive for coagulase-negative staphylococci collected in 1 year at an academic hospital, 100 were selected randomly for review and designated true positives or contaminated. For the 85 patients whose cultures were determined to be contaminated, chart abstractions revealed substantial unnecessary antibiotic administration, additional laboratory tests and procedures, and hospital readmissions.

Mortality rates associated with multidrug-resistant Acinetobacter baumannii infection in surgical intensive care units.

A retrospective, propensity-matched cohort study was conducted to determine the mortality rate in patients with healthcare-associated infection (HAI) due to multidrug-resistant (MDR) Acinetobacter baumannii. The 28-day mortality rate for patients with MDR A. baumannii HAI was not significantly different than that for patients with non-MDR A. baumannii HAI. The median length of hospital stay before diagnosis of HAI was 4.5 days longer for patients with MDR A. baumannii infection than for patients with non-MDR A. baumannii infection (P < .001).

Central Line–Associated Bloodstream Infection Surveillance outside the Intensive Care Unit: A Multicenter Survey

OBJECTIVE The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions. DESIGN AND SETTING An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU patients. PARTICIPANTS Ten tertiary care hospitals. METHODS In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data. RESULTS Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders ([Formula: see text]), or another automated method ([Formula: see text]). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days. CONCLUSIONS Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.

Blood Culture Collection through Peripheral Intravenous Catheters Increases the Risk of Specimen Contamination among Adult Emergency Department Patients

Five hundred five blood cultures collected through a peripheral intravenous catheter (PIV) in an emergency department were matched to cultures obtained by dedicated venipuncture from the same patient within 10 minutes. The relative risk of contamination for cultures collected through PIVs compared with dedicated venipuncture was 1.83 (95% confidence interval, 1.08-3.11).

Triaging patients at risk of influenza using a patient portal

Vanderbilt University has a widely adopted patient portal, MyHealthAtVanderbilt, which provides an infrastructure to deliver information that can empower patient decision making and enhance personalized healthcare. An interdisciplinary team has developed Flu Tool, a decision-support application targeted to patients with influenza-like illness and designed to be integrated into a patient portal. Flu Tool enables patients to make informed decisions about the level of care they require and guides them to seek timely treatment as appropriate. A pilot version of Flu Tool was deployed for a 9-week period during the 2010-2011 influenza season. During this time, Flu Tool was accessed 4040 times, and 1017 individual patients seen in the institution were diagnosed as having influenza. This early experience with Flu Tool suggests that healthcare consumers are willing to use patient-targeted decision support. The design, implementation, and lessons learned from the pilot release of Flu Tool are described as guidance for institutions implementing decision support through a patient portal infrastructure.

Steroids in the treatment of group A streptococcal necrotizing soft tissue infection.

BACKGROUND Group A streptococcal necrotizing soft-tissue infection with toxic shock is a life-threatening disease. Corticosteroid use in the treatment of this process has been reported rarely. METHOD Case reports and review of pertinent literature. RESULTS Two infections caused by the same clonal strain of Streptococcus pyogenes are presented. CONCLUSION The cases illustrate the possible utility of high-dose steroids in the treatment of this process.

Reconsidering Hand Hygiene Monitoring

Observations are also generally limited to work shifts when a full complement of personnel is available for administrative tasks (ie, daytime). Further, the direct observation strategy for measuring HH compliance has long been limited by the “Hawthorne effect,” which refers to a change in behavior that results from the direct visualization of activities. Anecdotally, virtually every healthcare epidemiologist can almost certainly retell a conversation in which an HCW recounted performing HH only when observers were present and conducting compliance audits. Though many organizations attempt to mitigate this effect by using unknown, nonstaff, volunteer, or other types of “secret” observers, over time most individuals working in patient care units will be able to determine the purpose of any person not usually identified as being part of the patient care environment. Implementation of electronic moni

Treatment outcomes in patients with third-generation cephalosporin-resistant Enterobacter bacteremia.

Abstract Background: Infections with resistant Enterobacter spp. are increasingly described, yet data on outcomes associated with these infections are limited. Methods: A retrospective cohort study was conducted to investigate outcomes of hospitalized patients with third-generation cephalosporin-resistant (CR) Enterobacter bacteremia. Cephalosporin resistance was detected using cefotaxime and cefpodoxime. Patients with Enterobacter spp. bacteremia from January 2006 through February 2008 defined the population. We defined cases as those with CR isolates; controls were patients with bacteremia due to non-CR isolates. Treatment failure was defined as persistence of the presenting signs of infection 72 h after initial culture collection. Results: Of the 95 Enterobacter cases identified, 31 (33%) were CR. CR cases were significantly associated with treatment failure (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.14–6.94). This association was not seen after adjustment for age, simplified acute physiology score (SAPS II), and inappropriate empiric antibiotic therapy. Inappropriate empiric therapy (adjusted OR 3.86, 95% CI 1.32–11.31) and SAPS II score (adjusted OR 1.09, 95% CI 1.02–1.16) were significantly associated with treatment failure in the multivariate analysis. Conclusions: Third-generation cephalosporin-resistant Enterobacter bacteremia is associated with treatment failure due to receipt of inappropriate empiric antibiotic therapy and severity of illness.

Let's Talk about Sex.

When taking a sexual history, which can give valuable information about the patient’s medical condition, well-being, and risk profile, always ensure privacy, avoid leading questions, tailor questions to the patient’s sexual orientation, ascertain the patient’s level of risky behavior, and discuss safe sex practices—all in a sensitive and nonjudgmental manner. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.