To determine the effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheters (UCs).

Quasi-experimental study with a control group, in 3 phases: preintervention, intervention, and postintervention.

Twelve medical-surgical units within a 608-bed teaching hospital, from May 2006 through April 2007.

A nurse trained in the indications for UC utilization participated in daily multidisciplinary rounds on 10 medical-surgical units. If no appropriate indication for a patient's UC was found, the patient's nurse was asked to contact the physician to request discontinuation. Data were collected before the intervention (for 5 days), during the intervention (for 10 days), and 4 weeks after the intervention (for 5 days). Two units served as controls.

Of 4,963 patient-days observed, a UC was present in 885 (for a total of 885 “UC-days”). There was a significant reduction in the rate of UC utilization from 203 UC-days per 1,000 patient-days in the preintervention phase to 162 UC-days per 1,000 patient-days in the intervention phase (P = .002). The postintervention rate of 187 UC-days per 1,000 patient-days was higher than the rate during the intervention (P = .05) but not significantly different from the preintervention rate (P = .32). The rate of unnecessary use of UCs also decreased from 102 UC-days per 1,000 patient-days in the preintervention phase to 64 UC-days per 1,000 patient-days during the intervention phase (P < .001); and, significantly, the rate rose to 91 UC-days per 1,000 patient-days in the postintervention phase (P = .01). The rate of discontinuation of unnecessary UCs in the intervention phase was 73 (45%) of 162.

A nurse-led multidisciplinary approach to evaluate the need for UCs was associated with a reduction of unnecessary UC use. Efforts to sustain the intervention-induced reduction may be successful when trained advocates continue this effort with each team.

Most nosocomial acquistion of vancomycin-resistant enterococci (VRE) is due to cross-transmission. We sought to identify risk factors for acquisition of VRE by roommates of patients colonized or infected with VRE.

Retrospective cohort study.

A 472-bed tertiary care teaching hospital.

All patients who shared a room with a patient colonized or infected with VRE at our hospital between January 1, 1999 and December 31, 2006 were identified. These roommates of VRE-positive patients were screened by rectal swab culture on days 2, 5, and 7 after the last exposure to the index patient. Chart reviews were performed to identify risk factors for VRE colonization in these roommates.

Eighty-eight roommates of patients colonized or infected with VRE were identified. Of the 38 roommates with complete follow-up, 8 (21%) became colonized with VRE. These 8 roommates were older (median, 87.5 vs 62.5 years of age; P = .001), had longer duration of room exposure (median, 8.5 vs 4 days; P = .002), and were more likely to have a urinary catheter (odds ratio [OR], 16 [95% confidence interval {CI}, 1.7-152]; P = .005), an elevated serum creatinine level (OR, 17 [95% CI, 1.4-196]; P = .02), low serum albumin level (OR, 9.9 [95% CI, 1.3-113]; P = .01), and recent third-generation cephalosporin use (OR, 8.3 [95% CI, 1.5-47]; P = .02).

Roommates of patients identified as colonized or infected with VRE are at substantial risk of becoming colonized, with the degree of risk increasing in older and more frail patients. VRE control programs should pay particular attention to such patients.

To determine the incidence density of highly resistant organisms (HROs) and the relative contribution of horizontal spread in a setting of endemicity.

Prospective surveillance was performed among hospitalized patients during an 18-month period. Enterobacteriaceae, non-fermentative gram-negative bacilli, Staphylococcus aureus, Streptococcus pneumoniae, and Enterococcus faecium—all considered highly resistant, according to Dutch guidelines—were included. Epidemiological linkage and nosocomial transmission were determined on the basis of molecular typing and hospital admission data.

From 119 patients, we recovered a total of 170 unique HRO isolates, as follows: Escherichia coli, 96 isolates; Klebsiella species, 11 isolates; Enterobacter species, 8 isolates; Proteus species, 9 isolates; Citrobacter species, 5 isolates; Pseudomonas species, 5 isolates; Aci-netobacter species, 3 isolates; Morganella species, 2 isolates; Salmonella species, 1 isolate; Serratia species, 1 isolate; S. pneumoniae, 20 isolates; and S. aureus, 9 isolates. No vancomycin-resistant E. faecium was found. The incidence density was 4.3 HRO isolates per 10,000 patient-days. The majority of HRO isolates were unique, and nosocomial transmission was observed 4 times for highly resistant gram-negative bacilli (case reproduction rate, 0.05) and 4 times for penicillin-nonsusceptible S. pneumoniae (case reproduction rate, 0.29). A stay on the intensive care unit was the main determinant for the recovery of an HRO.

Nosocomial transmission of HROs was observed 8 times during the 18-month period. The intensive care unit was identified as the main reservoir of horizontal spread of HROs. This study shows that nosocomial transmission of HROs is largely preventable using transmission precautions.

Although an increasing number of medical devices are labeled “for single use only,” cleaning and reuse of single-use medical devices continues, because of the economic incentive. We conducted a survey of the economic literature to obtain the current evidence available and to assess the costs and benefits of reusing single-use medical devices.

A comprehensive literature search was carried out to identify articles that compared single use and reuse of single-use medical devices and that met specific scientific criteria, including evaluation of economic outcomes. Each selected article was independently reviewed by 2 reviewers to extract cost and clinical outcome data and to assess the quality of the study.

Nine published articles met the selection criteria. The savings were about 49% of the direct cost. These savings would be offset by adverse-event costs, but none were detected. However, quality of the studies was generally poor.

There is little available evidence of quality in the published literature to assess the practice of reuse of single-use medical devices. Moreover, data on clinical outcomes are missing and, where available, cannot be attributed specifically to the reuse of single-use medical devices.

To determine whether methodological differences explain divergent results in case-control studies examining surgery as a risk factor for Creutzfeldt-Jakob disease (CJD).

After case-control studies were systematically identified using PubMed, we performed a homogeneity analysis and applied models to effect sizes (odds ratio [OR] with 95% confidence interval [CI]) using 2 parameters: type of control subject used and consistency of data ascertainment. The hospitals and communities were located in Europe, Japan, and Australia. Patients were CJD case subjects and age- and sex-matched control subjects in the hospital or community. Because of the natural history of the disease, CJD subjects are not considered reliable sources of information for these studies. Therefore, individuals who are considered close to the subjects and who have knowledge of their medical history, including spouses and relatives, are necessarily identified as proxy informants for the surgical record of the case subjects.

Overall, the effect sizes lacked homogeneity (P<.0001). Three studies that used control subjects from the community revealed a significantly elevated risk of CJD for patients who underwent surgery (OR, 1.82; 95% CI, 1.41-2.35 [P<.0001 ]), whereas 3 investigations that used control subjects from the hospital revealed a significantly reduced risk (OR, 0.69; 95% CI, 0.52-0.90 [P = .0069]). Two studies that used proxy informants to acquire information about case subjects and control subjects (consistent ascertainment) found that the risk of CJD was significantly lower in those subjects who underwent surgery (OR, 0.65; 95% CI, 0.48-0.87 [P = .0043]). Conversely, 4 studies in which proxy informants acted only on behalf of case subjects (inconsistent data ascertainment) found a significant positive association between surgery and CJD (OR, 1.67; 95% CI, 1.32-2.12 [P<.0001 ]). Both models fit the data very well, leaving no remaining variance in effect sizes to explain.

Variation in the type of control subjects used and in exposure assessment in case-control studies may partially explain conflicting data regarding the association between surgery and CJD. However, there was almost complete confounding of these 2 parameters, making interpretation more difficult. Planning of future investigations must carefully consider these design elements.

To evaluate the adequacy of discharge room cleaning and the impact of a cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) on environmental surfaces in intensive care unit (ICU) rooms.

Prospective environmental study.

Convenience sample of ICU rooms in an academic hospital.

The intervention consisted of (1) a change from the use of pour bottles to bucket immersion for applying disinfectant to cleaning cloths, (2) an educational campaign, and (3) feedback regarding adequacy of discharge cleaning. Cleaning of 15 surfaces was evaluated by inspecting for removal of a preapplied mark, visible only with an ultraviolet lamp (“black light”). Six surfaces were cultured for MRSA or VRE contamination. Outcomes of mark removal and culture positivity were evaluated by X2 testing and generalized linear mixed models, clustering by room.

The black-light mark was removed from 44% of surfaces at baseline, compared with 71 % during the intervention (P < .001). The intervention increased the likelihood of removal of black-light marks after discharge cleaning (odds ratio, 4.4; P < .001), controlling for ICU type (medical vs surgical) and type of surface. The intervention reduced the likelihood of an environmental culture positive for MRSA or VRE (proportion of cultures positive, 45% at baseline vs 27% during the intervention; adjusted odds ratio, 0.4; P = .02). Broad, flat surfaces were more likely to be cleaned than were doorknobs and sink or toilet handles.

Increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination.

To evaluate the economic impact of performing rapid testing for Staphylococcus aureus colonization before admission for all inpatients who are scheduled to undergo elective surgery and providing subsequent decolonization therapy for those patients found to be colonized with S. aureus.

A budget impact model that used probabilistic sensitivity analysis to account for the uncertainties in the input variables was developed. Primary input variables included the marginal effect of S. aureus infection on patient outcomes among patients who underwent elective surgery, patient demographic characteristics, the prevalence of nasal carriage of S. aureus, the sensitivity and specificity of the rapid diagnostic test for S. aureus colonization, the efficacy of decolonization therapy for nasal carriage of S. aureus, and cost data. Data sources for the input variables included the 2003 Nationwide Inpatient Sample data and the published literature.

In 2003, there were an estimated 7,181,484 patients admitted to US hospitals for elective surgery. Our analysis indicated preadmission testing and subsequent decolonization therapy for patients colonized with S. aureus would have produced a mean annual cost savings to US hospitals of $231,538,400 (95% confidence interval [CI], -$300 million to $1.3 billion). The mean annual number of hospital-days that could have been eliminated was estimated at 364,919 days (95% CI, 67,893-926,983 days), and a mean of 935 in-hospital deaths (95% CI, 88-3,691) could have been avoided per year. Sensitivity analysis indicated a 64.5% probability that there would be cost savings to US hospitals as a result of preadmission testing and subsequent decolonization therapy.

The addition of preadmission testing and decolonization therapy to standard care would result in significant cost savings, even after accounting for variations in the model input values.

To present healthcare-acquired infection surveillance data for 2001-2005 in Queensland, Australia.

Observational prospective cohort study.

Twenty-three public hospitals in Queensland.

We used computer-assisted surveillance to identify episodes of surgical site infection (SSI) in surgical patients. The risk-adjusted incidence of SSI was calculated by means of a risk-adjustment score modified from that of the US National Nosocomial Infections Surveillance System, and the incidence of inpatient bloodstream infection (BSI) was adjusted for risk on the basis of hospital level (level 1, tertiary referral center; level 2, large general hospital; level 3, small general hospital). Funnel and Bayesian shrinkage plots were used for between-hospital comparisons.

A total of 49,804 surgical patients and 4,663 patients who experienced healthcare-associated BSI.

The overall cumulative incidence of in-hospital SSI ranged from 0.28% (95% confidence interval [CI], 0%–1.54%) for radical mastectomies to 6.15% (95% CI, 3.22%–10.50%) for femoropopliteal bypass procedures. The incidence of inpatient BSI was 0.80,0.28, and 0.22 episodes per 1,000 occupied bed-days in level 1, 2, and 3 hospitals, respectively. Staphylococcus aureus was the most commonly isolated microorganism for SSI and BSI. Funnel and shrinkage plots showed at least 1 hospital with a signal indicating a possible higher-than-expected rate of S. aureus-associated BSI.

Comparisons between hospitals should be viewed with caution because of imperfect risk adjustment. It is our view that the data should be used to improve healthcare-acquired infection control practices using evidence-based systems rather than to judge institutions.

To identify independent risk factors for endometritis and urinary tract infection (UTI) after vaginal delivery, and to monitor changes in nosocomial infection rates and derive benchmarks for prevention.

Prospective study.

We analyzed routine surveillance data for all vaginal deliveries between January 1997 and December 2003 at 66 maternity units participating in the Mater Sud-Est surveillance network. Adjusted odds ratios for risk of endometritis or UTI were obtained using a logistic regression model.

The overall incidence rates were 0.5% for endometritis and 0.3% for UTI. There was a significant decrease in the incidence and risk of endometritis but not of UTI during the 7-year period. Significant risk factors for endometritis were fever during labor, parity of 1, and instrumental delivery and/or manual removal of the placenta. Significant risk factors for UTI were urinary infection on admission, premature rupture of membranes (more than 12 hours before admission), blood loss of more than 800 mL, parity of 1, instrumental delivery, and receipt of more than 5 vaginal digital examinations. Each maternity unit received a poster showing graphs of the number of expected and observed cases of UTI and endometritis associated with vaginal deliveries, which enabled each maternity unit to determine their rank within the network and to initiate prevention programs.

Although routine surveillance means additional work for maternity units, our results demonstrate the usefulness of regular targeted monitoring of risk factors and of the most common nosocomial infections in obstetrics. Most of the information needed for monitoring is already present in the patients' records.

To determine the effect of a pandemic influenza preparedness drill on the rate of influenza vaccination among healthcare workers (HCWs).

Before-after intervention trial.

The University of Iowa Hospitals and Clinics (UIHC), a large, academic medical center, during 2005.

Staff members at UIHC.

UIHC conducted a pandemic influenza preparedness drill that included a goal of vaccinating a large number of HCWs in 6 days without disrupting patient care. Peer vaccination and mobile vaccination teams were used to vaccinate HCWs, educational tools were distributed to encourage HCWs to be vaccinated, and resources were allocated on the basis of daily vaccination reports. Logit models were used to compare vaccination rates achieved during the 2005 vaccination drill with the vaccination rates achieved during the 2003 vaccination campaign.

UIHC vaccinated 54% of HCWs (2,934 of 5,467) who provided direct patient care in 6 days. In 2 additional weeks, this rate increased to 66% (3,625 of 5,467). Overall, 66% of resident physicians (311 of 470) and 63% of nursing staff (1,429 of 2,255) were vaccinated. Vaccination rates in 2005 were significantly higher than the hospitalwide rate of 41% (5,741 of 14, 086) in 2003.

UIHC dramatically increased the influenza vaccination rate among HCWs by conducting a pandemic influenza preparedness drill. Additionally, the drill allowed us to conduct a bioemergency drill in a realistic scenario, use innovative methods for vaccine delivery, and secure administrative support for future influenza vaccination campaigns. Our study demonstrates how a drill can be used to improve vaccination rates significantly.

The symptoms of influenza infection in outpatients are well described. The Centers for Disease Control and Prevention (CDC) definition of an influenza-like illness (ILI) includes fever and cough or sore throat. Few data exist on the clinical presentation of influenza in hospitalized patients, which may be distinct from the clinical presentation of influenza in ambulatory patients because of underlying medical conditions and medications.

Retrospective case-control study.

A 1,250-bed urban teaching hospital.

A total of 369 patients were admitted to the general medicine wards during 3 consecutive influenza seasons (2001-2004): 123 case patients with laboratory-confirmed influenza that was diagnosed during routine medical care and 246 control patients with active surveillance culture results negative for influenza.

Data on demographic characteristics, comorbidities, and signs and symptoms were obtained from a review of the medical records of the case and control patients. Analysis included stratified analysis and logistic regression.

Cough, coryza, sore throat, and fever were more common in patients with influenza infection. The CDC's definition of an ILI had a sensitivity of 43% and specificity of 86% in the study population, with a crude odds ratio (OR) of 4.7 (95% confidence interval [CI], 2.8-7.8). The sensitivity of the CDC's definition of an ILI decreased to 21% among asthmatic patients, who had similar rates of fever and/or ILI with or without influenza. By logistic regression, ILI was strongly associated with influenza infection in patients without asthma (adjusted OR, 7.5 [95% CI, 4.1-13.7]) but not in patients with asthma (adjusted OR, 1.1 [95% CI, 0.13-10]). The positive predictive value of an ILI in asthmatic patients was 50%.

The CDC's definition of an ILI lacks sensitivity among hospitalized patients, and the presence of an ILI is not associated with influenza infection in asthmatic patients.

We investigated the impact of bed occupancy, particularly overcrowding, on the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection in general ward settings.

We performed a time-series and mixed-model analysis of variance of monthly incidence of MRSA infection and corresponding bed occupancy rates, over 65 months, in the medicine and surgical wards within St. Luke's Hospital, a 900-bed tertiary care facility in Malta.

In the medicine wards, significant periodic fluctuations in bed demand were evident during the study period, with peaks of occupancy greater than 120% during the winter months. Cross-correlation analysis between the rate of bed occupancy and the rate of MRSA infection displayed an oscillatory configuration, with a periodicity of 12, similar to the periodicity evident in the autocorrelation bed-occupancy pattern. Further statistical analysis by means of analysis of variance confirmed that the months with excessive overcrowding tended to coincide with a significant increase in the rate of MRSA infection, occurring after a lag of approximately 2 months. Identical analysis of equivalent data from the surgical wards also revealed significant fluctuation in the rate of bed occupancy; however, occupancy never exceeded 100%. No cross-correlational relationship with MRSA infection incidence was present.

The study data suggest that, in our setting, simple fluctuations in the rate of bed occupancy did not have a direct impact on the incidence of MRSA infection as long as the rate of bed occupancy was within designated levels. Rather, it was episodes of significant overcrowding, with occupancy levels in excess of designated numbers, that triggered increases in infection incidence rates.