To assess the relative importance of independent risk factors for peripheral intravenous catheter (PIVC) failure.

Secondary data analysis from a randomized controlled trial of PIVC dwell time. The Prentice, Williams, and Peterson statistical model was used to identify and compare risk factors for phlebitis, occlusion, and accidental removal.

Three acute care hospitals in Queensland, Australia.

The trial included 3,283 adult medical and surgical patients (5,907 catheters) with a PIVC with greater than 4 days of expected use.

Modifiable risk factors for occlusion included hand, antecubital fossa, or upper arm insertion compared with forearm (hazard ratio [HR], 1.47 [95% confidence interval (CI), 1.28–1.68], 1.27 [95% CI, 1.08–1.49], and 1.25 [95% CI, 1.04–1.50], respectively); and for phlebitis, larger diameter PIVC (HR, 1.48 [95% CI, 1.08–2.03]). PIVCs inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions (HR, 0.80 [95% CI, 0.67–0.94]). Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm (HR, 2.45 [95% CI, 1.93–3.10] and 1.65 [95% CI, 1.23–2.22], respectively), clinical staff insertion compared with intravenous service (HR, 1.69 [95% CI, 1.30–2.20]); and smaller PIVC diameter (HR, 1.29 [95% CI, 1.02–1.61]). Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis (HR, 1.64 [95% CI, 1.28–2.09]) and occlusion (HR, 1.44 [95% CI, 1.30–1.61]).

PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.

The original randomized controlled trial on which this secondary analysis is based is registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12608000445370).

To estimate the level of hand or glove contamination with vancomycin-resistant enterococci (VRE) among healthcare workers (HCWs) who touch a patient colonized with VRE and/or the colonized patient's environment during routine care.

Structured observational study.

Medical intensive care unit of a 700-bed, tertiary-care teaching hospital.

VRE-colonized patients and their caregivers.

We obtained samples from sites on the intact skin of 22 patients colonized with VRE and samples from sites in the patients' rooms, before and after routine care, during 27 monitoring episodes. A total of 98 unique HCWs were observed during 131 HCW observations. Observers recorded the sites touched by HCWs. Culture samples were obtained from HCWs' hands and gloves before and after care.

VRE were isolated from a mean (±SD) of 55% ± 24% of patient sites (n = 256) and 17% ± 12% of environmental sites (n = 1,572). Most HCWs (131 [56%]) touched both the patient and the patient's environment; no HCW touched only the patient. Of 103 HCWs whose hand samples were negative for VRE when they entered the room, 52% contaminated their hands or gloves after touching the environment, and 70% contaminated their hands or gloves after touching the patient and the environment (P = .101). In a univariate logistic regression model, the risk of hand or glove contamination was associated with the number of contacts made (odds ratio, 1.1 [95% confidence interval, 1.01-1.19). In a multivariate model, the effect of the number of contacts could not be distinguished from the effect of type of contact (ie, touching the environment alone or touching both the patient and the environment). Overall, 37% of HCWs who did not wear gloves contaminated their hands, and 5% of HCWs who wore gloves did so (an 86% difference).

HCWs were nearly as likely to have contaminated their hands or gloves after touching the environment in a room occupied by a patient colonized by VRE as after touching the colonized patient and the patient's environment. Gloves were highly protective with respect to hand contamination.

To determine the attributable risk of death due to catheter-related septicemia (CRS) in critically ill patients when taking into account severity of illness during the intensive-care unit (ICU) stay but before CRS.

Pairwise-matched (1:2) exposed-unexposed study.

10-bed medical-surgical ICU and an 18-bed medical ICU.

Patients admitted to either ICU between January 1, 1990, and December 31, 1995, were eligible. Exposed patients were defined as patients with CRS; unexposed controls were selected according to matching variables.

Matching variables were diagnosis at ICU admission, length of central catheterization before the infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at admission, age, and gender. Severity scores (SAPS II, Organ System Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ Dysfunction System) were calculated four times for each patient: the day of ICU admission, the day of CRS onset, and 3 and 7 days before CRS. Matching was successful for 38 exposed patients. Statistical analysis was based on nonparametric tests for epidemiological data and on Cox's models for the exposed-unexposed study, with adjustment on matching variables and prognostic factors of mortality.

CRS complicated 1.17 per 100 ICU admissions during the study period. Twenty (53%) of the CRS cases were associated with septic shock. CRS was associated with a 28% increase in SAPS II. Crude ICU mortality rates from exposed and unexposed patients were 50% and 21%, respectively. CRS remained associated with mortality even when adjusted on other prognostic factors at ICU admission (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.08-3.73; P=.03). However, after adjustment on severity scores calculated between ICU admission and 1 week before CRS, the increased mortality was no longer significant (RR, 1.41; CI95, 0.76-2.61; P=.27).

CRS is associated with subsequent morbidity and mortality in the ICU, even when adjusted on severity factors at ICU admission. However, after adjustment on severity factors during the ICU stay and before the event, there was only a trend toward CRS-attributable mortality. The evolution of patient severity should be taken into account when evaluating excess mortality induced by nosocomial events in ICU patients.

To determine the cause and mode of transmission of a cluster of infections due to Enterobacter cloacae.

Retrospective cohort study in a neonatal intensive-care unit (NICU) from December 1996 to January 1997; environmental and laboratory investigations.

60 infants hospitalized in the NICU during the outbreak period.

Odds ratios (OR) linking E cloacae colonization or infection and various exposures. All available E cloacae isolates were typed and characterized by contour-clamped homogenous electric-field electrophoresis to confirm possible cross-transmission.

Of eight case-patients, two had bacteremia; one, pneumonia; one, soft-tissue infection; and four, respiratory colonization. Infants weighing <2,000 g and born before week 33 of gestation were more likely to become cases (P<.001). Multivariate analysis indicated that the use of multidose vials was independently associated with E cloacae carriage (OR, 16.3; 95% confidence interval [CI95], 1.8-∞ P=011). Molecular studies demonstrated three epidemic clones. Cross-transmission was facilitated by understaffing and overcrowding (up to 25 neonates in a unit designed for 15), with an increased risk of E cloacae carriage during the outbreak compared to periods without understaffing and overcrowding (relative risk, 5.97; CI95, 2.2-16.4). Concurrent observation of healthcare worker (HCW) handwashing practices indicated poor compliance. The outbreak was terminated after decrease of work load, increase of hand antisepsis, and reinforcement of single-dose medication.

Several factors caused and aggravated this outbreak: (1) introduction of E cloacae into the NICU, likely by two previously colonized infants; (2) further transmission by HCWs' hands, facilitated by substantial overcrowding and understaffing in the unit; (3) possible contamination of multidose vials with E cloacae. Overcrowding and understaffing in periods of increased work load may result in outbreaks of nosocomial infections and should be avoided.

To determine the roles of “colonization pressure,” work load or patient severity in patient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs).

Prospectively collected data from October 1996 through December 1998.

A 12-bed medical ICU in a university-affiliated general hospital.

Patients with risk factors for MRSA admitted to the ICU were screened within 72 hours of admission and weekly thereafter. MRSA was considered imported if detected during the first 72 hours of admission and nosocomial if detected only thereafter. Three screening strategies were used on admission during three consecutive periods.

The unit of time chosen for measurements was the week. Weekly colonization pressure (WCP) was defined as the number of MRSA-carrier patient-days/total number of patient-days. Patient severity (number of deaths, Simplified Acute Physiologic Score [SAPS] II), work load (number of admissions. Omega score), and colonization pressure (number of MRSA carriers at the time of admission, WCP) were compared with the number of MRSA-nosocomial cases during the following week.

Of the 1,016 patients admitted over 116 weeks, 691 (68%) were screened. MRSA was imported in 91 (8.9%) admitted patients (13.1% of screened patients) and nosocomial in 46 (4.5%). The number of MRSA-nosocomial cases was correlated to the SAPS II (P=.007), the Omega 3 score (P=.007), the number of MRSA-imported cases (P=.01), WCP (P<.0001), and the screening period (P<.0001). In multivariate analysis, WCP was the only independent predictive factor for MRSA acquisition (P=.0002). Above 30% of WCP, the risk of acquisition of MRSA was approximately fivefold times higher (relative risk, 4.9;95% confidence interval, 1.2-19.9; P<.0001).

Acquisition of MRSA in ICU patients is strongly and independently influenced by colonization pressure.

To identify the independent effect of pressure ulcers on excess length of stay and control for all observable factors that may also contribute to excess length of stay. Hospitalized patients who develop a pressure ulcer during their hospital stay are at a greater risk for increased length of stay as compared with patients who do not.

Cross-sectional, observational study.

Tertiary-care referral and teaching hospital in Australia.

Two thousand hospitalized patients 18 years and older who had a minimum stay in the hospital of 1 night and admission to selected clinical units.

Two thousand participants were randomly selected from 4,500 patients enrolled in a prospective survey conducted between October 2002 and January 2003. Quantile median robust regression was used to assess risk factors for excess length of hospital stay.

Having a pressure ulcer resulted in a median excess length of stay of 4.31 days. Twenty other variables were statistically significant at the 5% level in the final model.

Pressure ulcers make a significant independent contribution to excess length of hospitalization beyond what might be expected based on admission diagnosis. However, our estimates were substantially lower than those currently used to make predictions of the economic costs of pressure ulcers; existing estimates may overstate the true economic cost.

Current guidelines for control of Clostridium difficile infection (CDI) suggest that contact precautions be discontinued after diarrhea resolves. However, limited information is available regarding the frequency of skin contamination and environmental shedding of C. difficile during and after treatment.

We conducted a 9-month prospective, observational study involving 52 patients receiving therapy for CDI. Stool samples, skin (chest and abdomen) samples, and samples from environmental sites were cultured for C. difficile before, during, and after treatment. Polymerase chain reaction ribotyping was performed to determine the relatedness of stool, skin, and environmental isolates.

Fifty-two patients with CDI were studied. C. difficile was suppressed to undetectable levels in stool samples from most patients during treatment; however, 1-4 weeks after treatment, 56% of patients who had samples tested were asymptomatic carriers of C. difficile. The frequencies of skin contamination and environmental shedding remained high at the time of resolution of diarrhea (60% and 37%, respectively), were lower at the end of treatment (32% and 14%, respectively), and again increased 1-4 weeks after treatment (58% and 50%, respectively). Skin and environmental contamination after treatment was associated with use of antibiotics for non-CDI indications. Ninety-four percent of skin isolates and 82% of environmental isolates were genetically identical to concurrent stool isolates.

Skin contamination and environmental shedding of C. difficile often persist at the time of resolution of diarrhea, and recurrent shedding is common 1-4 weeks after therapy. These results provide support for the recommendation that contact precautions be continued until hospital discharge if rates of CDI remain high despite implementation of standard infection-control measures.

The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices.

Prospective quasi-experimental, before-after, study.

Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds.

We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions.

Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4-51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel (P = .02). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it was determined that 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P < .001). Improvement was unrelated to any demographic, fiscal, or staffing parameter but was related to the degree to which cleaning was suboptimal at baseline (P < .001).

Significant improvements in disinfection cleaning can be achieved in most hospitals, without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.

To determine whether hydrogen peroxide vapor (HPV) decontamination can reduce environmental contamination with and nosocomial transmission of Clostridium difficile.

A prospective before-after intervention study.

A hospital affected by an epidemic strain of C. difficile.

Intensive HPV decontamination of 5 high-incidence wards followed by hospital-wide decontamination of rooms vacated by patients with C. difficile-associated disease (CDAD). The preintervention period was June 2004 through March 2005, and the intervention period was June 2005 through March 2006.

Eleven (25.6%) of 43 cultures of samples collected by sponge from surfaces before HPV decontamination yielded C. difficile, compared with 0 of 37 cultures of samples obtained after HPV decontamination (P < .001). On 5 high-incidence wards, the incidence of nosocomial CDAD was significantly lower during the intervention period than during the preintervention period (1.28 vs 2.28 cases per 1,000 patient-days; P = .047). The hospital-wide CDAD incidence was lower during the intervention period than during the preintervention period (0.84 vs 1.36 cases per 1,000 patient-days; P = .26). In an analysis limited to months in which the epidemic strain was present during both the preintervention and the intervention periods, CDAD incidence was significandy lower during the intervention period than during the preintervention period (0.88 vs 1.89 cases per 1,000 patient-days; P = .047).

HPV decontamination was efficacious in eradicating C. difficile from contaminated surfaces. Further studies of the impact of HPV decontamination on nosocomial transmission of C. difficile are warranted.

In many hospitals, the only sterile precautions used during the insertion of a nontunneled central venous catheter are sterile gloves and small sterile drapes. We investigated whether the use of maximal sterile barrier (consisting of mask, cap, sterile gloves, gown, and large drape) would lower the risk of acquiring catheter-related infections.

Prospective randomized trial.

A 500-bed cancer referral center.

We randomized patients to have their nontunneled central catheter inserted under maximal sterile barrier precautions or control precautions (sterile gloves and small drape only). All patients were followed for 3 months postinsertion or until the catheter was removed, whichever came first. Catheter-related infections were diagnosed by quantitative catheter cultures and/or simultaneous quantitative blood cultures.

The 176 patients whose catheters were inserted by using maximal sterile barrier precautions were comparable to the 167 control patients in underlying disease, degree of immuno-suppression, therapeutic interventions, and catheter risk factors for infections (duration and site of catheterization, number of catheter lumen, catheter insertion difficulty, reason for catheter removal). There were a total of four catheter infections in the test group and 12 in the control group (P=0.03, chi-square test). The catheter-related septicemia rate was 6.3 times higher in the control group (P=0.06, Fisher's exact test). Most (67%) of the catheter infections in the control group occurred during the first 2 months after insertion, whereas 25% of the catheter infections in the maximal sterile precautions group occurred during the same period (P<0.01, Fisher's exact test). Cost-benefit analysis showed the use of such precautions to be highly cost-effective.

Maximal sterile barrier precautions during the insertion of nontunneled catheters reduce the risk of catheter infection. This practice is cost-effective and is consistent with the practice of universal precautions during an invasive procedure.

To determine healthcare-associated infection (HAI) prevalence in 9 hospitals in Jacksonville, Florida; to evaluate the performance of proxy indicators for HAIs; and to refine methodology in preparation for a multistate survey.

Point prevalence survey.

Acute care inpatients of any age.

HAIs were defined using National Healthcare Safety Network criteria. In each facility a trained primary team (PT) of infection prevention (IP) staff performed the survey on 1 day, reviewing records and collecting data on a random sample of inpatients. PTs assessed patients with one or more proxy indicators (abnormal white blood cell count, abnormal temperature, or antimicrobial therapy) for the presence of HAIs. An external IP expert team collected data from a subset of patient records reviewed by PTs to assess proxy indicator performance and PT data collection.

Of 851 patients surveyed by PTs, 51 had one or more HAIs (6.0%; 95% confidence interval, 4.5%–7.7%). Surgical site infections (n = 18), urinary tract infections (n = 9), pneumonia (n = 9), and bloodstream infections (n = 8) accounted for 75.8% of 58 HAIs detected by PTs. Staphylococcus aureus was the most common pathogen, causing 9 HAIs (15.5%). Antimicrobial therapy was the most sensitive proxy indicator, identifying 95.5% of patients with HAIs.

HAI prevalence in this pilot was similar to that reported in the 1970s by the Centers for Disease Control and Prevention's Study on the Efficacy of Nosocomial Infection Control. Antimicrobial therapy was a sensitive screening variable with which to identify those patients at higher risk for infection and reduce data collection burden. Additional work is needed on validation and feasibility to extend this methodology to a national scale.

Infect Control Hosp Epidemiol 2012;33(3):283-291

To assess the effects of interventions to prevent transmission of influenza and to increase employee compliance with influenza vaccination.

The change in the proportion of hospitalized patients with laboratory-confirmed nosocomial influenza was observed over time and assessed using chi-square for trend analysis. The association between nosocomial influenza in patients and healthcare worker (HCW) compliance with vaccine was assessed by logistic regression.

A 600-bed, tertiary-care academic hospital.

After an outbreak of influenza A at this hospital in 1988, a mobile cart program was instituted with increased efforts to motivate employees to be vaccinated and furloughed when ill as well as new measures to prevent nosocomial spread.

HCW vaccination rates increased from 4% in 1987–1988 to 67% in 1999–2000 (P < .0001). Proportions of nosocomially acquired influenza cases among employees or patients both declined significantly (P < .0001). Logistic regression analysis revealed a significant inverse association between HCW compliance with vaccination and the rate of nosocomial influenza among patients (P < .001).

A mobile cart vaccination program and an increased emphasis on HCWs to receive the vaccine were associated with a significant increase in vaccine acceptance and a significant decrease in the rate of nosocomial influenza among patients.

The rate of influenza vaccination among healthcare workers (HCWs) is low, despite a good rationale and strong recommendations for vaccination from many health organizations.

To increase influenza vaccination rates by instituting the first mandatory influenza vaccination program for HCWs.

A 5-year study (from 2005 to 2010) at Virginia Mason Medical Center, a tertiary care, multispecialty medical center in Seattle, Washington, with approximately 5,000 employees.

All HCWs of the medical center were required to receive influenza vaccination. HCWs who were granted an accommodation for medical or religious reasons were required to wear a mask at work during influenza season. The main outcome measure was rate of influenza vaccination among HCWs.

In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.

A mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years.