RESUMEN
BACKGROUND: Enhanced Barrier Precautions (EBP) recommends using gowns and gloves for certain nursing home residents during specific high-contact care activities associated with multidrug-resistant organism (MDRO) transmission. Though EBP is included in CDC guidance as an MDRO control strategy, optimal implementation approaches remain unclear. METHODS: We implemented a quality improvement initiative using the 4E process model (Engagement, Education, Execution, and Evaluation) to optimize EBP implementation in four Maryland nursing homes. Semi-structured interviews with healthcare personnel (HCP) occurred to understand EBP acceptability. RESULTS: Glove use during high-contact care increased from 85% in the baseline to 97% during the intervention (p<0.01). Gown use increased from 27% to 78% (p<0.01). Accuracy of identifying residents eligible for EBP improved from 63% to 99% (p<0.01). Of 780 residents observed, one-third met EBP indications - MDRO colonization (21%), indwelling medical device (14%), and/or chronic wound (10%). The most noted facilitator to EBP implementation included HCP perception that EBP reduces MDRO transmission to other residents and staff. The most noted barrier was uncomfortable gowns. CONCLUSIONS: Implementation was complex and required comprehensive assessments of barriers and facilitators within each facility. HCP interviews identified common barriers and facilitators of EBP that can inform future EBP implementation projects.
RESUMEN
BACKGROUND: There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA). METHODS: Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days. RESULTS: A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20-44 years, 11.2 [95% confidence interval, 1.46-86.22]; 45-64 years, 20.88 [2.84-153.58]; ≥65 years, 22.50 [2.98-169.93]) and lack of insurance (2.46 [1.08-5.59]), and it decreased with CVC removal (0.57 [.39-.84]). CONCLUSIONS: CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.
