Quality improvement in hospitals: barriers and facilitators.

Purpose The purpose of this paper is to examine quality improvement (QI) initiatives in acute care hospitals, the factors associated with success, and the impacts on patient care and safety. Design/methodology/approach An extensive online survey was completed by senior managers responsible for QI. The survey assessed QI project types, QI methods, staff engagement, and barriers and factors in the success of QI initiatives. Findings The response rate was 37 percent, 46 surveys were completed from 125 acute care hospitals. QI initiatives had positive impacts on patient safety and care. Staff in all hospitals reported conducting past or present hand-hygiene QI projects and C. difficile and surgical site infection were the next most frequent foci. Hospital staff not having time and problems with staff prioritizing QI with other duties were identified as important QI barriers. All respondents reported hospital leadership support, data utilization and internal champions as important QI facilitators. Multiple regression models identified nurses' active involvement and medical staff engagement in QI with improved patient care and physicians' active involvement and medical staff engagement with greater patient safety. Practical implications There is the need to study how best to support and encourage physicians and nurses to become more engaged in QI. Originality/value QI initiatives were shown to have positive impacts on patient safety and patient care and barriers and facilitating factors were identified. The results indicated patient care and safety would benefit from increased physician and nurse engagement in QI initiatives.

Herpes simplex virus lymphadenitis: the elusive doppelganger in immunocompromised patients.

Herpes simplex virus has protean manifestations and is an important cause of morbidity in the immunocompromised host. We report a case of recurrent lymphadenopathy and rash in a patient with chronic lymphocytic leukemia. The elusive clinical diagnosis eventually required core biopsy of a lymph node with immunohistochemistry and confirmation by polymerase chain reaction. This case illustrates the challenging clinical and laboratory diagnosis of herpes simplex virus lymphadenitis and the need to maintain a high index of suspicion for infection when treating an immunocompromised patient with unusual and/or persistent symptoms.

Environmental cleaning resources and activities in Canadian acute care hospitals.

BACKGROUND: Environmental cleaning interventions have increased cleaning effectiveness and reduced antibiotic-resistant organisms in hospitals. This study examined cleaning in Canadian acute care hospitals with the goal of developing strategies to improve cleaning and reduce antibiotic-resistant organism rates. METHODS: Managers most responsible for environmental services (EVS) completed an extensive online survey that assessed EVS resources and cleaning practices. RESULTS: The response rate was 50.5%; 96 surveys were completed, representing 103 of 204 hospitals. Whereas 86.3% (82/95) of managers responsible for EVS reported their staff was adequately trained and 76.0% (73/96) that supplies and equipment budgets were sufficient, only 46.9% (45/96) reported that EVS had enough personnel to satisfactorily clean their hospital. A substantial minority (36.8%, 35/95) of EVS departments did not audit the cleaning of medical surgical patient rooms on at least a monthly basis. Cleaning audits of medical surgical patient rooms frequently included environmental marking methods in only one third (33.3%, 31/93) of hospitals and frequently included the measurement of residual bioburden in only 13.8% (13/94). CONCLUSION: There was a general need for increased and improved auditing of environmental cleaning in Canadian hospitals, and there were perceived EVS staffing deficits in the majority of hospitals.

Working relationships of infection prevention and control programs and environmental services and associations with antibiotic-resistant organisms in Canadian acute care hospitals.

BACKGROUND: Environmental contamination in hospitals with antibiotic-resistant organisms (AROs) is associated with patient contraction of AROs. This study examined the working relationship of Infection Prevention and Control (IPAC) and Environmental Services and the impact of that relationship on ARO rates. METHODS: Lead infection control professionals completed an online survey that assessed the IPAC and Environmental Services working relationship in their acute care hospital in 2011. The survey assessed cleaning collaborations, staff training, hospital cleanliness, and nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection, vancomycin-resistant Enterococcus (VRE) infection, and Clostridium difficile infection (CDI). RESULTS: The survey was completed by 58.3% of hospitals (119 of 204). Two-thirds (65.8%; 77 of 117) of the respondents reported that their cleaners were adequately trained, and 62.4% (73 of 117) reported that their hospital was sufficiently clean. Greater cooperation between IPAC and Environmental Services was associated with lower rates of MRSA infection (r = -0.22; P = .02), and frequent collaboration regarding cleaning protocols was associated with lower rates of VRE infection (r = -0.20; P = .03) and CDI (r = -0.31; P < .001). CONCLUSIONS: Canadian IPAC programs generally had collaborative working relationships with Environmental Services, and this was associated with lower rates of ARO. Deficits in the adequacy of cleaning staff training and hospital cleanliness were identified. The promotion of collaborative working relationships and additional training for Environmental Services workers would be expected to lower ARO rates.

Chikungunya-related arthritis: case report and review of the literature.

INTRODUCTION: Chikungunya fever often presents with severe arthritis/arthralgias, high fever, myalgias, headache, and maculopapular rash (Chow et al., 2011 [1]; Das et al., 2010 [2]; Mizuno et al., 2011 [3]; Powers, 2010 [4]; Sissoko et al., 2010 [5]; Staples et al., 2009 [6]). Persistent arthritis/arthralgias commonly develop after symptomatic infection and are the most common long-term complication (Chow et al., 2011 [1]; Powers, 2010 [4]; Sissoko et al., 2010 [5]; Staples et al., 2009 [6]). The small joints are most often affected in a symmetric pattern that can mimic adult rheumatoid arthritis (RA) (Mizuno et al., 2011 [3]; Bouquillard and Combe, 2009 [7]; Chabbra et al., 2008 [8]; Jaffar-Bandjee et al., 2009 [9]; Simon et al., 2007 [10]). OBJECTIVE: We present a case of Chikungunya virus (CHIKV)-induced arthritis and review the literature surrounding Chikungunya-induced arthritis/arthralgias and associated musculoskeletal (MSK) manifestations. METHODS: A Medline search was completed from 1946--November 2011. Key words included Chikungunya virus and arthritis. A PubMed search was completed from 1996--November 2011. Search terms included Chikungunya virus, etiology, and fever. Searches were limited to humans and English language publications. Additional relevant articles were obtained from the reference lists.

Effectiveness of a novel ozone-based system for the rapid high-level disinfection of health care spaces and surfaces.

BACKGROUND: Vapor-based fumigant systems for disinfection of health care surfaces and spaces is an evolving technology. A new system (AsepticSure) uses an ozone-based process to create a highly reactive oxidative vapor with broad and high-level antimicrobial properties. METHODS: Ozone gas at 50-500 ppm was combined with 3% hydrogen peroxide vapor in a test chamber and upscaled in rooms measuring 82 m3 and 90 m3 in area. Test organisms included methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, Escherichia coli, Pseudomonas aeruginosa, Clostridium difficile, and Bacillus subtilis spores dried onto steel discs or cotton gauze pads. RESULTS: The combination of 80-ppm ozone with 1% hydrogen peroxide vapor achieved a very high level of disinfection, with a ≥6 log10 reduction in the bacteria and spores tested on steel discs and MRSA tested on cotton gauze during a 30- to 90-minute exposure. The entire system was scalable such that it achieved the same high level of disinfection in both the 81-m3 and 90-m3 rooms in 60-90 minutes. CONCLUSION: The ozone hydrogen peroxide vapor system provides a very high level of disinfection of steel and gauze surfaces against health care-associated bacterial pathogens. The system is an advanced oxidative process providing a rapid and effective means of disinfecting health care surfaces and spaces.

Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada.

BACKGROUND: In the 2003 Toronto SARS outbreak, SARS-CoV was transmitted in hospitals despite adherence to infection control procedures. Considerable controversy resulted regarding which procedures and behaviours were associated with the greatest risk of SARS-CoV transmission. METHODS: A retrospective cohort study was conducted to identify risk factors for transmission of SARS-CoV during intubation from laboratory confirmed SARS patients to HCWs involved in their care. All SARS patients requiring intubation during the Toronto outbreak were identified. All HCWs who provided care to intubated SARS patients during treatment or transportation and who entered a patient room or had direct patient contact from 24 hours before to 4 hours after intubation were eligible for this study. Data was collected on patients by chart review and on HCWs by interviewer-administered questionnaire. Generalized estimating equation (GEE) logistic regression models and classification and regression trees (CART) were used to identify risk factors for SARS transmission. RESULTS: 45 laboratory-confirmed intubated SARS patients were identified. Of the 697 HCWs involved in their care, 624 (90%) participated in the study. SARS-CoV was transmitted to 26 HCWs from 7 patients; 21 HCWs were infected by 3 patients. In multivariate GEE logistic regression models, presence in the room during fiberoptic intubation (OR = 2.79, p = .004) or ECG (OR = 3.52, p = .002), unprotected eye contact with secretions (OR = 7.34, p = .001), patient APACHE II score > or = 20 (OR = 17.05, p = .009) and patient Pa0(2)/Fi0(2) ratio < or = 59 (OR = 8.65, p = .001) were associated with increased risk of transmission of SARS-CoV. In CART analyses, the four covariates which explained the greatest amount of variation in SARS-CoV transmission were covariates representing individual patients. CONCLUSION: Close contact with the airway of severely ill patients and failure of infection control practices to prevent exposure to respiratory secretions were associated with transmission of SARS-CoV. Rates of transmission of SARS-CoV varied widely among patients.

Exposure to hospital roommates as a risk factor for health care-associated infection.

BACKGROUND: Numerous patient- and hospital-level characteristics have been established as risk factors for the transmission of health care-associated infections (HAIs). Few studies have quantitatively assessed the impact of exposure to hospital roommates on the acquisition of infections. This study evaluated the association between roommate exposures and the risk of HAIs. METHODS: A retrospective cohort of adult patients admitted to a Canadian teaching hospital between June 30, 2001, and December 31, 2005, was studied. Exposures were characterized as total daily roommate exposures and daily unique roommate exposures. Outcomes examined were methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile. RESULTS: The number of roommate exposures per day was significantly associated with MRSA and VRE infection or colonization (MRSA: hazard ratio [HR] = 1.10, 95% confidence interval [CI] = 1.05 to 1.15; VRE: HR = 1.11, 95% CI = 1.02 to 1.21), and with C difficile infection (HR = 1.11, 95% CI = 1.03 to 1.19). A significant association also was found for number of unique roommate exposures per day and VRE (HR = 1.15, 95% CI = 1.02 to 1.28). CONCLUSIONS: The significant associations found between daily roommate exposures and the infection outcomes suggest a possible role for limiting patient-to-patient contact in an infection prevention and control program in this facility. These findings have implications for the deployment and design of acute care hospitals.

The pandemic influenza planning process in Ontario acute care hospitals.

BACKGROUND: There will be little time to prepare when an influenza pandemic strikes; hospitals need to develop and test pandemic influenza plans beforehand. METHODS: Acute care hospitals in Ontario were surveyed regarding their pandemic influenza preparedness plans. RESULTS: The response rate was 78.5%, and 95 of 121 hospitals participated. Three quarters (76.8%, 73 of 95) of hospitals had pandemic influenza plans. Only 16.4% (12 of 73) of hospitals with plans had tested them. Larger (chi(2) = 6.7, P = .01) and urban hospitals (chi(2) = 5.0, P = .03) were more likely to have tested their plans. 70.4% (50 of 71) Of respondents thought the pandemic influenza planning process was not adequately funded. No respondents were "very satisfied" with the completeness of their hospital's pandemic plan, and only 18.3% were "satisfied." CONCLUSION: Important challenges were identified in pandemic planning: one quarter of hospitals did not have a plan, few plans were tested, key players were not involved, plans were frequently incomplete, funding was inadequate, and small and rural hospitals were especially disadvantaged. If these problems are not addressed, the result may be increased morbidity and mortality when a virulent influenza pandemic hits.

Molecular epidemiology of Acinetobacter baumannii in central intensive care unit in Kosova teaching hospital

Infections caused by bacteria of genus Acinetobacter pose a significant health care challenge worldwide. Information on molecular epidemiological investigation of outbreaks caused by Acinetobacter species in Kosova is lacking. The present investigation was carried out to enlight molecular epidemiology of Acinetobacterbaumannii in the Central Intensive Care Unit (CICU) of a University hospital in Kosova using pulse field gel electrophoresis (PFGE). During March - July 2006, A. baumannii was isolated from 30 patients, of whom 22 were infected and 8 were colonised. Twenty patients had ventilator-associated pneumonia, one patient had meningitis, and two had coinfection with bloodstream infection and surgical site infection. The most common diagnoses upon admission to the ICU were politrauma and cerebral hemorrhage. Bacterial isolates were most frequently recovered from endotracheal aspirate (86.7 percent). First isolation occurred, on average, on day 8 following admission (range 1-26 days). Genotype analysis of A. baumannii isolates identified nine distinct PFGE patterns, with predominance of PFGE clone E represented by isolates from 9 patients. Eight strains were resistant to carbapenems. The genetic relatedness of Acinetobacter baumannii was high, indicating cross-transmission within the ICU setting. These results emphasize the need for measures to prevent nosocomial transmission of A. baumannii in ICU.

A comparison of infection control program resources, activities, and antibiotic resistant organism rates in Canadian acute care hospitals in 1999 and 2005: pre- and post-severe acute respiratory syndrome.

INTRODUCTION: The Resources for Infection Control in Hospitals (RICH) project assessed infection control programs and rates of antibiotic-resistant organisms (AROs) in Canadian acute care hospitals in 1999. In the meantime, the Severe Acute Respiratory Syndrome (SARS) outbreak and the concern over pandemic influenza have stimulated considerable government and healthcare institutional efforts to improve infection control systems in Canada. METHODS: In 2006, a version of the RICH survey similar to the original RICH instrument was mailed to infection control programs in all Canadian acute care hospitals with 80 or more beds. Chi-square, ANOVA, and analysis of covariance analyses tested for differences between the 1999 and 2005 samples for infection control program components and ARO rates. RESULTS: 72.3% of Canadian acute care hospitals completed the RICH survey for 1999 and 60.1% for 2005. Hospital size was controlled for in analyses involving AROs and surveillance and control intensity levels. Methicillin-resistant Staphylococcus aureus (MRSA) rates increased from 1999 to 2005 (F = 9.4, P = 0.003). In 2005, the MRSA rate was 5.2 (SD 6.1) per 1,000 admissions and in 1999 was 2.0 (SD 2.9). Clostridium difficile-associated diarrhea (CDAD) rates, trended up from 1999 to 2005 (F = 2.9, P = 0.09). In 2005, the mean CDAD rate was 4.7 (SD 4.3) and in 1999 it was 3.8 (SD 4.3). The proportion of hospitals that reported having new nosocomial Vancomycin-resistant Enterococcus (VRE) cases was greater in 2005 than in 1999 (X = 10.5, P = 0.001). In 1999, 34.5% (40 of 116) hospitals reported having new nosocomial VRE cases and in 2005, 61.0% (64 of 105) reported new cases. Surveillance intensity index scores increased from 61.7 (SD 18.5) in 1999 to 68.1 (SD 15.4) in 2005 (F = 4.1, P = 0.04). Control intensity index scores, trended upwards slightly from 60.8 (SD 14.6) in 1999 to 64.1 (12.2) in 2005 (F = 3.2, P = 0.07). ICP full time equivalents (FTEs) per 100 beds increased from 0.5 (SD 0.2) in 1999 to 0.8 (SD 0.3) in 2005 (F = 90.8, P < 0.0001). However, the proportion of ICPs in hospitals certified by the Certification Board of Infection Control (CBIC) decreased from 53% (SD 46) in 1999 to 38% (SD 36) in 2005 (F = 8.7, P = 0.004). CONCLUSIONS: Canadian infection control programs in 2005 continued to fall short of expert recommendations for human resources and surveillance and control activities. Meanwhile, Nosocomial MRSA rates more than doubled between 1999 and 2005 and hospitals reporting new nosocomial VRE cases increased 77% over the same period. While investments have been made towards infection control programs in Canadian acute hospitals, the rapid rise in ICP positions has not yet translated into marked improvements in surveillance and control activities. In the face of substantial increases in ARO rates in Canada, continued efforts to train ICPs and support hospital infection control programs are necessary.

A cross-Canada survey of infection prevention and control in long-term care facilities.

BACKGROUND: Residents in long-term care facilities (LTCFs) are at considerable risk for developing infections. This is the first comprehensive examination of infection control programs in Canadian LTCFs in almost 20 years. METHODS: A survey designed to assess resident and LTCF characteristics; personnel, laboratory, computer, and reference resources; and surveillance and control activities of infection prevention and control programs was sent in 2005 to all eligible LTCFs across Canada. RESULTS: One third of LTCFs (34%, 488/1458) responded. Eighty-seven percent of LTCFs had infection control committees. Most LTCFs (91%) had 24-hour care by registered nurses, and 84% had on-site infection control staff. The mean number of full-time equivalent infection control professionals (ICPs) per 250 beds was 0.6 (standard deviation [SD], 1.0). Only 8% of ICPs were certified by the Certification Board of Infection Control and Epidemiology. Only one fifth of LTCFs had physicians or doctoral level professionals providing service to the infection control program. The median surveillance index score was 63 out of a possible 100, and the median control index score was 79 of 100. Influenza vaccinations were received by 93.0% (SD, 11.3) of residents in 2004. CONCLUSION: To bring infection control programs in Canadian LTCFs up to expert suggested resource and intensity levels will necessitate considerable investment. More and better trained ICPs are essential to providing effective infection prevention and control programs in LTCFs and protecting vulnerable residents from preventable infections.

Molecular epidemiology of Acinetobacter baumannii in central intensive care unit in Kosova Teaching Hospital.

Infections caused by bacteria of genus Acinetobacter pose a significant health care challenge worldwide. Information on molecular epidemiological investigation of outbreaks caused by Acinetobacter species in Kosova is lacking. The present investigation was carried out to enlight molecular epidemiology of Acinetobacter baumannii in the Central Intensive Care Unit (CICU) of a University hospital in Kosova using pulse field gel electrophoresis (PFGE). During March - July 2006, A. baumannii was isolated from 30 patients, of whom 22 were infected and 8 were colonised. Twenty patients had ventilator-associated pneumonia, one patient had meningitis, and two had coinfection with bloodstream infection and surgical site infection. The most common diagnoses upon admission to the ICU were politrauma and cerebral hemorrhage. Bacterial isolates were most frequently recovered from endotracheal aspirate (86.7%). First isolation occurred, on average, on day 8 following admission (range 1-26 days). Genotype analysis of A. baumannii isolates identified nine distinct PFGE patterns, with predominance of PFGE clone E represented by isolates from 9 patients. Eight strains were resistant to carbapenems. The genetic relatedness of Acinetobacter baumannii was high, indicating cross-transmission within the ICU setting. These results emphasize the need for measures to prevent nosocomial transmission of A. baumannii in ICU.

A comparison of infection control program resources, activities, and antibiotic resistant organism rates in Canadian acute care hospitals in 1999 and 2005: pre- and post-severe acute respiratory syndrome.

BACKGROUND: The Resources for Infection Control in Hospitals (RICH) project assessed infection control programs and rates of antibiotic-resistant organisms (AROs) in Canadian acute care hospitals in 1999. In the meantime, the severe acute respiratory syndrome (SARS) outbreak and the concern over pandemic influenza have stimulated considerable government and health care institutional efforts to improve infection control systems in Canada. METHODS: In 2006, a version of the RICH survey similar to the original RICH instrument was mailed to infection control programs in all Canadian acute care hospitals with 80 or more beds. We used chi(2), analysis of variance, and analysis of covariance analyses to test for differences between the 1999 and 2005 samples for infection control program components and ARO rates. RESULTS: 72.3% of Canadian acute care hospitals completed the RICH survey for 1999 and 60.1% for 2005. Hospital size was controlled for in analyses involving AROs and surveillance and control intensity levels. Methicillin-resistant Staphylococcus aureus (MRSA) rates increased from 1999 to 2005 (F = 9.4, P = .003). In 2005, the mean MRSA rate was 5.2 (standard deviation [SD], 6.1) per 1000 admissions, and, in 1999, it was 2.0 (SD, 2.9). Clostridium difficile-associated diarrhea rates trended up from 1999 to 2005 (F = 2.9, P = .09). In 2005, the mean Clostridium difficile-associated diarrhea rate was 4.7 (SD, 4.3), and, in 1999, it was 3.8 (SD, 4.3). The proportion of hospitals that reported having new nosocomial vancomycin-resistant Enterococcus (VRE) cases was greater in 2005 than in 1999 (chi(2) = 10.5, P = .001). In 1999, 34.5% (40/116) of hospitals reported having new nosocomial VRE cases, and, in 2005, 61.0% (64/105) reported new cases. Surveillance intensity index scores increased from a mean of 61.7 (SD, 18.5) in 1999 to 68.1 (SD, 15.4) in 2005 (F = 4.1, P = .04). Control intensity index scores trended upward slightly from a mean of 60.8 (SD, 14.6) in 1999 to 64.1 (SD, 12.2) in 2005 (F = 3.2, P = .07). Infection control professionals (ICP) full-time equivalents (FTEs) per 100 beds increased from a mean of 0.5 (SD, 0.2) in 1999 to 0.8 (SD, 0.3) in 2005 (F = 90.8, P < .0001). However, the proportion of ICPs in hospitals certified by the Certification Board of Infection Control decreased from 53% (SD, 46) in 1999 to 38% (SD, 36) in 2005 (F = 8.7, P = .004). CONCLUSION: Canadian infection control programs in 2005 continued to fall short of expert recommendations for human resources and surveillance and control activities. Meanwhile, nosocomial MRSA rates more than doubled between 1999 and 2005, and hospitals reporting new nosocomial VRE cases increased 77% over the same period. Although investments have been made toward infection control programs in Canadian acute care hospitals, the rapid rise in ICP positions has not yet translated into marked improvements in surveillance and control activities. In the face of substantial increases in ARO rates in Canada, continued efforts to train ICPs and support hospital infection control programs are necessary.

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.

BACKGROUND: The objectives of this integrative review were to critically examine the overall state of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections (HCAIs) in acute care and long-term care settings, and offer recommendations for future directions in the field based on our findings. METHODS: We searched for original research and reviews of research published between January 1, 1996, and July 31, 2006. Studies were identified through the electronic databases Medline, CINAHL, EMBASE, PUBMED, the Cochrane Library, and through expert consultation. Our comprehensive search strategy included all English articles for which hand hygiene or handwashing-related terms were combined with HCAIs. All studies that investigated a relationship between hand hygiene practices and HCAIs in acute care facilities were considered. These hand hygiene practices included the initiation of multimodal hand hygiene initiatives, the introduction of alcohol sanitizers, the implementation or changes of the infection control practices or infection control policies, and other organizational interventions. Studies only examining hand hygiene compliance, efficacy of alcohol hand gels, plain soap, and antimicrobial soap in reducing bacteria count recovered from hands were excluded. RESULTS: Of the 1120 articles retrieved, 35 publications, including 4 reviews of research discussed at the outset of this article, met our inclusion criteria. The remaining 31 eligible original studies included 18 (58.07%) before and after studies without control groups, 4 (12.90%) before and after studies with a control group, 3 (9.68%) cohort studies with no control group, 4 (12.90%) cohort studies with a control group, and 2 (6.45%) randomized trials. Over 50% (16 or 31) of the studies were conducted in the U.S. Two independent reviewers conducted independent evaluations of all eligible studies, critiquing and scoring each study using a rating scale for examining the fatal flaws of quasi-experimental and before and after studies. CONCLUSIONS: There is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs. The varied nature of the interventions used and the diverse factors affecting the acquisition of HCAIs make it difficult to show the specific effect of hand hygiene alone. The most frequent methodologies currently used in this research area are before and after observational studies without a control comparison group. Based on these findings, we recommend that researchers used a modified version of Larson's 2005 criteria to guide the design and conduct of future before and after observational studies in this area. We also argue that as we accumulate stronger evidence of which interventions are most effective, we need to develop additional research approaches to study how organizations succeed and fail in fostering the uptake of evidence-based hand hygiene interventions.

Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial.

OBJECTIVE: To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes. DESIGN: Cluster randomised controlled trial. SETTING: 24 nursing homes in Ontario, Canada, and Idaho, United States. PARTICIPANTS: 12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents. INTERVENTIONS: Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach--small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians. MAIN OUTCOME MEASURES: Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths. RESULTS: Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference -0.49, 95% confidence intervals -0.93 to -0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference -9.6%, -16.9% to -2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighted mean difference -0.37, -1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms. CONCLUSION: A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes.

Evaluation of hospital and patient factors that influence the effective administration of surgical antimicrobial prophylaxis.

OBJECTIVE: To analyze and model the patient and healthcare system factors that may interfere with the appropriate administration of surgical antimicrobial prophylaxis. DESIGN: Between 1994 and 1998, surgical-site surveillance data were collected prospectively for a cohort of eligible surgical patients. For all cases, and each individual procedure (cardiothoracic, colonic, gynecologic, orthopedic, or vascular), forward stepwise multiple logistic regression was applied to relate key hospital and patient factors to an effective first prophylactic dose (ie, appropriate administration time, dose, route, and drug). SETTING: A 450-bed, tertiary-care teaching hospital in Canada. PATIENTS: A total of 4,835 patients admitted for surgical procedures who required antimicrobial prophylaxis. RESULTS: Factors positive for an effective first prophylactic dose for all cases were when an order was written (OR, 19.7; CI95, 9.1-42.7; P < .001) and given in the operating room (OR, 13.9; CI95, 7.5-25.6; P < .001). Factors negative for an effective first prophylactic dose were beta-lactam allergy (OR, 0.49; CI95, 0.4-0.61; P < .001) and same-day surgery (OR, 0.57; CI95, 0.4-0.82; P < .001). CONCLUSIONS: With few exceptions, the four factors included in the procedure models showed that when a preoperative order was written or the antibiotic was given in the operating room, a patient was more likely to receive an effective first prophylactic dose. Conversely, when a patient had a beta-lactam allergy or the surgery was performed on the day the patient was admitted, the administration of an effective first prophylactic dose was less likely.

The relationship between hospital infection surveillance and control activities and antibiotic-resistant pathogen rates.

BACKGROUND: Antibiotic-resistant pathogen rates are rising in Canada and the United States with significant health and economic costs. The examination of the relationship of surveillance and control activities in hospitals with rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile -associated diarrhea (CDAD), and vancomycin-resistant Enterococcus (VRE) may identify strategies for controlling this growing problem. METHODS: Surveys were sent to infection control programs in hospitals that participated in an earlier survey of infection control practices in Canadian acute care hospitals. RESULTS: One hundred twenty of 145 (82.8%) hospitals responded to the survey. The mean MRSA rate was 2.0 (SD 2.9) per 1000 admissions, the mean CDAD rate was 3.8 (SD 4.3), and the mean VRE rate was 0.4 (SD 1.5). Multiple stepwise regression analysis found that hospitals that reported infection rates by specific risk groups ( r = -0.27, P < .01) and that kept attendance records of infection control teaching activities ( r = -0.23, P < .01) were associated with lower MRSA rates. Multiple stepwise regression analysis found that larger hospitals ( r = 0.25, P < .01) and hospitals at which infection control committees or staff had the direct authority to close a ward or unit to further admissions because of outbreaks ( r = 0.22, P < .05) were associated with higher CDAD rates. Multiple logistic regression analysis found that larger hospitals (OR, 1.6; 95% CI, 1.2-2.0; P = .003) and teaching hospitals (OR, 3.7 95% CI, 1.2-11.8; P = .02) were associated with the presence of VRE. Hospitals were less likely to have VRE when infection control staff frequently contacted physicians and nurses for reports of new infections (OR, 0.5; 95% CI, 0.3-0.7; P = .02) and there were in-service programs for updating nursing and ancillary staff on current infection control practices (OR, 0.2; 95% CI, 0.1-0.7; P = .01). CONCLUSION: Surveillance and control activities were associated with MRSA and CDAD rates and the presence of VRE. Surveillance and control activities might be especially beneficial in large and teaching hospitals.

Health effects of anthrax vaccination in the Canadian forces.

OBJECTIVE: The objective of this study was to determine whether anthrax vaccine resulted in adverse health effects in Canadian Forces members 8 months after vaccination. METHODS: A quasi-experimental, retrospective chart review was undertaken for two groups within the Canadian Forces, one group that received anthrax vaccination and another that did not. Information on symptoms, diagnoses, and injuries for 848 persons for which there were approximately 35,000 chart entries was abstracted from charts over a 4.5-year period and was coded using the International Statistical Classification of Diseases and Related Health Problems, 10th edition. RESULTS: The chart retrieval rate was 84%. The mean number of chart entries per person was higher in the comparison group (43.4) than in the vaccine group (38.2). No statistically significant differences were seen in the percent change before and after vaccination in the number of chart entries for specific diagnoses and symptoms for the vaccine group compared with the comparison group. Visual inspection of the time trend in rates showed no unexplained increases in the rate of diagnosis and symptoms in the vaccine group after vaccination. CONCLUSION: This study found no evidence that the anthrax vaccination resulted in an increase in adverse health effects in the 8-month period after vaccination.