The CLABs collaborative: a regionwide effort to improve the quality of care in hospitals.

BACKGROUND: Each year, nearly 250,000 cases of central line-associated bloodstream infections (CLABs) occur in hospitals in the United States. In 2005, the Greater New York Hospital Association and the United Hospital Fund launched a collaborative initiative to eliminate CLABs in hospital intensive care units (ICUs). COLLABORATIVE DESIGN: Hospital leadership at 36 hospitals committed to support their staffs' participation in specific activities, including three learning sessions. An infectious disease physician consultant served as an on-call consultant to provide the necessary clinical guidance, real-time feedback, and support. Most hospitals' interdisciplinary CLABs teams met weekly to implement evidence-based practices known collectively as the central line bundle, determine areas for additional focus, and to reassess strategies using the Plan-Do-Study-Act (PDSA) model. RESULTS: There was a statistically significant decrease of 54% (p < .001) between the mean CLABs rate during the intervention period (2.24 infections per 1,000 central line days) compared with the mean baseline rate (4.85 infections per 1,000 central line days). By March 2008, the rate had dropped by 70% (1.44 infections per 1,000 central line days) compared with baseline. At the hospital level, decreases in CLABs rates up to 88% were observed between the baseline period and the intervention period, with 56% of hospitals achieving at least a 50% decrease in their CLABs rate. The hospitals beginning above the national rate decreased their CLABs rates by almost twice as much as hospitals that began below the national average. SUMMARY AND CONCLUSIONS: Each participating hospital sustained implementation of the central line bundle throughout the 33-month intervention, which, along with standardized line maintenance procedures, resulted in reduction in, and sometimes elimination of, CLABs.

Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery.

OBJECTIVE: Antibiotic use, particularly type and duration, is a crucial modifiable risk factor for Clostridium difficile. Cardiac surgery is of particular interest because prophylactic antibiotics are recommended for 48 hours or less (vs ≤24 hours for noncardiac surgery), with increasing vancomycin use. We aimed to study associations between antibiotic prophylaxis (duration/vancomycin use) and C difficile among patients undergoing coronary artery bypass grafting. METHODS: We extracted data on coronary artery bypass grafting procedures from the national Premier Perspective claims database (2006-2013, n = 154,200, 233 hospitals). Multilevel multivariable logistic regressions measured associations between (1) duration (<2 days, "standard" vs ≥2 days, "extended") and (2) type of antibiotic used ("cephalosporin," "cephalosporin + vancomycin," "vancomycin") and C difficile as outcome. RESULTS: Overall C difficile prevalence was 0.21% (n = 329). Most patients (59.7%) received a cephalosporin only; in 33.1% vancomycin was added, whereas 7.2% received vancomycin only. Extended prophylaxis was used in 20.9%. In adjusted analyses, extended prophylaxis (vs standard) was associated with significantly increased C difficile risk (odds ratio, 1.43; confidence interval, 1.07-1.92), whereas no significant associations existed for vancomycin use as adjuvant or primary prophylactic compared with the use of cephalosporins (odds ratio, 1.21; confidence interval, 0.92-1.60, and odds ratio, 1.39; confidence interval, 0.94-2.05, respectively). Substantial inter-hospital variation exists in the percentage of extended antibiotic prophylaxis (interquartile range, 2.5-35.7), use of adjuvant vancomycin (interquartile range, 4.2-61.1), and vancomycin alone (interquartile range, 2.3-10.4). CONCLUSIONS: Although extended use of antibiotic prophylaxis was associated with increased C difficile risk after coronary artery bypass grafting, vancomycin use was not. The observed hospital variation in antibiotic prophylaxis practices suggests great potential for efforts aimed at standardizing practices that subsequently could reduce C difficile risk.

Antiretroviral drug resistance in human immunodeficiency virus-infected source patients for occupational exposures to healthcare workers.

OBJECTIVE: To assess the prevalence of HIV antiretroviral resistance among source patients for occupational HIV exposures. DESIGN: Blood and data (eg, stage of HIV, previous antiretroviral drug therapy, and HIV RNA viral load) were collected from HIV-infected patients who were source patients for occupational exposures. SETTING: Seven tertiary-care medical centers in five U.S. cities (San Diego, California; Miami, Florida; Boston, Massachusetts; Albany, New York; and New York, New York [three sites]) during 1998 to 1999. PARTICIPANTS: Sixty-four HIV-infected patients who were source patients for occupational exposures. RESULTS: Virus from 50 patients was sequenced; virus from 14 patients with an undetectable (ie, < 400 RNA copies/mL) viral load could not be sequenced. Overall, 19 (38%) of the 50 patients had primary genotypic mutations associated with resistance to reverse transcriptase or protease inhibitors. Eighteen of the 19 viruses with primary mutations and 13 wild type viruses were phenotyped by recombinant assays; 19 had phenotypic resistance to at least one antiretroviral agent. Of the 50 source patients studied, 26 had taken antiretroviral agents in the 3 months before the occupational exposure incident. Sixteen (62%) of the 26 drug-treated patients had virus that was phenotypically resistant to at least one drug. Four (17%) of 23 untreated patients had phenotypically resistant virus. No episodes of HIV transmission were observed among the exposed HCWs. CONCLUSIONS: There was a high prevalence of drug-resistant HIV among source patients for occupational HIV exposures. Healthcare providers should use the drug treatment information of source patients when making decisions about post-exposure prophylaxis.

Addendum: Safety Standards for Gua sha (press-stroking) and Ba guan (cupping).

Our previous article Safety Standards for Gua sha (press-stroking) and Baguan (cupping) discussed the risk of transfer of blood-borne pathogens with Gua sha and Ba guan, identified Gua sha and Ba guan 'instrument criticality' as semi-critical and offered recommendations for safe practice based on hospital disinfection standards. Based on the article's feedback, we feel the need to clarify that Gua sha and Ba guan instruments, if intended for reuse, must undergo high level disinfection (HLD) or, in the case of 'wet-cupping', sterilization. We update our recommendations to be amenable to both private practice and education settings.

Prevention of hospital-onset Clostridium difficile infection in the New York metropolitan region using a collaborative intervention model.

The incidence, severity, and associated costs of Clostridium difficile (C. difficile) infection (CDI) have dramatically increased in hospitals over the past decade, indicating an urgent need for strategies to prevent transmission of C. difficile. This article describes a multifaceted collaborative approach to reduce hospital-onset CDI rates in 35 acute care hospitals in the New York metropolitan region. Hospitals participated in a comprehensive CDI reduction intervention and formed interdisciplinary teams to coordinate their efforts. Standardized clinical infection prevention and environmental cleaning protocols were implemented and monitored using checklists. Monthly data reports were provided to hospitals for facility-specific performance evaluation and comparison to aggregate data from all participants. Hospitals also participated in monthly teleconferences to review data and highlight successes, challenges, and strategies to reduce CDI. Incidence of hospital-onset CDI per 10,000 patient days was the primary outcome measure. Additionally, the incidence of nonhospital-associated, community-onset, hospital-associated, and recurrent CDIs were measured. The use of a collaborative model to implement a multifaceted infection prevention strategy was temporally associated with a significant reduction in hospital-onset CDI rates in participating New York metropolitan regional hospitals.

Safety protocols for gua sha (press-stroking) and baguan (cupping).

Gua sha (press-stroking) and Baguan (cupping) are therapeutic procedures of traditional East Asian medicine (TEAM) that are also practiced in integrative clinical as well as domestic or familial settings. They may be defined as instrument assisted mechanical stimulation of the body surface that intentionally creates therapeutic petechiae and ecchymosis representing extravasation of blood in the subcutis. Blood and 'other potentially infectious material' (OPIM) can sometimes be drawn through the surface of the skin leading to potential contamination of instruments and to risk of bloodborne pathogen exposure. Neither the literature nor the current national standards of the acupuncture profession sufficiently address safety standards for Gua sha and Baguan. This paper presents the nature of the potential risks and applies current hospital safety standards as proposed protocols for Gua sha and Baguan.

Prospective, multicenter surveillance study of Candida glabrata: fluconazole and itraconazole susceptibility profiles in bloodstream, invasive, and colonizing strains and differences between isolates from three urban teaching hospitals in New York City (Candida Susceptibility Trends Study, 1998 to 1999).

Since the 1990s, the substantial increase in the rate of Candida glabrata infections has become a serious problem. As most C. glabrata infections arise from the host's endogenous microflora, the present prospective, multicenter analysis included all clinical isolates associated with colonization and with systemic and hematogenous candidiasis. Among 347 C. glabrata isolates, the overall rates of resistance to fluconazole (MIC > or = 64 micro g/ml) and itraconazole (MIC > or = 1 micro g/ml) were 10.7 and 15.2%, respectively, although for half (n = 148) of the itraconazole-susceptible isolates the MICs (0.25 to 0.5 micro g/ml) were in the susceptible-dependent upon dose range. Fluconazole resistance was more common among C. glabrata isolates obtained from centers caring for patients with cancer (MICs at which 90% of isolates are inhibited [MIC(90)s] = 32 micro g/ml) or AIDS (MIC(90)s > 64 micro g/ml) than among C. glabrata isolates from a community-based university medical center (MIC(90)s = 16 micro g/ml) (P = 0.001). Thirty-three bloodstream isolates and those obtained from other body sites had similar in vitro susceptibility profiles. The fluconazole MIC(90)s (< or =16 micro g/ml) for C. glabrata yeast isolates from the gastrointestinal tract were lower than those (> or =64 micro g/ml) for C. glabrata isolates from respiratory and urinary tract samples (P = 0.01). A similar discrepancy for itraconazole was not significant (P > 0.5). We did not observe differences in fluconazole or itraconazole susceptibility profiles among C. glabrata isolates associated with either hematogenous dissemination or colonization. The significant discrepancy in antifungal susceptibility among C. glabrata organisms isolated from hospitals in the same geographic region emphasizes the significance of periodic susceptibility surveillance programs for individual institutions, especially those providing care to patients at risk.