An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery.

PURPOSE: The primary goal of the Surgical Care Improvement Project is to improve quality of care by implementing evidence-based health care practices that prevent surgical complications. This study was designed to test the hypothesis that an increase in compliance with quality process measures decreases the rate of surgical site infections in patients undergoing colorectal surgeries. METHODS: A multidisciplinary task force implemented and monitored compliance with individual quality measures in patients undergoing elective colorectal resections at a tertiary institution. Individual compliance rates and infections were collected prospectively and reviewed monthly. For data analysis, patients were assigned to 2 consecutive 14-month periods: period A (April 1, 2006 to May 31, 2007) and period B (June 1, 2007 to July 31, 2008). Comparisons between periods were performed to determine the association of compliance with process measures and outcomes in infections. RESULTS: A total of 491 consecutive patients were treated during the study periods (period A: n = 238; period B: n = 253). There were no statistically significant differences in patient characteristics, diagnoses, or surgical procedures between periods. Compliance with all process measures significantly increased within periods except for perioperative glucose control. Global compliance (compliance with all measures per patient) significantly improved from period A to B (40%-68%, respectively; P < .001). In total, 99 patients (19%) developed surgical site infections (period A, 18.9%; period B, 19.4%). CONCLUSION: An increase in compliance with the Surgical Care Improvement Project aimed to prevent surgical site infections does not translate into a significant reduction of surgical site infections in patients undergoing colorectal resections.

Evaluation of the National Healthcare Safety Network standardized infection ratio risk adjustment for healthcare-facility-onset Clostridioides difficile infection in intensive care, oncology, and hematopoietic cell transplant units in general acute-care hospitals.

OBJECTIVE: To evaluate the National Health Safety Network (NHSN) hospital-onset Clostridioides difficile infection (HO-CDI) standardized infection ratio (SIR) risk adjustment for general acute-care hospitals with large numbers of intensive care unit (ICU), oncology unit, and hematopoietic cell transplant (HCT) patients. DESIGN: Retrospective cohort study. SETTING: Eight tertiary-care referral general hospitals in California. METHODS: We used FY 2016 data and the published 2015 rebaseline NHSN HO-CDI SIR. We compared facility-wide inpatient HO-CDI events and SIRs, with and without ICU data, oncology and/or HCT unit data, and ICU bed adjustment. RESULTS: For these hospitals, the median unmodified HO-CDI SIR was 1.24 (interquartile range [IQR], 1.15-1.34); 7 hospitals qualified for the highest ICU bed adjustment; 1 hospital received the second highest ICU bed adjustment; and all had oncology-HCT units with no additional adjustment per the NHSN. Removal of ICU data and the ICU bed adjustment decreased HO-CDI events (median, -25%; IQR, -20% to -29%) but increased the SIR at all hospitals (median, 104%; IQR, 90%-105%). Removal of oncology-HCT unit data decreased HO-CDI events (median, -15%; IQR, -14% to -21%) and decreased the SIR at all hospitals (median, -8%; IQR, -4% to -11%). CONCLUSIONS: For tertiary-care referral hospitals with specialized ICUs and a large number of ICU beds, the ICU bed adjustor functions as a global adjustment in the SIR calculation, accounting for the increased complexity of patients in ICUs and non-ICUs at these facilities. However, the SIR decrease with removal of oncology and HCT unit data, even with the ICU bed adjustment, suggests that an additional adjustment should be considered for oncology and HCT units within general hospitals, perhaps similar to what is done for ICU beds in the current SIR.

Implementation of quality measures to reduce surgical site infection in colorectal patients.

PURPOSE: The goal of this study was to determine the rate of surgical site infection and compliance with process measures designed to prevent infection in a defined population of patients undergoing colorectal operations. METHODS: A task-force consisting of surgeons, hospital infection control personnel, anesthesiologists, and nurses was convened to enforce the use of process measures to prevent infections. We monitored antibiotic selection, dosage, timing, redosing and discontinuation, hair removal technique, intraoperative and postoperative body temperature, and perioperative glucose control for 12 months by using electronic medical records. Patients underwent a minimum of 30 days of postoperative follow-up and the attending surgeon diagnosed infections. RESULTS: Between April 2006 and March 2007, 298 patients underwent abdominal colorectal operations. The overall infection rate was 20 percent for colon procedures and 11 percent for small-bowel procedures. Compliance for most process measures improved from the first to the fourth quarter, and during the final quarter, correct antibiotic dose and hair removal with clippers exceeded 90 percent. CONCLUSIONS: The rate of surgical site infection after colorectal surgery is likely to be higher than that reported in national quality improvement programs. Perfect compliance with performance measures may be difficult to attain.

Impact of a piperacillin-tazobactam shortage on antimicrobial prescribing and the rate of vancomycin-resistant enterococci and Clostridium difficile infections.

UNLABELLED: States in 2002 on antimicrobial prescribing and associated rates of vancomycin-resistant enterococci (VRE) and Clostridium difficile infections.Design. Retrospective chart review.Setting. University-affiliated medical center. Measurements and Main Results. Microbiologic reports, patient demographics, and antimicrobial utilization were evaluated for patients admitted 6 months before the shortage (March 1-August 31, 2001) and for 6 months during the shortage (March 1-August 31, 2002). Significant increases in usage of alternative mu-lactamase inhibitor combinations, cefepime, levofloxacin, vancomycin, clindamycin, and metronidazole were observed during the shortage; in contrast, a significant decrease in the use of ceftriaxone took place. No change in the rate of VRE infection was observed from before to during the piperacillin-tazobactam shortage. However, a paradoxical 47% decrease in the rate of C. difficile colitis was documented during the shortage. Subsequent multivariate analyses suggested the reduced use of ceftriaxone and increased use of levofloxacin, but not the reduced use of piperacillin-tazobactam, correlated with the decreased rate of C. difficile infections. CONCLUSION: The piperacillin-tazobactam shortage was associated with significant changes in antimicrobial prescribing, which resulted in a significant reduction in the rate of C. difficile but not VRE infections.

Impact of a series of interventions in vancomycin prescribing on use and prevalence of vancomycin-resistant enterococci.

BACKGROUND: In response to vancomycin-resistant bacteria, particularly vancomycin-resistant enterococci (VRE), measures have been recommended to improve on the appropriate use of vancomycin. METHODS: Intervention 1 consisted of an automatic 72-hour vancomycin stop order; Intervention 2, a standardized procedure for sampling of blood cultures; and Intervention 3, an interdisciplinary critical care team. RESULTS: After Intervention 1, inappropriate use decreased, particularly in treatment of febrile neutropenia and undocumented gram-positive infections. After Intervention 2, the baseline rate of inappropriately drawn blood cultures (IDBCs) was unchanged, and use in patients with IDBCs was comparable during both periods. Before Intervention 3, 38/55 orders continuing > 72 hours were considered inappropriate versus 24/53 (p < .025) after. After the interventions, hospitalwide vancomycin use was reduced. Yet the overall rate of VRE infection initially decreased but then increased once again over time. DISCUSSION: Despite substantial reduction in hospitalwide vancomycin use, the impact on the overall rate of VRE was inconsistent and ward dependent.

An outbreak of group A Streptococcal infection among health care workers.

We describe the nosocomial transmission of group A Streptococcus species (GAS) from a single source patient to 24 health care workers (HCWs). DNA typing revealed that all of the isolates were identical to that of the source patient. The isolates were M type 1, positive for production of nicotine adenine dinucleotidase, and negative for opacity factor, all of which are factors reported to have a higher correlation with invasive disease. The 24 HCWs developed symptoms of pharyngitis < or =4 days after exposure to the source patient. Nosocomial transmission occurred < or =25 h after exposure to the source patient, before the institution of outbreak-control measures. A questionnaire was distributed to HCWs to help identify the factors responsible for the high attack rate among those who were exposed. Invasive GAS disease in a nosocomial setting can be highly transmissible. Rapid identification, early treatment, and adherence to infection-control practices may prevent or control outbreaks of infection.

Bone wax as a risk factor for surgical-site infection following neurospinal surgery.

Surgical-site infection occurred in 6 of 42 neurospinal cases in which bone wax was used and in 1 of 72 cases in which it was not used during a 3-month period (P < .01). Increased risk of infection should be considered when using bone wax as a hemostatic agent.

Discord among performance measures for central line-associated bloodstream infection.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures. OBJECTIVE: Evaluate consistency and reasons for discordance among chart review and claims-based CLABSI events. METHODS: We conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). All events had full-text medical record reviews and were identified as concordant or discordant with the other metric. RESULTS: In the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source. CONCLUSION: Substantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.