Nosocomial infections in a community hospital: 1972 through 1976.

Of 78,057 patients discharged from a community hospital from 1972 through 1976, nosocomial infections developed in 3.58 per cent. Nosocomial infections of all types were 13.2 times more frequent for patients with rapidly fatal underlying illness and 3.4 times more frequent for patients with ultimately fatal underlying illness than in cases of nonfatal underlying illness. Outbreaks of epidemics or clusters of infections caused by the same organism were distinctly uncommon. These outbreaks accounted for only 49 of the 2,798 nosocomial infections found. No distinct trends, either increases or decreases, of infection rates by pathogen, site of infection, or service were noted during the study period. Sensitivity of the common pathogens to antibiotics also remained stable.

Infections and infection control among residents of eight rural Wisconsin nursing homes.

During 1984 and 1985, an initial prevalence survey and six consecutive months of comprehensive prospective surveillance were conducted in eight rural Wisconsin nonproprietary nursing homes managed by eight nonprofit hospitals in the same communities. Our purpose was to define the infections in the residents and the infection control programs in the nursing homes. The initial prevalence survey analyzed the records of all 403 residents of the eight nursing homes. The average resident was 83.4 years old and had 3.4 chronic diseases noted on the chart. During this initial survey, 52 (12.9%) of the residents were found to have 56 active infections of all types. During six consecutive months of comprehensive surveillance in the eight nursing homes, 265 episodes of acute infection were found for an overall incidence of 10.7 infections per 100 resident months. Clusters of infection by site, pathogen, or month of onset were quite uncommon throughout the study. Susceptibility testing of organisms recovered from infections failed to reveal any clinically important resistance patterns. Because nursing homes are different in many respects from hospitals, appropriately modified definitions and infection control strategies are required for nursing homes and their residents.

Temporal trends in septicemia in a community hospital.

A prior study of septicemia in our community teaching hospital demonstrated the importance of case mix categories in understanding differences in rates of septicemia seen in hospitals. This study provides a 10 year, in 1982, and a 15 year, in 1987, follow-up of septicemia from the same hospital. A substantial increase in the incidence of septicemia was noted in 1982 and 1987. Underlying illness categories continued to be important predictors of incidence of septicemia and fatality rates. The sites of infections, relative mix of community-acquired and nosocomial infections, and mix of organisms were fairly stable throughout the period. The overall incidence of septicemia increased from 34/10,000 admissions in 1970-1973 to 87/10,000 in 1982 and 103/10,000 in 1987. The major explanations for these increases are: (a) a striking increase in the use of blood cultures from 1 blood culture per 10.4 patients in 1973 to 1 blood culture per 3.3 patients in 1987; (b) an increase in the proportion of patients in the Medicare age group from 13% in 1970-1973 to 24% in 1987, with that age group accounting for 33% of the cases of septicemia in 1970-1973 and 55% in 1982 and 1987; and (c) a modest change in the case mix category of ultimately fatal underlying illness and a probable increase in the acuity of illness for most patients admitted. Parallel changes in frequency of use of blood cultures have occurred at the previously evaluated medical school teaching hospital in the same community. These same explanations are likely to be applicable for the same time period in other acute care hospitals as well.

Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting.

OBJECTIVE: Our objective was to identify risk factors for deep sternal site infection after coronary artery bypass grafting at a community hospital. METHODS: We compared the prevalence of deep sternal site infection among patients having coronary artery bypass grafting during the study (January 1995-March 1998) and pre-study (January 1992-December 1994) periods. We compared any patient having a deep sternal site infection after coronary artery bypass graft surgery during the study period (case-patients) with randomly selected patients who had coronary artery bypass graft surgery but no deep sternal site infection during the same period (control-patients). RESULTS: Deep sternal site infections were significantly more common during the study than during the pre-study period (30/1796 [1.7%] vs 9/1232 [0.7%]; P =.04). Among 30 case-patients, 29 (97%) returned to the operating room for sternal debridement or rewiring, and 2 (7%) died. In multivariable analyses, cefuroxime receipt 2 hours or more before incision (odds ratio = 5.0), diabetes mellitus with a preoperative blood glucose level of 200 mg/dL or more (odds ratio = 10.2), and staple use for skin closure (odds ratio = 4.0) were independent risk factors for deep sternal site infection. Staple use was a risk factor only for patients with a normal body mass index. CONCLUSIONS: Appropriate timing of antimicrobial prophylaxis, control of preoperative blood glucose levels, and avoidance of staple use in patients with a normal body mass index should prevent deep sternal site infection after coronary artery bypass graft operations.

Description of case-mix adjusters by the Severity of Illness Working Group of the Society of Hospital Epidemiologists of America (SHEA).

Hospitals, insurance companies, and federal and state governments are increasingly concerned about reducing patient cost expenditures while maintaining high quality patient care. One method of reducing expenditures has been to tie hospital reimbursement with a prospective payment system based on diagnosis-related groups (DRGs). However, reimbursement under the DRG system is not acceptable for all patients in all hospitals because it is neither an accurate predictor of costs nor of clinical outcome. This deficiency poses significant problems for hospitals because DRGs are used nationwide as the prospective payment system for inpatients covered by Medicare. Several case-mix adjusters have been proposed to modify DRGs to improve their accuracy in predicting costs and outcome. We reviewed five of the most widely available indices: Acute Physiologic and Chronic Health Evaluation (APACHE II), Coded Disease Staging, Computerized Severity Index (CSI), Medical Illness Severity Group System (MEDISGROUPS), and Patient Management Categories (PMC). Recommendations for the use of a single case-mix adjuster cannot be made at this time because all indices have not been compared in sufficiently diverse settings and because some are better predictors of costs while others are better predictors of clinical outcome. Hospital epidemiologists and other infection control practitioners should be informed about these indices and their potential applications as they expand their role beyond infection control problems to issues concerning cost containment, quality assurance, and reimbursement.

Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Society for Healthcare Epidemiology of America.

The scientific basis for claims of efficacy of nosocomial infection surveillance and control programs was established by the Study on the Efficacy of Nosocomial Infection Control project. Subsequent analyses have demonstrated nosocomial infection prevention and control programs to be not only clinically effective but also cost-effective. Although governmental and professional organizations have developed a wide variety of useful recommendations and guidelines for infection control, and apart from general guidance provided by the Joint Commission on Accreditation of Healthcare Organizations, there are surprisingly few recommendations on infrastructure and essential activities for infection control and epidemiology programs. In April 1996, the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The following report represents the consensus panel's best assessment of needs for a healthy and effective hospital-based infection control and epidemiology program. The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and nonpersonnel resources. The consensus panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee.

A creative method for determining the immunization status of a community hospital medical staff.

During 1985 and 1986, 191 of the 212 (90%) medical staff members in active private practice, who were surveyed responded to a one-page report regarding the status of their immunity and immunization to important infectious illnesses. Response rates were improved by including the survey form with the hospital privilege-renewal form that was required to be returned to the medical staff office. Of the respondents 96% reported prior history of chickenpox and 95% reported prior immunization to tetanus; of the 42 who reported prior bacille Calmette-Guérin (BCG) vaccination, only 17 reported a positive tuberculin skin test. An additional 32 medical staff members had a history of a positive tuberculin skin test with no prior BCG vaccination. Only 2 (1%) reported prior history of hepatitis B, and only 15 (8%) reported hepatitis B vaccination begun or completed at the time of the survey. This survey allows targeting of infection control activities, such as implementation of the hepatitis B vaccine promotion program and serologic testing of those with a negative history of chickenpox, to be developed for the medical staff. It allows the hospital infection control team instant access to data that can be simply obtained and updated regularly when information is needed about the immunization status of selected medical staff members during an outbreak situation.

Recommended practices for surveillance. Association for Professionals in Infection Control and Epidemiology, Inc. Surveillance Initiative working Group.

Demonstration of quality health care includes documentation of outcomes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the health care team to assist in improving those outcomes. Surveillance is an essential component of effective clinical programs designed to reduce the frequency of adverse events such as infection or injury. Although there is no single or "right" method of surveillance design or implementation, sound epidemiologic principles must form the foundation of effective systems and must be understood by key participants in the surveillance program and supported by senior management. Teamwork and collaboration across the health care spectrum are important for the development of surveillance plans. Each health care organization must tailor its surveillance systems to maximize resources by focusing on population characteristics, outcome priorities, and organizational objectives. To ensure quality of surveillance, the following elements must be incorporated: A written plan should serve as the foundation of any surveillance program. The plan should outline important objectives and elements of the surveillance process so that resources can be targeted appropriately. Thoroughness or intensity of surveillance for an area of interest must be maintained at the same level over time. Fluctuations of a surveillance rate have no meaning unless the same level of data collection is maintained. External rate comparisons are meaningless unless the systems used have comparable intensity. All the elements of surveillance should be used with consistency over time. This includes application of surveillance definitions and rate calculation methods. Personnel resources need to be appropriate for the type of surveillance being performed. This includes trained professionals who understand epidemiology and who have access to continuing professional education opportunities. Other resources essential to surveillance include computer support, information and technology services, clerical services, and administrative understanding and support to maintain a quality program. As a means of quality control and to ensure accuracy, the data and process of surveillance should undergo periodic evaluation and validation. This document is intended to assist professionals who plan and conduct surveillance programs as well as those who assure that there is appropriate organizational support to accomplish appropriate surveillance. While design of surveillance systems must be unique for each organization, incorporation of these seven core Recommended Practices for Surveillance provides a scientific framework to approach surveillance programs.

Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Society for Healthcare Epidemiology of America.

The scientific basis for claims of efficacy of nosocomial infection surveillance and control programs was established by the Study on the Efficacy of Nosocomial Infection Control project. Subsequent analyses have demonstrated nosocomial infection prevention and control programs to be not only clinically effective but also cost-effective. Although governmental and professional organizations have developed a wide variety of useful recommendations and guidelines for infection control, and apart from general guidance provided by the Joint Commission on Accreditation of Healthcare Organizations, there are surprisingly few recommendations on infrastructure and essential activities for infection control and epidemiology programs. In April 1996, the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The following report represents the consensus panel's best assessment of needs for a healthy and effective hospital-based infection control and epidemiology program. The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and nonpersonnel resources. The consensus panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee.

Physician adaptation to health maintenance organizations and implications for management.

The growth of health maintenance organizations (HMOs) and other forms of managed care presents a challenge to traditional patterns of private practice. In Dane County, Wisconsin (Madison Metropolitan Area), the proportion of the population enrolled in closed-panel HMOs increased dramatically, from 10 percent in 1983 to over 40 percent by 1986. This study surveyed 850 practicing physicians regarding their expectations before, and experiences after this rapid change to competitive HMOs. Although most physicians expected a loss of earnings and lower-quality care, the majority reported that neither declined. However, most physicians expected and reported a decline in their autonomy. Primary care physicians were most supportive of the change to HMOs. The implications of these findings for management practices are discussed.

Rapid change to HMO systems: profile of the Dane County, Wisconsin, experience.

Dane County (Madison), Wisconsin, has experienced a dramatic transformation of its health services into competing closed-panel health maintenance organizations (HMOs). The change occurred literally overnight after the state, as the dominant employer, implemented price competition. In 1983, 22 percent of the 24,000 state employees in Dane County were enrolled in closed-panel HMOs; in 1984 about 85 percent enrolled in one of seven major competing physician HMO plans. In 1985 state employees basically stayed with the HMO they had chosen in 1984, and the only major shift was continued movement away from the standard fee-for-service plan. The Dane County HMO plans were less costly than fee-for-service plans to the state and to the state employee. Fee-for-service state enrollees self-reported greater use of inpatient hospital services and self-reported poorer health than employees selecting HMOs when controlling for age between the two groups. This article describes these changes, why they occurred, and the initial impact on employees as an example relevant to HMO development that may occur elsewhere.

Documentation of inpatient clinical experience of family practice residents: a manual system.

A simple, efficient, and inexpensive system for quantitatively documenting the range of clinical experience of individual residents on inpatient rotations is described. Information provided by this system can be used by program faculty to make informed educational decisions concerning both the design of rotations and individual resident program planning. The data are also useful to residency graduates to document their clinical experience when applying for hospital privileges.

Physician satisfaction in a managed care environment.

BACKGROUND: The professional literature suggests that changes toward the bureaucratization of medical practice have led to increasing job dissatisfaction, especially in primary care. To investigate this claim, we surveyed physicians in Dane County, Wisconsin, who practice in a bureaucratic setting. Dane County has experienced essentially a demise in independent practice, ie, most physicians practice in organizational settings where expenses and total patient income are pooled. About 85% of physicians have joined one of the six competing health maintenance organizations (HMOs). METHODS: In 1986 all 850 physicians in Dane County were surveyed to determine their perceptions of clinical freedom, satisfaction with income, status in their profession, autonomy, resources, and professional relations, and their overall satisfaction. RESULTS: We found that over 69% of primary care physicians were very satisfied or satisfied with their practices overall compared with 68% of physicians in all specialties. Differences between family practice and other primary care specialties were not statistically significant. Our regression analysis showed that only for satisfaction with income were responses from primary care physicians significantly different from those of physicians in surgical specialties. Perceptions of clinical autonomy and specific organizational settings were more important to predicting satisfaction. Also, age and sex contributed to differences in satisfaction with resources and status, respectively. CONCLUSIONS: We conclude that satisfaction can be fairly high for primary care physicians in bureaucratic settings similar to that of Dane County.

Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices.

BACKGROUND: Managed care practice arrangements, or health maintenance organizations (HMOs), are sufficiently mature to examine whether physicians' level of satisfaction has changed as managed care has developed. This study compares Dane County, Wisconsin, physicians' satisfaction with HMO and fee-for-service (FFS) practices in 1986 with that of 1993 and examines factors that contribute to satisfaction in an HMO-dominated environment. METHODS: Cross-sectional surveys were mailed to all Dane County physicians in active practice in 1986 and 1993. Physician overall support for HMO development and satisfaction with work situation was measured with single items. Overall satisfaction and clinical freedom within HMO and FFS practices were measured using statistically reliable scales. RESULTS: Significantly more physicians were supportive of the development of HMOs in 1993 than in 1986, and more than two thirds of physicians in 1993 were satisfied in their current work situation. Primary care physicians were significantly more satisfied than subspecialists across most dimensions of satisfaction. Perceived clinical freedom and satisfaction with income continued to be major predictors of satisfaction in 1993 as in 1986. While physicians' satisfaction with HMO practice remained stable, their satisfaction with FFS practice was significantly lower in 1993 than in 1986. Satisfaction with Medicare practice, which was not measured in 1986, was significantly less than with HMO or FFS practice in 1993. CONCLUSIONS: Analyses suggest that primary care physicians are more satisfied than subspecialists with their HMO practice because of their greater satisfaction with HMO-generated income and the expanded clinical freedom they have in HMO practice. An across-the-board decline in satisfaction with FFS practice may be attributable to diminishing clinical freedom resulting from indemnity carriers' increasing micromanagement of patient care.

Comparison of low-dose cinoxacin therapy and placebo in the prevention of recurrent urinary tract infections.

Fifty-nine female patients with a history of at least three episodes of urinary tract infection in the preceding year were enrolled in a two-center, double-blind study comparing cinoxacin and placebo as preventive therapy. Evaluation of efficacy was based on the results from 41 patients for whom complete data were available. In the cinoxacin-treated group, 18 of 20 patients remained asymptomatic during the study, compared with 11 of 21 patients in the placebo group. This difference between the two treatment groups was significant (P = 0.031). One patient in the cinoxacin group and eight patients in the placebo group developed an infection during the study. This difference was also significant (P = 0.045). Nine patients spontaneously reported adverse reactions, four in the cinoxacin group and five in the placebo group. In four instances, these were sufficiently severe for the treatment to be withdrawn from one patient who received cinoxacin and three patients who received placebo. The results of this study have shown that cinoxacin was significantly more effective than placebo in preventing urinary tract infection in patients with a history of frequent recurrent infections.