The impact of vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated VRE bacteremia.

OBJECTIVE: To evaluate the impact of a vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated (HA)-VRE bacteremia in an endemic hospital setting. DESIGN: A quasi-experimental before-and-after study. SETTING: A 1,989-bed tertiary-care referral center in Seoul, Republic of Korea. METHODS: Since May 2010, our hospital has diminished VRE screening for admitted patients transferred from other healthcare facilities. We assessed the impact of this policy change on the incidence of HA-VRE bacteremia using segmented autoregression analysis of interrupted time series from January 2006 to December 2014 at the hospital and unit levels. In addition, we compared the molecular characteristics of VRE blood isolates collected before and after the screening policy change using multilocus sequence typing and pulsed-field gel electrophoresis. RESULTS: After the VRE screening policy change, the incidence of hospital-wide HA-VRE bacteremia increased, although no significant changes of level or slope were observed. In addition, a significant slope change in the incidence of HA-VRE bacteremia (change in slope, 0.007; 95% CI, 0.001-0.013; P = .02) was observed in the hemato-oncology department. Molecular analysis revealed that various VRE sequence types appeared after the policy change and that clonally related strains became more predominant (increasing from 26.1% to 59.3%). CONCLUSIONS: The incidence of HA-VRE bacteremia increased significantly after VRE screening policy change, and this increase was mainly driven by high-risk patient populations. When planning VRE control programs in hospitals, different approaches that consider risk for severe VRE infection in patients may be required.

Implementing a multidisciplinary care bundle to reduce colon surgical site infections.

PURPOSE: The aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery. METHODS: The multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014. RESULTS: Overall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014. CONCLUSION: After implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.

Validation of semiautomated surgical site infection surveillance using electronic screening algorithms in 38 surgery categories.

OBJECTIVE: To verify the validity of a semiautomated surgical site infection (SSI) surveillance system using electronic screening algorithms in 38 categories of surgery. DESIGN: A cohort study for validation of semiautomated SSI surveillance system using screening algorithms. SETTING: A 1,989-bed tertiary-care referral center in Seoul, Republic of Korea. METHODS: A dataset of 40,516 surgical procedures in 38 categories stored in the conventional SSI surveillance registry at the Samsung Medical Center between January 2013 and December 2014 was used as the reference standard. In the semiautomated surveillance system, electronic screening algorithms flagged cases meeting at least 1 of 3 criteria: antibiotic prescription, microbial culture, and infectious disease consultation. Flagged cases were audited by infection preventionists. Analyses of sensitivity, specificity, and positive predictive value (PPV) were conducted for the semiautomated surveillance system, and its effect on reducing the workload for chart review was evaluated. RESULTS: A total of 575 SSI events (1·42%) were identified by conventional SSI surveillance. The sensitivity of the semiautomated SSI surveillance was 96·7%, and the PPV of the screening algorithms alone was 4·1%. Semiautomated SSI surveillance reduced the chart review workload of the infection preventionists from 1,283 to 482 person hours per year (a 62·4% decrease). CONCLUSIONS: Compared to conventional surveillance, semiautomated surveillance using electronic screening algorithms followed by chart review of selected cases can provide high-validity surveillance results and can significantly reduce the workload of infection preventionists.

Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis.

PURPOSE: We evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT3)-receptor antagonist after the general anesthesia. MATERIALS AND METHODS: In this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries. RESULTS: Four hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV. CONCLUSION: Despite antiemetic prophylaxis with 5 HT3-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel's score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.

Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection.

BACKGROUND: Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery in heterogeneous patient cohorts, including various aortic diseases and the use of deep hypothermic circulatory arrest. Moderate hypothermia with cerebral perfusion makes deep hypothermia nonessential, but can make end organs susceptible to ischemia during circulatory arrest. We investigated the incidence and risk factors of AKI after thoracic aortic surgery with and without moderate hypothermic circulatory arrest for acute dissection. METHODS: We reviewed the medical records of 98 patients undergoing graft replacement of the thoracic aorta for acute dissection between 2008 and 2011 at a university hospital. Acute kidney injury was defined by RIFLE criteria, which is based on serum creatinine or glomerular filtration rate. RESULTS: The mean age was 55±15 years. The surgical procedures, 96% of which were emergencies, involved the ascending aorta (67%), aortic arch (41%), descending aorta (41%), and aortic valve (5%). Moderate hypothermic circulatory arrest was performed in 75%. The overall incidence of AKI was 54%, and 11% of 98 patients required renal replacement therapy. Thirty-day mortality increased with AKI severity (p=0.002). Independent risk factors for AKI were long cardiopulmonary bypass duration (>180 minutes; odds ratio, 7.50; p=0.008) and preoperative serum creatinine level (odds ratio, 8.43; p=0.016). CONCLUSIONS: Acute kidney injury was common after thoracic aortic surgery for acute dissection with or without moderate hypothermic circulatory arrest and worsened 30-day mortality. Prolonged cardiopulmonary bypass and increased preoperative serum creatinine were independent risk factors for AKI, but moderate hypothermic circulatory arrest was not.