Trends in Health Care-Associated Infection Prevention Practices in US Veterans Affairs Hospitals From 2005 to 2017.

Importance: Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown. Objective: To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership. Design, Settings, and Participants: For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019. Main Outcomes and Measures: Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership. Results: Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P < .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse. Conclusions and Relevance: From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Qualitative Assessment of a State Partner-Facilitated Health Care-Associated Infection Prevention National Collaborative.

Background: The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs. Objective: To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals. Design: Qualitative case study, by U.S. state. Setting: 7 of 22 eligible STRIVE state partnerships. Participants: Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners." Measurements: Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed. Results: State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship. Limitation: Only 7 participating states were included; direct feedback from participating hospitals was not available. Conclusion: Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies. Primary Funding Source: Centers for Disease Control and Prevention.

Perception of Resources Spent on Defensive Medicine and History of Being Sued Among Hospitalists: Results from a National Survey.

The United States spends substantially more per capita for healthcare than any other nation. Defensive medicine is 1 source of such spending, but its extent is unclear. Using a national survey of approximately 1500 US hospitalists, we report the estimates the US hospitalists provided of the percent of resources spent on defensive medicine and correlates of their estimates. We also ascertained how many reported being sued. Sixty-eight percent of eligible recipients responded. Overall, respondents estimated that 37.5% of healthcare costs are due to defensive medicine. Just over 25% of our respondents, including 55% of those in practice for 20 years or more, reported being sued for medical malpractice. Veterans Affairs (VA) hospital affiliation, more years practicing as a physician, being male, and being a non-Hispanic white individual were all independently associated with decreased estimates of resources spent for defensive medicine.

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment.

BACKGROUND: Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. METHODS: Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach. RESULTS: Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover. CONCLUSIONS: Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Prevalence and Appropriateness of Urinary Catheters in Japanese Intensive Care Units: Results From a Multicenter Point Prevalence Study.

BACKGROUND: Catheter-associated urinary tract infection is a common and costly problem throughout the world. As limited data from Asia exist regarding the prevalence and appropriateness of urinary catheters in critically ill patients, we sought to assess both prevalence and appropriateness of urinary catheters in Japan. METHODS: Using independent observers, we evaluated the prevalence and clinical necessity of indwelling urinary catheters in 7 Japanese intensive care units. RESULTS: Data were collected on 1289 catheter-days and 1706 patient days in the 7 participating intensive care units between August 2015 and May 2016. Urinary catheter prevalence was 76% (range, 49%-94%). The observers deemed that only 54% of the catheters met an appropriate indication for use (range, 40%-74%). The most common appropriate indications for urinary catheter use were (1) the need for accurate input and output monitoring in critically ill patients; (2) perioperative use; and (3) prolonged immobilization. The use of monitoring accurate input and output in critically ill patients, however, may be overused as bedside nurses used this indication in 27% more patients than the objective observer deemed necessary. CONCLUSIONS: Urinary catheters were frequently used in the 7 participating Japanese intensive care units and almost half did not meet an appropriate indication for use. Overusing catheters for monitoring accurate input and output was especially notable. Multimodal interventions may be needed to limit inappropriate urinary catheter use.

Qualitative validation of the CAUTI Guide to Patient Safety assessment tool.

BACKGROUND: Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS. METHODS: We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement. RESULTS: A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues. CONCLUSIONS: Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.