Severity of illness classification for infection control departments: a study in nosocomial pneumonia.

BACKGROUND: A subjective severity of illness classification was evaluated in a study of nosocomial pneumonia. This is a 5-category system based on the determination of the control of underlying illness and the risk of death during current hospital admission. METHODS: A case-control study was performed with 128 cases of nosocomial pneumonia and 252 control patients. An additional 60 case and 90 control patients were used to compare this classification with APACHE II scoring in intensive care unit patients. RESULTS: In univariate analysis, the severity illness classification was significantly associated with nosocomial pneumonia risk (p < 0.01). APACHE II adequately predicted mortality rate but was not statistically significantly associated with nosocomial pneumonia risk among intensive care unit patients. In logistic regression analysis, the severity of illness classification, surgery, age, nasogastric tube placement, and histamine blockers each showed significant independent association with nosocomial pneumonia. CONCLUSIONS: The role of the severity of illness classification for risk stratification in nosocomial pneumonia is valid. Its roles in the evaluation of surgical wound infection, nosocomial bacteremia, and quality of care remain to be determined in subsequent studies.

An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia.

In 1989, our medical center used continuous quality improvement concepts in the creation of a Nosocomial Pneumonia Prevention Team whose aim was to significantly reduce nosocomial ventilator-associated pneumonia. The team included representatives from nursing, respiratory therapy, pulmonary medicine, internal medicine, anesthesiology, education and training, and infection control. Because the majority of mechanically ventilated patients were located in the intensive care unit, this unit became the focus of the prevention efforts. Team meetings were held regularly, with all representatives brainstorming barriers, possible interventions, methods of outcome measurement, and frequency of evaluation. Policies and procedures were reviewed, surveillance was increased, handwashing practices were surveyed, periodic feedback to staff was begun, and an educational program was developed and presented. During 1990, we observed a 57% reduction in ventilator-associated pneumonia from the baseline years, 1987 and 1988. Statistical comparison of proportions by z test indicated a p value less than 0.05. Fifteen cases of nosocomial ventilator-associated pneumonia were prevented and a cost saving of $105,000 was realized. Performance of traditional surveillance for outliers, coupled with literature-based thresholds, can lead to tolerance of inordinately high endemic rates. Infection control programs can significantly reduce endemic rates of nosocomial ventilator-associated pneumonia through continuous quality improvement methods and multidisciplinary interventions, with standard infection control procedures used for improvement.