A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care.

BACKGROUND: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001). CONCLUSIONS: A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

A trial of a real-time alert for clinical deterioration in patients hospitalized on general medical wards.

BACKGROUND: With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. OBJECTIVE: To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. DESIGN: Randomized, controlled crossover study. SETTING/PATIENTS: Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. INTERVENTIONS: Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. MEASUREMENTS: Intensive care unit transfer, hospital mortality, and hospital length of stay. RESULTS: Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. CONCLUSIONS: Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return.

Patient satisfaction is a critical part of the quality outcomes of healthcare. Every industry is interested in customer satisfaction because satisfied customers are loyal customers. Healthcare is no exception. Many research studies assume that satisfied patients are more likely to recommend their providers to their friends and to return when they need care again. Although this assumption sounds logical, we argue that three dependent variables-the Evaluation of Overall Quality of Care, Willingness to Recommend, and Willingness to Return-are unique constructs. Thus, we examine how patient reactions (experiences) to different hospital care attributes (factors or dimensions) influence these dependent variables. Our study analyzed a comprehensive patient satisfaction data set collected by BJC HealthCare. We used a multiple linear regression model with a scatter term to analyze 14,432 cases. In Evaluation of Overall Quality of Care model, we found that the nursing care attribute showed the strongest influence, followed by staff care. In assessing the other two models-Willingness to Recommend and Willingness to Return-we found that staff care showed the strongest influence, followed by nursing care. Patients put a different emphasis or a different priority on their reactions to hospital care attributes, depending on which outcome they arrive at. In addition, we found that patients are disproportionately influenced by a weak or poor attribute reaction, which is a conjunctive strategy (risk averse). In general, nursing care and staff care should be the first priority for improvement. This may be good news because these areas are under the control of hospital managers.

Patient satisfaction: focusing on "excellent".

In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others. When it comes to customer loyalty, "excellent" has a different meaning. Customers who are merely satisfied often do not come back. The purpose of this study was to find out what influences adult patients to rate their overall experience as "excellent." The study used patient satisfaction data collected from one major academic hospital and four community hospitals. After conducting a multiple logistic regression analysis, certain attributes were shown to be more likely than others to influence patients to rate their experiences as excellent. The study revealed that staff care is the most influential attribute, followed by nursing care. These two attributes are distinctively stronger drivers of overall satisfaction than are the other attributes studied (i.e., physician care, admission process, room, and food). Staff care and nursing care are under the control of healthcare managers. If improvements are needed, they can be accomplished through training programs such as total quality management or continuous quality improvement, through which staff employees and nurses learn to be sensitive to patients' needs. Satisfying patients' needs is the first step toward having loyal patients, so hospitals that strive to ensure their patients are completely satisfied are more likely to prosper.

Production and identification repetition priming in amnestic mild cognitive impairment.

The experiment reported here examined implicit memory function, as measured through repetition priming, in amnestic mild cognitive impairment (MCI) to examine whether impairments exist in this aspect of memory function. Young adults, healthy older controls, Alzheimer's disease patients, and MCI participants were asked to perform two types of implicit memory tests (word stem completion and threshold identification repetition priming tasks), as well as a recognition test for studied items. As expected, young adults performed better than the other participants on the recognition test and the word stem completion task; there was equivalent priming across groups on the word identification task. While both the older control and MCI participants showed lower levels of priming on the word stem completion task relative to the young adults, the magnitude of priming was equivalent for these two groups, and reliably greater than that of the dementia participants. These results suggest that not all aspects of memory function are impaired in MCI relative to healthy aging.

Frontal lobe dysfunction and false memory susceptibility in older adults.

The study reported here was conducted to examine the role of frontal lobe function in false memory susceptibility in older adults, as little research has specifically examined this question in older adults. False recognition was compared in three groups of older adults (one with no evidence of cognitive impairment, one with evident frontal impairment but no other dysfunction, and an Alzheimer's dementia group) to a single group of young adults. Results indicate that false memory susceptibility was highest in the frontally impaired group, with young and older control participants performing similarly. In contrast, Alzheimer's dementia patients showed relatively low levels of false memory susceptibility, likely due to overall poor memory for list items, indicating that general memory impairments are not likely to be driving false memory susceptibility. Potential mechanisms underlying these effects are discussed.