Early recognition and response to increases in surgical site infections using optimised statistical process control charts-The early 2RIS trial: A multicentre stepped wedge cluster randomised controlled trial.

Background: Traditional approaches for surgical site infection (SSI) surveillance have deficiencies that delay detection of SSI outbreaks and other clinically important increases in SSI rates. We investigated whether use of optimised statistical process control (SPC) methods and feedback for SSI surveillance would decrease rates of SSI in a network of US community hospitals. Methods: We conducted a stepped wedge cluster randomised trial of patients who underwent any of 13 types of common surgical procedures across 29 community hospitals in the Southeastern United States. We divided the 13 procedures into six clusters; a cluster of procedures at a single hospital was the unit of randomisation and analysis. In total, 105 clusters were randomised to 12 groups of 8-10 clusters. All participating clusters began the trial in a 12-month baseline period of control or "traditional" SSI surveillance, including prospective analysis of SSI rates and consultative support for SSI outbreaks and investigations. Thereafter, a group of clusters transitioned from control to intervention surveillance every three months until all clusters received the intervention. Electronic randomisation by the study statistician determined the sequence by which clusters crossed over from control to intervention surveillance. The intervention was the addition of weekly application of optimised SPC methods and feedback to existing traditional SSI surveillance methods. Epidemiologists were blinded to hospital identity and randomisation status while adjudicating SPC signals of increased SSI rates, but blinding was not possible during SSI investigations. The primary outcome was the overall SSI prevalence rate (PR=SSIs/100 procedures), evaluated via generalised estimating equations with a Poisson regression model. Secondary outcomes compared traditional and optimised SPC signals that identified SSI rate increases, including the number of formal SSI investigations generated and deficiencies identified in best practices for SSI prevention. This trial was registered at ClinicalTrials.gov, NCT03075813. Findings: Between Mar 1, 2016, and Feb 29, 2020, 204,233 unique patients underwent 237,704 surgical procedures. 148,365 procedures received traditional SSI surveillance and feedback alone, and 89,339 procedures additionally received the intervention of optimised SPC surveillance. The primary outcome of SSI was assessed for all procedures performed within participating clusters. SSIs occurred after 1171 procedures assigned control surveillance (prevalence rate [PR] 0.79 per 100 procedures), compared to 781 procedures that received the intervention (PR 0·87 per 100 procedures; model-based PR ratio 1.10, 95% CI 0.94-1.30, p=0.25). Traditional surveillance generated 24 formal SSI investigations that identified 120 SSIs with deficiencies in two or more perioperative best practices for SSI prevention. In comparison, optimised SPC surveillance generated 74 formal investigations that identified 458 SSIs with multiple best practice deficiencies. Interpretation: The addition of optimised SPC methods and feedback to traditional methods for SSI surveillance led to greater detection of important SSI rate increases and best practice deficiencies but did not decrease SSI rates. Additional research is needed to determine how to best utilise SPC methods and feedback to improve adherence to SSI quality measures and prevent SSIs. Funding: Agency for Healthcare Research and Quality.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update.

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Non-ventilator health care-associated pneumonia (NV-HAP).

This guide is intended for IPs, nurses, and others who are involved in infection prevention efforts across the continuum of care. It reviews current literature, suggested prevention strategies, and potential tools and techniques to guide surveillance, detection, and prevention efforts for NV-HAP.

Non-ventilator health care associated pneumonia (NV-HAP): Oncology.

Literature suggests that cancer patients can become colonized or infected with a variety of opportunistic and health care-associated pathogens, putting them at higher risk for nonventilator health care-associated pneumonia. This section will review the epidemiology of nonventilator health care-associated pneumonia and the importance of prevention strategies in this vulnerable population. Prevention strategies for cancer patients across the continuum of care are highlighted.

Non-ventilator health care-associated pneumonia (NV-HAP): Putting it all together.

This section highlights the necessary steps to implement a robust plan to connect surveillance and prevention strategies for nonventilator health care-associated pneumonia (NV-HAP) as described in previous sections. In addition to specific NV-HAP strategies, the importance of general infection prevention principles that are common to all settings for prevention of all health care-associated infections are reviewed. The section also provides an overview of a step-wise model to develop a comprehensive NV-HAP surveillance plan. A sample case review form is included.

Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis.

IMPORTANCE: Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality. OBJECTIVE: To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation. DATA SOURCES: PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language. STUDY SELECTION: Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria. DATA EXTRACTION AND SYNTHESIS: Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES: Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing. RESULTS: There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited. CONCLUSIONS AND RELEVANCE: Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.

Guide to the elimination of orthopedic surgery surgical site infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide.

This article is an executive summary of the APIC Guide to the Elimination of Orthopedic Surgical Site Infections. Infection preventionists, care providers, and perioperative personnel are encouraged to obtain the original, full length APIC Elimination Guide for more thorough coverage on strategies to prevent surgical site infections in orthopedic surgery.

Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide.

The Association for Professionals in Infection Control and Epidemiology (APIC) began publishing their series of Elimination Guides in 2007. Since then, 9 Elimination Guides have been developed that cover a range of important infection prevention issues, including the prevention of catheter-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections (CAUTIs), as well as mediastinitis surgical site surveillance. Multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus, Clostridium difficile, and multidrug-resistant Acinetobacter baumannii, also have been the focus of APIC Elimination Guides. The content of each of these Elimination Guides will be summarized in a series of upcoming Brief Reports published in The Journal. This article provides an executive summary of the APIC Elimination Guide for CAUTIs. Infection preventionists are encouraged to obtain the original, full-length APIC Elimination Guide for more thorough coverage of CAUTI prevention.

Preventing ventilator-associated pneumonia: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide.

This article is an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for ventilator-associated pneumonia. Infection preventionists are encouraged to obtain the original, full-length Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for more thorough coverage of ventilator-associated pneumonia prevention.

Curbing infections via electronic surveillance.

Infection control programs can generate a wealth of data, but many professionals become overwhelmed when trying to translate the data into actionable knowledge. Automated surveillance systems have the potential to greatly streamline these efforts, but many questions arise about how to evaluate these systems, their costs, benefits and more. Here are answers to some of the most important questions on this issue.