Network analysis of cases with methicillin-resistant Staphylococcus aureus and controls in a large tertiary care facility.

BACKGROUND: Despite increased awareness of infection control precautions, methicillin-resistant Staphylococcus aureus (MRSA) still spreads through patients and contaminated objects, causing a substantial burden of illness and cost. Our objective was to define risk factors for contracting MRSA in a tertiary health care facility using a historic case-control study and to validate health care network changes during pre-outbreak and outbreak periods. METHODS: We conducted a case-control study using secondary data on hospitalizations where infected or colonized cases were compared with matched controls who tested negative by age, sex, and campus over 1 year. Social networks of all cases and controls were built from links joining patients to rooms, roommates, and health care providers over time. RESULTS: Matched controls were similar to cases in comorbidity, lengths of stay, mortality, and number of roommates, rooms, and health care providers. As expected, the number of rooms and roommates increased in the outbreak by more than 50%. A timed animation of the network at one campus identified potential source patients linked to 2 rooms and many roommates, after which cases connected to those same rooms proliferated. CONCLUSIONS: Only the network animation over time revealed possible transmission of MRSA through the network, rather than attributes measured in the traditional case control study.

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty.

BACKGROUND: The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool. METHODS: Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori. RESULTS: A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service. CONCLUSION: Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.