Identifying individual and organizational predictors of accidental exposure to blood (AEB) among hospital healthcare workers: A longitudinal study.

BACKGROUND: Accidental exposure to blood (AEB) poses a risk of bloodborne infections for healthcare workers (HCWs) during hospital activities. In this study, we identified individual behavioral and organizational predictors of AEB among HCWs. METHODS: The study was a prospective, 1-year follow-up cohort study conducted in university hospitals in Paris, France. Data were collected from the Stress at Work and Infectious Risk in Patients and Caregivers (STRIPPS) study. Eligible participants included nurses, nursing assistants, midwives, and physicians from 32 randomly selected wards in 4 hospitals. AEB occurrences were reported at baseline, 4 months, 8 months, and 12 months, and descriptive statistical and multilevel risk-factor analyses were performed. RESULTS: The study included 730 HCWs from 32 wards, predominantly nurses (52.6%), nursing assistants (41.1%), physicians (4.8%), and midwives (1.5%). The incidence rate of AEB remained stable across the 4 visits. The multilevel longitudinal analysis identified several significant predictors of AEB occurrence. Individual-level predictors included younger age, occupation as nurses or midwives, irregular work schedule, rotating shifts, and lack of support from supervisors. The use of external nurses was the most significant ward-level predictor associated with AEB occurrence. CONCLUSIONS: AEBs among HCWs are strongly associated with organizational predictors, highlighting the importance of complementing infection control policies with improved staff management and targeted training. This approach can help reduce AEB occurrences and enhance workplace safety for HCWs.

Knowledge, attitudes and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France.

INTRODUCTION: Smoking remains a leading cause of preventable death in France, even among the elderly. Although smoking prevalence has decreased overall, it still affects a significant portion of older adults. This study investigates the knowledge, attitudes, and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France. METHODS: A cross-sectional study involved 300 primary care professionals (general practitioners, pharmacists, nurses) in the Ile-de-France region. Data collection occurred via telephone interviews in September and October 2019. The study employed a questionnaire focusing on knowledge (10 questions), attitudes (12 statements), and clinical practices (7 questions) related to tobacco dependence in older adults. Responses were scored based on correctness for knowledge and appropriateness for attitudes and practices. RESULTS: The surveyed professionals were predominantly female (57.7%), with a mean age of 53.0 years, and most were non-smokers or former smokers (85.3%). While 66.7% believed older smokers had lower cessation rates, only 64.3% knew it was safe to prescribe nicotine replacement therapy for the elderly. Attitude scores averaged 8.8/12, with pharmacists scoring highest (9.9) and nurses lowest (8.2). Practices scores averaged 2.8/7, with physicians scoring highest (3.8) and pharmacists lowest (1.9). CONCLUSIONS: Primary healthcare professionals have a relatively good knowledge of the management of tobacco dependence in the elderly and consider it to be part of their mission. However, their confidence in their abilities needs to be strengthened, and many opportunities to counsel and assist this population to quit smoking are still being missed. Preventive approaches to older smokers are essential, in keeping with the concept that 'every contact with the healthcare system counts'. Improving practice will require education and training that will not only build knowledge but also change perceptions, leading to better attitudes and practices in the management of smoking cessation among older adults.

Validation of the first computerized indicator for orthopaedic surgical site infections in France: ISO-ORTHO.

BACKGROUND: The French national authority for health (HAS) develops in-hospital indicators for improving quality of care, safety and patient outcome. Since 2017, it has developed a measurement of surgical site infections (SSI) after total hip or knee arthroplasty (TH/KA) by using a computerized indicator, called ISO-ORTHO, based on a hospital discharge database (HDD) algorithm. The aim of the study was to assess the performance of this new indicator . METHODS: The ISO-ORTHO performance was estimated via its positive predictive value (PPV) among adult patients having undergone a TH/KA between January 1st and September 30th 2018, based on the orthopaedic procedure codes. Patients at very high risk of SSI and/or with SSI not related to the in-hospital care were excluded. SSI were detected from the date of admission up to 90 days after the TH/KA using the ISO-ORTHO algorithm, based on 15 combinations of ICD-10 and procedure codes. Its PPV was estimated by a chart review in volunteer healthcare organisations (HCO). RESULTS: Over the study period, 777 HCO including 143,227 TH/KA stays were selected, providing 1,279 SSI according to the ISO-ORTHO indicator. The 90-day SSI rate was 0.89 per 100 TH/KA stays (0.98% for THA and 0.80% for TKA). Among the 448 HCO with at least 1 SSI, 250 HCO participated in reviewing 725 SSI charts; 665 were confirmed, giving a PPV of 90.3% [88.2-92.5%], 89.9% [87.1-92.8%] in THA and 90.9% [87.7-94.2%] in TKA. CONCLUSIONS: The PPV of ISO-ORTHO over 90% confirms its validity for any use according to the HAS method. ISO-ORTHO and detailed information were provided in 2020 to HCO and used for quality assessment and in-hospital risk management.

Multilevel approach to individual and organisational predictors of stress and fatigue among healthcare workers of a university hospital: a longitudinal study.

OBJECTIVE: Healthcare workers (HCWs) are at high risk of experiencing stress and fatigue due to the demands of their work within hospitals. Improving their physical and mental health and, in turn, the quality and safety of care requires considering factors at both individual and organisational/ward levels. Using a multicentre prospective cohort, this study aims to identify the individual and organisational predictors of stress and fatigue of HCWs in several wards from university hospitals. METHODS: Our cohort consists of 695 HCWs from 32 hospital wards drawn at random within four volunteer hospital centres in Paris-area. Three-level longitudinal analyses, accounting for repeated measures (level 1) across participants (level 2) nested within wards (level 3) and adjusted for relevant fixed and time-varying confounders, were performed. RESULTS: At baseline, the sample was composed by 384 registered nurses, 300 auxiliary nurses and 11 midwives. According to the three-level longitudinal models, some predictors were found in common for both stress and fatigue (low social support from supervisors, work overcommitment, sickness presenteeism and number of beds per ward). However, specific predictors for high level of stress (negative life events, low social support from colleagues and breaks frequently cancelled due to work overload) and fatigue (longer commuting duration, frequent use of interim staff in the ward) were also found. CONCLUSION: Our results may help identify at-risk HCWs and wards, where interventions to reduce stress and fatigue should be focused. These interventions could include manager training to favour better staff support and overall safety culture of HCWs.

A computerized indicator for surgical site infection (SSI) assessment after total hip or total knee replacement: The French ISO-ORTHO indicator.

OBJECTIVE: The French National Authority for Health (HAS), with a multidisciplinary working group, developed an indicator 'ISO-ORTHO' to assess surgical site infections (SSIs) after total hip arthroplasty or total knee arthroplasty (THA/TKA) based on the hospital discharge database. We present the ISO-ORTHO indicator designed for SSI automated detection and its relevance for quality improvement and hospital benchmarks. METHODS: The algorithm is based on a combination of International Statistical Classification of Diseases, Tenth Revision (ICD-10) and procedure codes of the hospital stay. The target population was selected among adult patients who had a THA or TKA between January 1, 2017, and September 30, 2017. Patients at very high risk of SSI and/or with SSI not related to hospital care were excluded. We searched databases for SSIs up to 3 months after THA/TKA. The standardized infection ratio (SIR) of observed versus expected SSIs was calculated (logistic regression) and displayed as funnel plot with 2 and 3 standard deviations (SD) after adjustment for 13 factors known to increase SSI risk. RESULTS: In total, 790 hospitals and 139,926 THA/TKA stays were assessed; 1,253 SSI were detected in the 473 included hospitals (incidence, 0.9%: 1.0% for THA, 0.80% for TKA). The SSI rate was significantly higher in males (1.2%), in patients with previous osteo-articular infection (4.4%), and those with cancer (2.3%), obesity, or diabetes. Most hospitals (89.9%) were within 2 SD; however, 12 hospitals were classified as outliers at more than +3 SD (1.6% of facilities), and 59 hospitals (7.9%) were outliers between +2 SD and +3 SD. CONCLUSION: ISO-ORTHO is a relevant indicator for automated surveillance; it can provide hospitals a metric for SSI assessment that may contribute to improving patient outcomes.

How to measure hospital antibiotic consumption: comparison of two methods from data surveillance in France.

BACKGROUND: Antibiotic use (ABU) surveillance in healthcare facilities (HCFs) is essential to guide stewardship. Two methods are recommended: antibiotic consumption (ABC), expressed as the number of DDD/1000 patient-days; and prevalence of antibiotic prescription (ABP) measured through point prevalence surveys. However, no evidence is provided about whether they lead to similar conclusions. OBJECTIVES: To compare ABC and ABP regarding HCF ranking and their ability to identify outliers. METHODS: The comparison was made using 2012 national databases from the antibiotic surveillance network and prevalence study. HCF rankings according to each method were compared with Spearman's correlation coefficient. Analyses included the ABU from entire HCFs as well as according to type, clinical ward and by antibiotic class and specific molecule. RESULTS: A total of 1076 HCFs were included. HCF rankings were strongly correlated in the whole cohort. The correlation was stronger for HCFs with a higher number of beds or with a low or moderate proportion of acute care beds. ABU correlation between ABC or ABP was globally moderate or weak in specific wards. Furthermore, the two methods did not identify the same outliers, whichever HCF characteristics were analysed. Correlation between HCF ranking varied according to the antibiotic class. CONCLUSIONS: Both methods ranked HCFs similarly overall according to ABC or ABP; however, major differences were observed in ranking of clinical wards, antibiotic classes and detection of outliers. ABC and ABP are two markers of ABU that could be used as two complementary approaches to identify targets for improvement.

Peripheral Venous Catheter-Related Adverse Events: Evaluation from a Multicentre Epidemiological Study in France (the CATHEVAL Project).

INTRODUCTION: Peripheral venous catheters (PVC) are medical devices most frequently used during hospital care. Although the frequency of specific PVC-related adverse events (PVCAEs) has been reported, the global risk related to the insertion of this device is poorly estimated. The aim of this study is to determine the incidence of PVCAEs during the indwell time, after catheter removal, and to identify practice-mirroring risk factors. METHODS: A prospective observational study was conducted as a part of a research project, called CATHEVAL, in one surgery ward and four medicine wards from three public general tertiary care hospitals in Northern France that were invited to participate between June-2013 and June-2014. Each participating ward included during a two-month study period all patients older than 15 years carrying a PVC. All inserted PVCs were monitored from insertion of PVC to up to 48 hours after removal. Monitored data included several practice-mirroring items, as well as the occurrence of at least one PVCAE. A multivariate Cox proportional hazard model, based on a marginal risk approach, was used to identify factors associated with the occurrence of at least one PVCAE. RESULTS: Data were analysed for 815 PVCs (1964 PVC-days) in 573 patients. The incidence of PVCAE was 52.3/100 PVCs (21.9/100 PVC-days). PVCAEs were mainly clinical: phlebitis (20.1/100 PVCs), haematoma (17.7/100 PVCs) and liquid/blood escape (13.1/100 PVCs). Infections accounted for only 0.4/100 PVCs. The most frequent mechanical PVCAEs, was obstruction/occlusion of PVC (12.4/100 PVCs). The incidence of post-removal PVCAEs was 21.7/100 PVCs. Unstable PVC and unclean dressing were the two main risk factors. CONCLUSION: Limitation of breaches in healthcare quality including post-removal monitoring should be reinforced to prevent PVC-related adverse events in hospital settings.

Management of nurse shortage and its impact on pathogen dissemination in the intensive care unit.

INTRODUCTION: Studies provide evidence that reduced nurse staffing resources are associated to an increase in health care-associated infections in intensive care units, but tools to assess the contribution of the mechanisms driving these relations are still lacking. We present an agent-based model of pathogen spread that can be used to evaluate the impact on nosocomial risk of alternative management decisions adopted to deal with transitory nurse shortage. MATERIALS AND METHODS: We constructed a model simulating contact-mediated dissemination of pathogens in an intensive-care unit with explicit staffing where nurse availability could be temporarily reduced while maintaining requisites of patient care. We used the model to explore the impact of alternative management decisions adopted to deal with transitory nurse shortage under different pathogen- and institution-specific scenarios. Three alternative strategies could be adopted: increasing the workload of working nurses, hiring substitute nurses, or transferring patients to other intensive-care units. The impact of these decisions on pathogen spread was examined while varying pathogen transmissibility and severity of nurse shortage. RESULTS: The model-predicted changes in pathogen prevalence among patients were impacted by management decisions. Simulations showed that increasing nurse workload led to an increase in pathogen spread and that patient transfer could reduce prevalence of pathogens among patients in the intensive-care unit. The outcome of nurse substitution depended on the assumed skills of substitute nurses. Differences between predicted outcomes of each strategy became more evident with increasing transmissibility of the pathogen and with higher rates of nurse shortage. CONCLUSIONS: Agent-based models with explicit staff management such as the model presented may prove useful to design staff management policies that mitigate the risk of healthcare-associated infections under episodes of increased nurse shortage.

Is high consumption of antibiotics associated with Clostridium difficile polymerase chain reaction-ribotype 027 infections in France?

We compared antibiotic consumption between hospitals affected by a strain of Clostridium difficile designated as polymerase chain reaction-ribotype 027 (CD-027) and those unaffected during an outbreak in northern France. The mean consumption of several beta-lactams, amikacin, and fluoroquinolones was high in affected hospitals (P < .05). However, only levofloxacin and imipenem remained associated with emerging CD-027 in the multivariate analysis, suggesting that those antibiotics should be better targeted by prevention campaigns.

Non-compliance with recommendations for the practice of antibiotic prophylaxis and risk of surgical site infection: results of a multilevel analysis from the INCISO Surveillance Network.

OBJECTIVES: The aim of this study was to determine which surgical antibiotic prophylaxis (SAP) practices alter surgical site infection (SSI) risk. METHODS: Data were collected during a 7 year surveillance period (2001-07) from volunteer surgery wards participating in the INCISO Surveillance Network in Northern France. Main SAP practices, i.e. antibiotic choice, timing of first dose and total SAP duration, were evaluated and compliance checked based on French recommendations. The study focused on selected procedures in digestive, orthopaedic, gynaecological and cardiovascular surgery, for which standard SAP is recommended. Multilevel logistic regression analysis (a two-level random effect model) was carried out to identify SAP-, patient- and procedure-specific factors associated with SSI. RESULTS: Of 8029 patients who underwent the selected surgeries, 91.3% received SAP and 2.5% developed SSI. Among those receiving SAP, 83.3% received appropriate antibiotic agents and 76.6% had an optimal timing of administration. SAP duration was considered to be appropriate in 35.0%, too long (SAP unnecessarily prolonged) in 45.2% and too short (lack of intra-operative redosing when recommended) in 19.8%. In the multivariate analysis, a too-short SAP duration remained the only inappropriate practice associated with higher SSI risk (odds ratio = 1.8, 95% confidence interval: 1.14-2.81), after adjustment for surgery procedure group, the National Nosocomial Infections Surveillance System risk index, age and infection risk variability among hospitals. No significant relationships were observed between SSI and the other SAP parameters. CONCLUSIONS: A too-short SAP duration was the most important SAP malpractice associated with an increased risk of SSI. Information directed at practitioners should be reinforced based on standard recommendations.

Specific control measures for antibiotic prescription are related to lower consumption in hospitals: results from a French multicentre pilot study.

BACKGROUND: In France, antibiotic consumption (ABC) is dramatically high in parallel with the high rate of multidrug-resistant bacteria. For the last few years, a nationwide policy has been implemented at the national level to control and monitor ABC. Since 2002, surveillance networks have been set up with voluntary hospitals to evaluate the antibiotic policy and consumption. The present study was conducted to identify whether specific control measures of the antibiotic policy could reduce ABC in hospitals. METHODS: Based on the data from the Northern France surveillance system, local recommendations and antibiotic use were collected annually on a standardized questionnaire that had 21 items. ABC was expressed in defined daily doses (DDDs) per 1000 patient-days (PDs). The ABC indicator was the overall antibiotic consumption. A multivariate logistic regression analysis was performed using low (< or =75th percentile) and high (>75th percentile) ABC as the dependent variable. RESULTS: A total of 83/111 hospitals were included in the study. In 75% of the hospitals, total ABC was < or =669.5 DDDs/1000 PDs. The less frequent practices were educational antibiotic programmes (17%), authorization from an antibiotic specialist for selected antibiotics (26%) and systematic reassessment of AB treatment after 72 h (27%). In the multivariate analysis, three variables remained significantly and independently associated (P < 0.05) with ABC: the type of hospital, the proportion of non-acute-care beds and the nominative delivery form as the only antibiotic control measure. Total ABC was lower in hospitals having a nominative delivery form, compared with hospitals not having it. Conversely, ABC was significantly higher in public teaching hospitals compared with non-teaching hospitals. Similarly, ABC was higher in hospitals with a lowest proportion (i.e. < or =25%) of non-acute-care beds compared with hospitals where this proportion was >25%. CONCLUSIONS: Specific control measures could lower ABC. Sustained control efforts should focus on antibiotics with the highest potential for emerging bacterial resistance.