The impact of a quality improvement intervention to reduce nosocomial infections in a PICU.

OBJECTIVE: To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes. DESIGN: Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up. SETTING: A 14-bed medical and surgical PICU in a university hospital for children. INTERVENTIONS: The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing nosocomial infections. MEASUREMENTS AND MAIN RESULTS: We included 851 patients in the preintervention period, 822 in the intervention period, and 940 in the long-term follow-up period. Compared with the preintervention period, in the intervention period, the rates of central line-associated bloodstream infection decreased from 8.1 to 6/1,000 central venous catheter-days (p = 0.640), ventilator-associated pneumonia decreased from 28.3 to 10.6/1,000 days' ventilation (p = 0.005), and catheter-associated urinary tract infection decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). Multivariable logistic regression found that nosocomial infections was independently associated with increased mortality (odds ratio, 2.35 [95% CI, 1.02-5.55]; p = 0.046). Compared with the preintervention period, in the long-term follow-up period, central line-associated bloodstream infection decreased to 4.6/1,000 central venous catheter-days (p = 0.205); ventilator-associated pneumonia decreased to 9.1/1,000 ventilation-days (p = 0.001), and catheter-associated urinary tract infection decreased to 5.2/1,000 urinary catheter-days (p < 0.001). Hospital length of stay (14.45 days; p = 0.048) and mortality (3.2%; p = 0.058) also decreased. CONCLUSIONS: A multifaceted quality improvement intervention reduced nosocomial infection rates, hospital length of stay, and mortality in our PICU. The effects of the intervention were sustained over time.

Prospective surveillance study of blood stream infections associated with central venous access devices (port-type) in children with acute leukemia: an intervention program.

The use of intensive chemotherapy and central devices has improved patients survival, but it is associated with catheter-related blood-stream infections (CRBSI). An educational program was instituted for preventing CRBSI occurrence in acute leukemia pediatric patients having totally implanted central devices. The Centers of Disease Control and Prevention criteria were used as definition for CRBSI. Data collected were age, sex, diagnosis, chemotherapy, inpatient versus outpatient, microbiological data, risk factors, social risk score, and treatment performed. CRBSI rate decreased from 6.7 to 3.7/1000 catheter-days with preventive measures (P=0.05). A further decrease to 1.5/1000 catheter-days was reached after the intensification of the educational program (P=0.01). Severe neutropenia at the time of catheter insertion was related to CRBSI and to infection recurrence (P<0.05). Most of the episodes occurred during induction chemotherapy. Thirty-six CRBSI episodes occurred in 25 of 73 patients. The most frequent microorganism isolated was Staphylococcus spp. Antibiotherapy was successful in 83.3% of episodes. Six patients needed a central venous access device replacement. Our intervention program was successful to decrease the CRBSI rates and its intensification allowed a further decrease, approaching reported rates in this setting. Severe neutropenia at the time of central venous access device insertion was related to CRBSI occurrence and recurrence.

Exposición a dispositivos extrínsecos, un indicador de infección intrahospitalaria / Exposure to devices: an indicator of nosocomial infection

Objetivo: Diseñar un protocolo de vigilancia sistemática de la infección nosocomial (IN) asociada a dispositivos extrínsecos, más frecuentemente usados en una Unidad de Cuidados Intensivos Pediátricos (UCIP). Material y métodos: Estudio prospectivo de vigilancia de la IN asociada a la exposición de dispositivos extrínsecos tipo catéter venoso central, ventilación mecánica y sonda urinaria en una UCIP, durante el período de abril a junio de 2004. Se tuvo en cuenta las infecciones tipo: bacteriemia, neumonía e infección del tracto urinario, utilizando los criterios del Centers for Disease Control and Prevention. Resultados: Se realizó el seguimiento a un total de 326 pacientes pediátricos, el 45% portadores de sonda urinaria, el 30% con catéter venoso central y el 25% expuestos a ventilación mecánica. La tasa de IN fue de 0,6 bacteriemias, 0,4 neumonías y 0,3 infecciones del tracto urinario, por 100 días de exposición al catéter venoso central, ventilación mecánica y sonda urinaria, respectivamente. Conclusiones: La vigilancia epidemiológica de la IN permite conocer las tasas de infección por factores de riesgo asociados a su desarrollo, en un período definido y, por tanto, implementar las medidas de control de la infección, con el fin de disminuir su frecuencia y reducir el coste de estancia hospitalaria secundario a éstas

Objective: To design a protocol for the systematic surveillance of nosocomial infections associated with the devices most frequently used in pediatric intensive care units (PICUs). Material and methods: We performed a prospective epidemiological surveillance study of nosocomial infections associated with devices such as central venous catheters, mechanical ventilation and urinary catheters in a PICU from April to June 2004. The criteria of the Centers for Disease Control and Prevention (CDC) were used to define bacteremia, pneumonia, and urinary tract infection. Results: A total of 326 pediatric patients were studied (45% with urinary catheters, 30% with venous catheters, and 25% under mechanical ventilation). The nosocomial infection rate was 0.6 cases of bacteremia, 0.4 cases of pneumonia and 0.3 cases of urinary tract infection per 100 device days. Conclusions: Epidemiological surveillance of nosocomial infections using a simple protocol allows risk factor-associated infection rates to be determined in a specific time period and measures for infection control to be implemented. These strategies aim to reduce the frequency of infections and consequent cost per days of hospital stay

Incidence study of nosocomial infection in pediatric trauma patients.

In this article we intend to describe the epidemiological profile of nosocomial infection in pediatric patients with multiple trauma. We conducted a prospective study from July to November 2003 in a pediatric teaching hospital in Barcelona. We used US Centers for Disease Control and Prevention standard criteria to define nosocomial infection. Of the 121 patients included in the study, 33% had at least one episode of nosocomial infection, with an incidence rate of 9.9 infections per 100 admissions and 1.1 infections per 100 patient-days. The most frequent episode of nosocomial infection was bacteremia. Coagulase-negative staphylococci were the most common pathogens. Nosocomial infection rates per 100 device-days were 3.2 for bacteremia, 1.6 for respiratory infection and 1.0 for urinary tract infection. These findings suggest the need to evaluate infection control measures aimed at reducing the morbidity associated with infections.

[Longitudinal study of hospital readmission for congestive heart failure in Cataluña. 1996-1999]. / Estudio longitudinal de los reingresos en pacientes con insuficiencia cardiaca en Cataluña, 1996-1999.

BACKGROUND: This study is aimed at describing the readmission phenomenon for heart failure patients and identifying some of their related clinical factors by means of a follow-up study with administrative data. METHODS: Longitudinal study of readmissions due to heart failure (HF) among a population > or = age 65 in Catalonia throughout the 1996-1999 period. Information source: Minimum Basic Set of Data of Hospital Discharges from the Catalan Health Service. Definition of HF, etiological or precipitating cause, and comorbility by means of a ICD-9 discharge release codes combination. Analysis units "patient with HF" and an index population or cohort". STATISTICS: Survival analysis (Kaplan-Meier and Log-rank test) and regression models (Cox). RESULTS: The follow-up populations, comprised of 16,919 patients, generated 44,283 admissions (61.8%). The length of time free of readmissions (Mean "ME" in months) and the comparison of the survival curves is statistically significant with lower values in the following categories: 'age 65-74' (ME = 21.6 months); 'male' (23.3); 'healthcare region 6' (16.3); 'reference hospital' (22.9) and 'pure COPD related to the HF (17.7),. The highest risk of readmission, adjusted by the other variables under study, has been found for 'pure COPD' [RR = 1.03, (95% CI: 1.02-1.04), p < 0.001], and ischaemic heart disease [RR = 1.03, (95% CI: 1.01-1.05), p = 0.003]. CONCLUSIONS: This study reveals the clinical complexity and patterns of utilization of hospitals on the part of patients with heart failure, identifying that those having COPD or ischaemic heart disease being top-priority groups for care intervention and thus revealing the potential which administrative data has for clinical planning and management.

Nosocomial infections among pediatric hematology/oncology patients: results of a prospective incidence study.

BACKGROUND: Nosocomial infections (NI) are an important clinical complication in adult and children patients at the different hospital wards. NI cause considerable morbidity and mortality and are associated with prolonged hospital stay and increased health care costs. OBJECTIVE: The objective of this study was to describe the incidence of NI in pediatric patients with neoplastic disease as a first step toward improving infection control policies. METHODS: A prospective surveillance study from March through May 2001 was performed in the pediatric hematology/oncology unit at the University Hospital in Barcelona. The Centers for Disease Control and Prevention criteria were used as standard definition for NI. NI rates were calculated as a density incidence rate (per 100 patient-days). RESULTS: Fifty-one patients were admitted during the study period. Twelve patients had a total of 18 NI. The incidence of NI was 1.77 per 100 patient-days. Patients with acute lymphoblastic leukemia had the highest NI rate (2.71 per 100 patient-days). The most frequent episodes of NI were bacteremia (55.5%) and fever of unknown origin (16.6%). The most frequently isolated microorganisms were gram-positive bacteria (78.6%). Coagulase-negative Staphylococci were the most common isolates in bacteremias (70%). The extrinsic risk factors related with the highest incidence rates of NI per 100 patient-days were central venous catheterization (1.7 infections) and parenteral nutrition (3.2 infections). CONCLUSIONS: Extrinsic risk factors associated with NI have been identified in this high-risk population. These findings suggest the need to evaluate the infection control measures to reduce the morbidity and mortality in a hematology/oncology unit.

A prospective incidence study of nosocomial infections in a neonatal care unit.

BACKGROUND: Health care improvements and technical advances for diagnostic and therapeutic management in the neonatal care unit (NCU) have made possible the increasing survival of neonates with severe pathologic conditions. However, nosocomial infections (NI) still represent an important cause of morbidity and mortality in this population. OBJECTIVE: To describe the epidemiologic profile of NI in the NCU. METHODS: A prospective surveillance study was performed in the NCU at a university hospital in Barcelona during 6 months. Two hundred sixty-eight neonates were admitted during the study period. Centers for Disease Control and Prevention criteria were used as standard definitions for NI. Data including risk factors associated with NI were recorded. RESULTS: Sixty-five neonates had a total of 88 NI. The incidence rate of NI was 1.6 per 100 patient-days. The accumulative rate of NI was 32.7 per 100 admissions. Bacteremia (28.4%), conjunctivitis (19.5%), respiratory infection (10.2%), and urinary tract infection (7.9%) were the most common episodes observed. Gram-positive bacteria were the most commonly isolated germs (76.4%), with coagulase-negative Staphylococcus (72.5%) being the main pathogen. Intrinsic risk factors related to NI were low birth weight (<1000 g) and urinary catheter and peripheral venous catheter (P<.01). CONCLUSIONS: NI represent an important and frequent problem in neonates. Knowledge of the incidence of NI allows the targeting and implementation of preventive strategies for reducing morbidity and mortality related to NI in an NCU.

Prospective incidence study of nosocomial infections in a pediatric intensive care unit.

BACKGROUND: Nosocomial infections are important causes of substantial morbidity, mortality and prolonged hospital stay in pediatric intensive care units (PICU). METHODS: A prospective surveillance study was performed in the PICU at a university hospital in Barcelona during the 6 months from May through October 2000 to describe the epidemiologic profile of nosocomial infections. Centers for Disease Control and Prevention criteria were used as standard definitions for nosocomial infections. Data including extrinsic risk factors (invasive devices) associated with nosocomial infections were recorded and device-associated infections were calculated for the specific site. RESULTS: During the study period 257 patients were admitted; 15.1% (39) patients had a total of 58 nosocomial infections. The incidence of nosocomial infection was 1.5 per 100 patient-days. Patients with cardiac surgery had the highest nosocomial infection rate, 2.3 per 100 patient-days. Bacteremia (51.7%), respiratory infection (19.0%) and urinary tract infection (17.2%) were the most frequent nosocomial infections observed, and these were associated with use of invasive device. Coagulase-negative staphylococci (39%) and Pseudomonas aeruginosa (24%) were the most common organisms isolated. Nosocomial infection rates per 1000 device days were 23.9 for respiratory infection, 12.4 for bacteremia and 10.7 for urinary tract infection. The durations of hospitalization for patients with and without infection were 22.5 and 9 days, respectively (P < 0.001). CONCLUSIONS: Performance of surveillance highlights the importance of nosocomial infections and their influence in the hospital stay and can guide selection of prevention and control measures to reduce morbidity and mortality in a PICU.