Identifying and Mitigating Disparities in Central Line-Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups.

Importance: Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. Objective: To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. Design, Setting, and Participants: This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Exposures: Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Main Outcomes and Measures: Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Results: Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). Conclusions and Relevance: The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Healthcare-associated Staphylococcus aureus bacteraemia: time to reduce the harm caused by a largely preventable event.

Staphylococcus aureus disease is associated with significant morbidity and mortality and of concern, it disproportionally affects Maori and Pacific Peoples. New Zealand has high rates of skin and soft tissue infection caused by S. aureus. Healthcare-associated S. aureus bacteraemia (HA-SAB) accounts for a significant proportion of all S. aureus bacteraemia events. Measurement of HA-SAB has been reported in New Zealand for over 20 years but it has not been linked to quality improvement interventions to reduce the rate. It has been used as an outcome measure for the Hand Hygiene New Zealand programme; however, a recent review of submitted data questioned the accuracy of it. This has been addressed. National programmes such as the Health Quality & Safety Commissions Hand Hygiene New Zealand and the Surgical Site Infection Improvement programme have led to reduced harm from healthcare-associated infections. Interventions targeted at reducing the HA-SAB rate, such as bundles of care for insertion and maintenance of vascular access devices and skin and nasal decolonisation of staphylococci prior to surgery, are urgently required.

Disparities in Health Care-Associated Infections in the NICU.

OBJECTIVES: This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals. STUDY DESIGN: This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative. RESULTS: Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection. CONCLUSION: Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.

Hospital-associated Clostridium difficile infection and reservoirs within the hospital environment.

BACKGROUND: Clostridium difficile infection (CDI) is a leading cause of hospital-associated infections. Antibiotic stewardship, environmental disinfection, and reduction of transmission via health care workers are the major modes of CDI prevention within hospitals. METHODS: The aim of this study was to evaluate the role of the environment in the spread of CDI within hospital rooms. Bed tracing of positive-CDI inpatients was performed to detect the strength of association to specific rooms. Environmental cultures were conducted to identify adequacy of environmental C difficile (CD) spores. Whole-genome sequencing was performed to evaluate the degree of CD relatedness. RESULTS: Bed tracing performed for 211 CDI patients showed a limited list of high-burden rooms. Environmental cultures for surfaces disinfected with a sporicidal agent were almost entirely negative, whereas the floors were positive for CDI in 15% of the studied patient rooms. Whole-genome sequencing did not detect any close genetic relatedness. CONCLUSIONS: Unlike in an outbreak setting, bed tracing did not yield conclusive results of room reservoirs. The C diff Banana Broth culture was inexpensive, sensitive, and easy to incubate under aerobic conditions. Sporicidal disinfectants were effective in eliminating CD from the environment. CD spores were found on floors and hard-to-clean surfaces.

Racial Disparities in Invasive Methicillin-resistant Staphylococcus aureus Infections, 2005-2014.

Background: Despite substantial attention to the individual topics, little is known about the relationship between racial disparities and antimicrobial-resistant and/or healthcare-associated infection trends, such as for methicillin-resistant Staphylococcus aureus (MRSA). Methods: We analyzed Emerging Infections Program 2005-2014 surveillance data (9 US states) to determine whether reductions in invasive MRSA incidence (isolated from normally sterile body sites) affected racial disparities in rates. Case classification included hospital-onset (HO, culture >3 days after admission), healthcare-associated community onset (HACO, culture ≤3 days after admission and dialysis, hospitalization, surgery, or long-term care residence within 1 year prior), or community-associated (CA, all others). Negative binomial regression models were used to evaluate the adjusted rate ratio (aRR) of MRSA in black patients (vs in white patients) controlling for age, sex, and temporal trends. Results: During 2005-2014, invasive HO and HACO (but not CA) MRSA rates decreased. Despite this, blacks had higher rates for HO (aRR, 3.20; 95% confidence interval [CI], 2.35-4.35), HACO (aRR, 3.84; 95% CI, 2.94-5.01), and CA (aRR, 2.78; 95% CI, 2.30-3.37) MRSA. Limiting the analysis to chronic dialysis patients reduced, but did not eliminate, the higher HACO MRSA rates among blacks (aRR, 1.83; 95% CI, 1.72-1.96), even though invasive MRSA rates among dialysis patients decreased during 2005-2014. These racial differences did not change over time. Conclusions: Previous reductions in healthcare-associated MRSA infections have not affected racial disparities in MRSA rates. Improved understanding of the underlying causes of these differences is needed to develop effective prevention interventions that reduce racial disparities in MRSA infections.

Hospital-Onset MRSA Bacteremia Rates Are Significantly Correlated With Sociodemographic Factors: A Step Toward Risk Adjustment.

The correlations between census-derived sociodemographic variables and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia (HO-MRSAB) rates were examined at the US state level. On multivariable analysis, only percent African American remained statistically significant. This finding highlights an important disparity and suggests that risk adjustment is needed when comparing HO-MRSAB rates among US states. Infect Control Hosp Epidemiol 2018;39:479-481.

The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line-Associated Bloodstream Infection Risk-Adjustment Methodology.

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolates from two Korean hospitals.

Clostridium difficile is one of the main etiological agents causing antibiotic-associated diarrhea. This study investigated the genetic diversity of 70 toxigenic C. difficile isolates from two Korean hospitals by employing toxinotyping, ribotyping, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE). Toxin gene amplification resulted in 68 A⁺B⁺ and two A-B+ isolates. Most isolates (95.7-100%) were susceptible to daptomycin, metronidazole, and vancomycin. Seventy C. difficile isolates were classified into five toxinotypes, 19 ribotypes, 16 sequence types (STs), and 33 arbitrary pulsotypes. All C. difficile isolates of ribotype 018 (n = 38) were classified into ST17, which was the most prevalent ST in both hospitals. However, C. difficile isolates of ST17 (ribotype 018) exhibited pulsotypes that differed by hospital. ST2 (ribotype 014/020), 8 (ribotypes 002), 17 (ribotype 018), and 35 (ribotypes 015) were detected in both hospitals, whereas other STs were unique to each hospital. Statistical comparison of the different typing methods revealed that ribotyping and PFGE were highly predictive of STs. In conclusion, our epidemiological study indicates that C. difficile infections in both hospitals are associated with the persistence of endemic clones coupled with the emergence of many unique clones. A combination of MLST with PFGE or ribotyping could be useful for monitoring epidemic C. difficile strains and the emergence of new clones in hospitals.

Racial and ethnic disparities in health care-associated Clostridium difficile infections in the United States: State of the science.

BACKGROUND: Among health care-associated infections (HAIs), Clostridium difficile infections (CDIs) are a major cause of morbidity and mortality in the United States. As national progress toward CDI prevention continues, it will be critical to ensure that the benefits from CDI prevention are realized across different patient demographic groups, including any targeted interventions. METHODS: Through a comprehensive review of existing evidence for racial/ethnic and other disparities in CDIs, we identified a few general trends, but the results were heterogeneous and highlight significant gaps in the literature. RESULTS: The majority of analyzed studies identified white patients as at increased risk of CDIs, although there is a very limited literature base, and many studies had significant methodological limitations. CONCLUSION: Key recommendations for future research are provided to address antimicrobial stewardship programs and populations that may be at increased risk for CDIs.

Burden of present-on-admission infections and health care-associated infections, by race and ethnicity.

BACKGROUND: In the United States incidence of sepsis and pneumonia differ by race, but it is unclear whether this is due to intrinsic factors or health care factors. METHODS: We conducted a study of 52,006 patients hospitalized during 2006-2008 at a referral hospital in upper Manhattan. We examined how the prevalence of present-on-admission and health care-associated infection compared between non-Hispanic blacks, Hispanics, and non-Hispanic whites adjusting for sociodemographic factors, admission through the emergency department, and comorbid conditions. RESULTS: Non-Hispanic blacks had 1.59-fold (95% confidence interval [CI], 1.29-1.96) and 1.55-fold (95% CI, 1.35-1.77) risk of community-acquired bloodstream infection and urinary tract infection compared with non-Hispanic whites. Hispanic patients had 1.31-fold (95% CI, 1.15-1.49) risk of presenting with community-acquired urinary tract infection compared with non-Hispanic whites. Controlling for admission through the emergency department, comorbidity, and neighborhood income attenuated the differences in prevalence of infections. CONCLUSIONS: We found that health disparities in present-on-admission infections might be largely explained by potential lack of ambulatory care, socioeconomic factors, and comorbidity.

Racial and ethnic disparities in healthcare-associated infections in the United States, 2009-2011.

BACKGROUND: Little is known about racial and ethnic disparities in the occurrence of healthcare-associated infections (HAIs) in hospitalized patients. OBJECTIVE: To determine whether racial/ethnic disparities exist in the rate of occurrence of HAIs captured in the Medicare Patient Safety Monitoring System (MPSMS). METHODS: Chart-abstracted MPSMS data from randomly selected all-payer hospital discharges of adult patients (18 years old or above) between January 1, 2009, and December 31, 2011, for 3 common medical conditions: acute cardiovascular disease (composed of acute myocardial infarction and heart failure), pneumonia, and major surgery for 6 HAI measures (hospital-acquired antibiotic-associated Clostridium difficile, central line-associated bloodstream infections, postoperative pneumonia, catheter-associated urinary tract infections, hospital-acquired methicillin-resistant Staphylococcus aureus, and ventilator-associated pneumonia). RESULTS: The study sample included 79,019 patients who had valid racial/ethnic information divided into 6 racial/ethnic groups-white non-Hispanic (n = 62,533), black non-Hispanic (n = 9,693), Hispanic (n = 4,681), Asian (n = 1,225), Native Hawaiian/Pacific Islander (n = 94), and other (n = 793)-who were at risk for at least 1 HAI. The occurrence rate for HAIs was 1.1% for non-Hispanic white patients, 1.3% for non-Hispanic black patients, 1.5% for Hispanic patients, 1.8% for Asian patients, 1.7% for Native Hawaiian/Pacific Islander patients, and 0.70% for other patients. Compared with white patients, the age/gender/comorbidity-adjusted odds ratios of occurrence of HAIs were 1.1 (95% confidence interval [CI], 0.99-1.23), 1.3 (95% CI, 1.15-1.53), 1.4 (95% CI, 1.07-1.75), and 0.7 (95% CI, 0.40-1.12) for black, Hispanic, Asian, and a combined group of Native Hawaiian/Pacific Islander and other patients, respectively. CONCLUSIONS: Among patients hospitalized with acute cardiovascular disease, pneumonia, and major surgery, Asian and Hispanic patients had significantly higher rates of HAIs than white non-Hispanic patients.

Risk factors of stroke-associated pneumonia in Chinese patients.

OBJECTIVE: To explore the risk factors for stroke-associated pneumonia (SAP). METHODS: A retrospective research study was carried out to investigate the clinical data of 1435 patients admitted to the neurological intensive care unit at our university hospital between 1 January 2000 and 31 December 2009. RESULTS: A multi-factorial analysis produced the following results: (1) SAP is 1.113 times more likely to occur for each 1-year increase in age; (2) diabetic patients are 1.612 times more likely to develop SAP than non-diabetic patients; (3) the incidence of SAP decreases by a factor of 0.890 with a one-point increase in the Glasgow coma scale score; (4) nasal feeding patients are 4.981 times more likely to develop SAP than non-nasal feeding patients; (5) patients who use H2-receptor blocking agents are 2.837 times more likely to develop SAP than those who do not; (6) patients who preventively use antibiotics are 2.675 times more likely to develop SAP than those who do not; (7) patients whose hospitalization periods are >20 days are 0.500 times more likely to develop SAP than those who do not; (8) patients who suffer from tracheal intubation are 2.980 times more likely to develop SAP than those who do not; and (9) patients who suffer from tracheal incision are 2.190 times more likely to develop SAP than those who do not. CONCLUSIONS: SAP was more closely related with diabetes, age, consciousness, days of hospitalization, tracheal intubation, tracheal incision, nasal feeding treatment, and the application of H2-receptor blocking agents and antimicrobials.

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

BACKGROUND: There is increasing policy interest in public reporting and tying financial incentives to metrics of patient safety. How black-serving hospitals fare on these measures will have important implications for disparities in care. OBJECTIVES: To determine how black-serving hospitals perform on patient safety indicators (PSIs). RESEARCH DESIGN: We used national Medicare data to calculate the performance of hospitals on 11 medical and surgical PSIs. We designated US hospitals in the top decile of proportion of hospitalized patients who are black as "black-serving." We calculated overall and race-specific rates and examined the relationship between being a black-serving hospital and PSI rates. SUBJECTS: Medicare fee-for-service enrollees discharged from 4488 acute-care US hospitals. RESULTS: Black-serving hospitals performed worse than other hospitals on 6 of 11 PSIs. For example, black-serving hospitals had nearly twice the rate of postoperative pulmonary embolism or deep venous thrombosis (19.4 vs. 11.5 per 1000 discharges, P < 0.001). Adjusting for hospital characteristics had moderate effects. In race-specific analyses, we found that both white and black patients generally had higher rates of potential safety events in black-serving hospitals than they did in non-black-serving hospitals. CONCLUSIONS: Hospitals that disproportionately care for black patients have higher rates of potential safety events among both black and white patients than other hospitals. Current efforts to penalize hospitals with high PSI rates will have a greater effect on hospitals that disproportionately care for black patients.

Infectious complications after elective vascular surgical procedures.

OBJECTIVE: This study was conducted to evaluate and compare the rates of postoperative infectious complications and death after elective vascular surgery, define vascular procedures with the greatest risk of developing nosocomial infections, and assess the effect of infection on health care resource utilization. METHODS: The Nationwide Inpatient Sample (2002-2006) was used to identify major vascular procedures by International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) codes. Infectious complications identified included pneumonia, urinary tract infections (UTI), postoperative sepsis, and surgical site infections (SSI). Case-mix-adjusted rates were calculated using a multivariate logistic regression model for infectious complication or death as an outcome and indirect standardization. RESULTS: A total of 870,778 elective vascular surgical procedures were estimated and evaluated with an overall postoperative infection rate of 3.70%. Open abdominal aortic surgery had the greatest rate of postoperative infections, followed by open thoracic procedures and aorta-iliac-femoral bypass. Thoracic endovascular aneurysm repair (TEVAR) infectious complication rates were two times greater than after EVAR (P < .0001). Pneumonia was the most common infectious complication after open aortic surgery (6.63%). UTI was the most common after TEVAR (2.86%) and EVAR (1.31%). Infectious complications were greater in octogenarians (P < .0002), women (P < .0001), and blacks (P < .0001 vs whites and Hispanics). Nosocomial infections after elective vascular surgery significantly increased hospital length of stay (13.8 +/- 15.4 vs 3.5 +/- 4.2 days; P < .001) and reported total hospital cost ($37,834 +/- $42,905 vs $11,851 +/- $11,816; P < .001). CONCLUSIONS: Elective vascular surgical procedures vary widely in the estimated risk of postoperative infection. Open aortic surgery and endarterectomy of the head and neck vessels have, respectively, the greatest and the lowest reported incidence for postoperative infectious complications. Women, octogenarians, and blacks have the highest risk of infectious complications after elective vascular surgery. Disparities in the development of infectious complications on a systems level were also found in larger hospitals and teaching hospitals. Hospital infectious complications were found to significantly increase health care resource utilization. Strategies that reduce nosocomial complications and target high-risk procedures may offer significant future cost savings.

Increasing incidence of clostridium difficile-associated diarrhea in African-American and Hispanic patients: association with the use of proton pump inhibitor therapy.

BACKGROUND: Clostridium difficile-associated diarrhea (CDAD) has been increasingly diagnosed in hospitalized patients. The number of prescriptions for proton pump inhibitors (PPIs) has also increased significantly over time. Few studies have reported an association between CDAD and PPI use; however, the results are inconclusive. OBJECTIVE: To determine the relationship between CDAD and PPI use in African-American and Hispanic patients. METHODS: We retrospectively reviewed medical records of 640 cases with CDAD over nine years, diagnosed by the presence of C. difficile toxin in the stools. Age-/ sex-matched 650 patients with diarrhea but absent C. difficile toxin in stools were used as controls. RESULTS: Of the 640 cases, 576 (90%) received antibiotics and 32 (5%) received chemotherapy during the preceding three months. Of the 650 controls, 540 (83%) received antibiotics and 39 (6%) received chemotherapy during the preceding three months. CDAD was associated with the use of antibiotics or chemotherapy (OR = 2.3, 95% CI: 1.5-3.7). Of the 608 cases receiving antibiotics or chemotherapy, 274 (45%) also received PPI within the preceding three months. Of the 579 controls who received antibiotics or chemotherapy, 169 (29%) also received PPI within preceding three months. CDAD was associated with the use of PPI (OR = 2.0, 95% CI: 1.6-2.6). CONCLUSION: Our findings indicate that PPI may be an emerging and potentially modifiable risk factor for CDAD and point out the importance of vigilance in prescribing PPI, particularly to patients who are hospitalized, taking multiple antibiotics and suffering from multiple comorbidities.

The role of infection and comorbidity: Factors that influence disparities in sepsis.

OBJECTIVE: Large healthcare disparities exist in the incidence of sepsis based on both race and gender. We sought to determine factors that may influence the occurrence of these healthcare disparities, with respect to the source of infection, causal organisms, and chronic comorbid medical conditions. DESIGN: Historical cohort study. SETTING: U.S. acute care hospitals from 1979 to 2003. PATIENTS: Hospitalized patients with a diagnosis of sepsis were identified from the National Hospital Discharge Survey per codes of the International Statistical Classification of Diseases, Ninth Revision (ICD-9CM). Chronic comorbid medical conditions and the source and type of infection were characterized by corresponding ICD-9CM diagnoses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sepsis incidence rates are mean cases per 100,000 after age adjustment to the 2000 U.S. Census. Males and nonwhite races were confirmed at increased risk for sepsis. Both proportional source distribution and incidence rates favored respiratory sources of sepsis in males (36% vs. 29%, p < .01) and genitourinary sources in females (35% vs. 27%, p < .01). Incidence rates for all common sources of sepsis were greater in nonwhite races, but proportional source distribution was approximately equal. After stratification by the source of infection, males (proportionate ratio 1.16, 95% confidence interval 1.04-1.29) and black persons (proportionate ratio 1.25, 95% confidence interval 1.18-1.32) remained more likely to have Gram-positive infections. Chronic comorbid conditions that alter immune function (chronic renal failure, diabetes mellitus, HIV, alcohol abuse) were more common in nonwhite sepsis patients, and cumulative comorbidities were associated with greater acute organ dysfunction. Compared with white sepsis patients, nonwhite sepsis patients had longer hospital length of stay (2.0 days, 95% confidence interval 1.9-2.1) and were less likely to be discharged to another medical facility (30% whites, 25% blacks, 18% other races). Case-fatality rates were not significantly different across racial and gender groups. CONCLUSIONS: Healthcare disparities exist in the incidence of sepsis within all major sources of infection, and males and blacks have greater frequency of Gram-positive infections independent of the infection source. The differential distribution of specific chronic comorbid medical conditions may contribute to these disparities. Large cohort and administrative studies are required to confirm discrete root causes of sepsis disparities.

Evaluation of hospitalisation for indigenous children with malnutrition living in central Australia.

OBJECTIVE: To evaluate the effectiveness of hospital admissions for indigenous children with malnutrition in a rural/remote Australian centre. DESIGN: Retrospective review of the medical records. SETTING: Rural secondary hospital. SUBJECTS: Remote and rural indigenous children aged less than four years managed for malnutrition in Alice Springs Hospital (ASH). MAIN OUTCOME MEASURE: The primary outcome measure was weight gain during hospitalisation and posthospitalisation. Secondary outcome measures were yield of investigations, diagnoses made, treatments given, social interventions, readmission rate and nosocomial infection. RESULTS: Median age of the 55 children was 15.1 months. Median weight change was 1.5 g day(-1)prior to hospitalisation, 36.7 g day(-1)during and 9 g day(-1)two months following hospitalisation (P < 0.05). Investigations performed had high yields (80% of children had a treatable organic contributor to malnutrition). Nosocomial infection occurred in 21 (38%) children. Readmission occurred at an average of 1.9 times per child (range 0-5), 34 (37%) occurred within three months and 48 (52%) within six months. CONCLUSION: In rural Indigenous children with malnutrition, hospitalisation was effective in re-establishing growth and defining organic contributors to malnutrition. However, the high readmission rate and nosocomial infection mandates that alternative models to nutritional rehabilitation, in addition to a broad psychosocial and public health approach to prevention and management of malnutrition, is required.