Development of a statewide collaborative to decrease NICU central line-associated bloodstream infections.

OBJECTIVE: To characterize hospital-acquired bloodstream infection rates among New York State's 19 regional referral NICUs (at regional perinatal centers; RPCs) and develop strategies to promote best practices to reduce central line-associated bloodstream infections (CLABSIs). STUDY DESIGN: During 2006 and 2007, RPC NICUs reported bloodstream infections, patient-days and central line-days to the Department of Health, and shared their results. Aiming to improve, participants created a central line-care bundle based on visiting a potentially best performing NICU and reviewing the literature. RESULT: All 19 RPCs participated in this quality initiative, contributing 218,096 patient-days and 56,911 central line-days of observation. Individual RPC nosocomial sepsis infection (NI) rates ranged from 1.0 to 5.8 NIs per 1000 patient-days (2006), and CLABSI rates ranged from 2.6 to 15.1 CLABSIs per 1000 central line-days (2007). A six-fold rate variation among RPC NICUs was observed. Participants unanimously approved a level-1 evidence-based central line-care bundle. CONCLUSION: Individual RPC rates and consequent morbidity and resource use attributable to these infections were substantial and varied greatly. No center was without infections. It is hoped that the cooperation and accountability exhibited by the RPCs will result in a major network for characterizing performance and improving outcomes.

Negative-Pressure monitoring of tuberculosis isolation rooms within New York State hospitals.

A previously published study recommended the daily use of visible smoke to test for negative air pressure in isolation rooms occupied by potentially infectious tuberculosis cases. Continuous monitoring devices were found to have poor reliability. Findings from our survey of engineering controls in acute-care hospitals within New York State support this recommendation.

Causes and costs of hospitalization of tuberculosis patients in the United States.

OBJECTIVE: To examine the costs, lengths of stay and patient characteristics associated with tuberculosis (TB) hospitalizations. METHODS: A prospective cohort study of 1493 TB patients followed from diagnosis to completion of therapy at 10 public health programs and area hospitals in the US. The main outcome measures were the following: 1) occurrence, 2) cost, and 3) length of stay of TB-related hospitalizations. RESULTS: There were 821 TB-related hospitalizations among the study participants; 678 (83%) were initial hospitalizations and 143 (17%) were hospitalizations during the treatment of TB. Patients infected with human immunodeficiency virus (HIV) (OR 1.8, 95% CI 1.2-2.6), and homeless patients (OR, 1.7 95% CI 1.1-2.8) were at increased risk of being hospitalized at diagnosis. Homeless patients (RR 2.5, 95%CI 1.5-4.3), patients who used alcohol excessively (RR 1.9, 95% CI 1.2-3.0), and patients with multidrug-resistant TB (RR 5.7, 95% CI 2.7-11.8) were at increased risk of hospitalization during treatment. The median length of stay varied from 9 to 17 days, and median costs per hospitalization varied from $6441 to $12968 among the sites. CONCLUSION: Important social factors, HIV infection, and local hospitalization practice patterns contribute significantly to the high cost of TB-related hospitalizations. Efforts to address these specific factors are needed to reduce the cost of preventable hospitalizations.

Identification of factors that disrupt negative air pressurization of respiratory isolation rooms.

OBJECTIVES: To investigate the airflow characteristics of respiratory isolation rooms (IRs) and to evaluate the use of visible smoke as a monitoring tool. METHODS: Industrial hygienists from the New York State Department of Health evaluated 140 designated IRs in 38 facilities within New York State during 1992 to 1998. The rooms were located in the following settings: hospitals (59%), correctional facilities (40%), and nursing homes (1%). Each room was tested with visible smoke for directional airflow into the patient room (ie, negative air pressure relative to adjacent areas). Information was obtained on each facility's policies and procedures for maintaining and monitoring the operation of the IRs. RESULTS: Inappropriate outward airflow was observed in 38% of the IRs tested. Multiple factors were associated with outward airflow direction, including ventilation systems not balanced (54% of failed rooms), shared anterooms (14%), turbulent airflow patterns (11%), and automated control system inaccuracies (10%). Of the 140 tested rooms, 38 (27%) had either electrical or mechanical devices to monitor air pressurization continuously. The direction of airflow at the door to 50% (19/38) of these rooms was the opposite of that indicated by the continuous monitors at the time of our evaluations. The inability of continuous monitors to indicate the direction of airflow was associated with instrument limitations (74%) and malfunction of the devices (26%). In one facility, daily smoke testing by infection control staff was responsible for identifying the malfunction of a state-of-the-art computerized ventilation monitoring and control system in a room housing a patient infectious with drug-resistant tuberculosis. CONCLUSION: A substantial percentage of IRs did not meet the negative air pressure criterion. These failures were associated with a variety of characteristics in the design and operation of the IRs. Our findings indicate that a balanced ventilation system does not guarantee inward airflow direction. Devices that continuously monitor and, in some cases, control the pressurization of IRs had poor reliability. This study demonstrates the utility of using visible smoke for testing directional airflow of IRs, whether or not continuous monitors are used. Institutional tuberculosis control pro grams should include provisions for appropriate monitoring and maintenance of IR systems on a frequent basis, including the use of visible smoke.

Tuberculosis control in New York City hospitals.

OBJECTIVES: To assess the implementation of tuberculosis (TB) control measures in New York City hospitals in 1992 and determine trends during the subsequent 2 years. METHODS: The 22 acute care facilities with the largest number of hospitalized TB patients in 1991 were selected for inclusion in the study. Medical and laboratory records of the 10 most recent acid fast bacilli (AFB) smear-positive patients in each of the selected facilities in 1992, 1993, and 1994 were reviewed by using a standardized questionnaire to determine risk factors for TB, previous history of TB, clinical signs and symptoms, AFB laboratory turnaround times, emergency department contact, timing of isolation, timing of treatment, case reporting, and status on discharge. The patients' rooms were evaluated for TB environmental control measures if the patient was still on respiratory isolation precautions. RESULTS: More than one third of patients were admitted with a previous history of TB, 31% were admitted with a cavitary lesion on chest x-ray examination, and 48% were known to have HIV infection. Eighty-five percent were admitted from the emergency department where they stayed for up to 116 hours (mean stay: 17 hours). The proportion of patients placed in AFB isolation on admission to the floor increased from 75% in 1992 to 84% in 1994. The proportion of patients given a minimum of four anti-TB drugs increased from 88% in 1992 to 94% in 1994. Patients "on isolation" were sharing rooms with up to nine other patients in 1992, whereas no patients were sharing rooms in the 1994 survey. In 1992, 51% of the rooms were under negative air flow with respect to the corridor. During the 1994 survey, 80% of rooms were under negative air flow. Between 1992 and 1994, the proportion of AFB isolation rooms with dust/mist respirators increased from 28% to 76% (p < 0.00001). Approximately 25% of discharged patients left against medical advice (no trend over time). The proportion of medically discharged patients with three negative AFB smears before discharge increased from 26% to 48% (p = 0.03) and the proportion referred for directly observed therapy increased from 15% to 53% (p = 0.00001). CONCLUSION: TB control efforts in New York City hospitals improved dramatically between 1992 and 1994. The ultimate control of TB will continue to depend on the coordinated efforts within and between health care facilities, providers, and the community.

Newborn seroprevalence study: methods and results.

For the 28-month period, November 30, 1987 through March 31, 1990, 653,117 blood specimens obtained on all newborn infants in New York State for detection of metabolic disorders were also analyzed for HIV serologic status. The overall seroprevalence rate was 0.66 percent: 1.24 percent in New York City and 0.17 percent in New York State exclusive of New York City. Rates of seropositivity were highest in the Bronx (1.72 percent) and Manhattan (1.59 percent). Outside of New York City, HIV seropositivity was concentrated in certain areas. Sixty-four zip codes with two or more seropositives and an HIV seroprevalence rate twice the average outside of New York City contained 65 percent of the HIV seropositives but only 16 percent of the newborns tested. Newborn seropositivity increased with maternal age. In New York City, the seroprevalence rates increased from 0.16 percent (1 in 624) for 14-year-olds to 1.41 percent (1 in 71) for 24-year-olds, a ninefold rise. This survey has provided the impetus for a number of preventive initiatives.

HIV seroprevalence in clients of sentinel family planning clinics.

In February 1988 the New York State Department of Health initiated a study to determine the prevalence of HIV antibody in women attending selected, publicly subsidized family planning clinics. During a 26-month study period, 27,549 blood specimens were obtained from women having an initial medical examination in 41 clinic sites throughout the state. Of these clients 144 (0.52 percent) were seropositive. The HIV seroprevalence rate increased with age to a high of 1.56 percent for 831 women ages 35 to 39. The seroprevalence rate for non-Hispanic Black or Hispanic clients (0.76 percent) was about six times the rate for non-Hispanic Whites (0.13 percent). No overall increasing or decreasing trend in prevalence of HIV infection was detected during the study period.

HIV seroprevalence in a facility for runaway and homeless adolescents.

In October 1987, the New York State Department of Health initiated a study to determine the prevalence of antibody to HIV in clients of a facility for runaway and homeless adolescents in New York City. A risk-assessment component was added in May 1988. As of December 1989, a total of 2,667 adolescents had been tested, and 142 (5.3 percent) were found to be HIV-seropositive (males 6.0 percent, females 4.2 percent). The seroprevalence rate increased from 1.3 percent for 15-year-olds to 8.6 percent for 20-year-olds. Hispanics had the highest seroprevalence rate (6.8 percent), followed by non-Hispanic Whites (6.0 percent) and non-Hispanic Blacks (4.6 percent). HIV seropositivity was associated with intravenous drug use, male homosexual/bisexual activity, prostitution, and history of another sexually transmitted disease. The alarmingly high prevalence of HIV infection in this selected population illustrates the immediate need for prevention programs for adolescents.

HIV seroprevalence in newborns in New York State.

The prevalence of human immunodeficiency virus (HIV) infection was determined in women at the time of childbirth throughout New York State between November 30, 1987, and November 30, 1988. Mandatory blood specimens (276,609) obtained from all newborns were examined for HIV. The overall HIV seroprevalence rate was 0.66% (1816 newborns), with 0.16% in Upstate New York and 1.25% in New York City. Rates for newborns whose mothers were aged 20 to 29 years (1.30%) and 30 to 39 years (1.35%) were significantly higher than rates for those with mothers younger than 20 years of age (0.72%). Rates of seropositivity were higher among blacks (1.8%) and Hispanics (1.3%) than among whites (0.13%). Seropositivity of HIV was higher in zip code areas with high rates of drug use (2.2%) than in the rest of New York City (0.8%). It is estimated that more than 726 HIV-infected children were born in New York State during the 1-year study period, using 40% as the probable proportion of seropositives that will become infected.

Cluster of Haemophilus influenzae type b infections in adults.

Haemophilus influenzae type b commonly causes illness in young children, among whom transmission is known to occur. Most adults are believed to be immune to H influenzae type b and outbreaks of disease among adults appear to be uncommon. From July 14 to Aug 12, 1985, a cluster of six cases of acute febrile illness with cultures positive for H influenzae, biotype II (five cases) or untyped H influenzae (one case), occurred among adults in a nursing home and an adjoining hospital. All six case-patients had personal contact with at least one other case-patient. Among the 46 nursing home residents, men were more likely than women to become ill (44% vs 0%). This cluster of disease suggests that elderly adults may be more susceptible to H influenzae infection than is generally recognized and that outbreaks among adults may result from person-to-person transmission.

Fatal Salmonella septicemia after platelet transfusion.

A thrombocytopenic, leukopenic patient with multiple myeloma who was given 7 units of platelets died 6 days later from complications of Salmonella heidelberg septicemia. A platelet donor who was asymptomatic at the time of donation had group B Salmonella on stool culture. His clinical history and the results of serologic studies and stool culture were consistent with a mild Salmonella gastroenteritis 5 days before donation. Antibiotic sensitivity patterns and plasmid profiles indicated that the organism (S. heidelberg) isolated from the donor's stool was identical to that isolated from the patient's blood and from the platelet bags. It is believed that low-grade, asymptomatic bacteremia in the donor was the source of infection in the recipient. Food and Drug Administration records contain reports of six septic deaths due to platelet transfusions since 1979, compared with none in the preceding 4 years. Increased use of platelet products and the standard practice of storage at room temperature may contribute to the risk of sepsis after platelet transfusion, particularly in immunocompromised patients.

Widespread outbreaks of clam- and oyster-associated gastroenteritis. Role of Norwalk virus.

Consumption of raw shellfish has long been known to be associated with individual cases and sporadic outbreaks of enteric illness. However, during 1982, outbreaks of gastroenteritis associated with eating raw shellfish reached epidemic proportions in New York State. Between May 1 and December 31, there were 103 well-documented outbreaks in which 1017 persons became ill: 813 cases were related to eating clams, and 204 to eating oysters. The most common symptoms were diarrhea, nausea, abdominal cramps, and vomiting. Incubation periods were generally 24 to 48 hours long, and the duration of illness was 24 to 48 hours. Bacteriologic analyses of stool and shellfish specimens did not reveal a causative agent. Norwalk virus was implicated as the predominant etiologic agent by clinical features of the illness and by seroconversion and the formation of IgM antibody to Norwalk virus in paired serum samples from persons in five (71 percent) of seven outbreaks in which testing was done. In addition, Norwalk virus was identified by radioimmunoassay in clam and oyster specimens from two of the outbreaks. Determining the source of the shellfish was not always possible, but northeastern coastal waters were implicated. The magnitude, persistence, and widespread nature of these outbreaks raise further questions about the safety of consuming raw shellfish.

Use of influenza vaccine in nursing homes.

The organization and outcome of influenza immunization programs were studied in 67 randomly or systematically selected nursing homes (8354 residents) in six states during the autumn of 1982 and/or 1983. In each home, influenza vaccine was usually offered to all residents on a voluntary basis, independent of their age, level of required nursing care, or underlying medical conditions. However, the proportion of residents who were vaccinated ranged from 8 to 98% (mean, 62% overall), with significantly lower rates in homes that also required consent from relatives (usually by return mail) than in homes that did not (P less than .00001; median, 57 versus 90%, respectively). These observations suggest that distribution of educational materials about the risks and benefits of influenza vaccine and systematic follow-up of relatives who fail to return the consent form may be useful strategies to further increase the number of nursing home residents who are immunized.

Nosocomial outbreak of Candida parapsilosis fungemia related to intravenous infusions.

Candida parapsilosis is rarely isolated from blood cultures. Our hospital surveillance detected an increased rate of isolation of C parapsilosis during a four month period. Fourteen postoperative patients receiving intravenous (IV) hyperalimentation and eight burn patients receiving IV albumin were involved. Hectic fever, the major clinical manifestation, was seen in 61% of cases. Therapy in the postoperative patients consisted merely of discontinuing IV catheters and hyperalimentation, while amphotericin B was needed in five of eight burn patients to control persistent fungemia. Epidemiologic analysis identified a source of the organism in the IV-additive preparation room where C parapsilosis was found contaminating a vacuum system. Organisms apparently refluxed into IV bottles when aliquots were removed to accommodate additives. Of 103 patients who received fluids prepared with the contaminated system, 21% became infected with C parapsilosis. Infection surveillance was instrumental in detection and control of the outbreak. Routine guideline should be established to insure the sterility of IV fluids containing additives.