SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update.

Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes.

BACKGROUND: Standard precautions may prevent patient health care associated infections and provider occupational exposures but are not often used by health care workers. A positive patient safety climate might contribute to improved adherence. The aim of this study was to determine the relationships among patient safety climate, standard precaution adherence, and health care worker exposures and HAIs. METHODS: This multi-site, cross-sectional study included survey data from nurses on patient safety climate, observational data on adherence, and existing health care worker exposure and health care associated infections data. Data were aggregated to hospital unit level for correlational and multivariable regression analyses. RESULTS: A total of 5,285 standard precaution observations and 452 surveys were collected across 43 hospital units. Observed adherence to all categories of standard precautions was 64.4%; there were significant differences by provider role. Multivariable models identified key predictors explaining sizeable variance in methicillin-resistant Staphylococcus aureus (41%), catheter associated urinary tract infections (23%), mucotaneous exposures (43%) and needlestick and sharps injuries (38%). DISCUSSION: This study produced findings not previously published thus advancing the state of the science in patient and occupational health safety. These include identifying modifiable features of the safety climate and key organizational characteristics associated better outcomes. CONCLUSIONS: In this novel study we identified that a positive patient safety climate and adherence to standard precautions predict key HAI and occupational health outcomes.

Nurse Engagement in Antibiotic Stewardship Programs: A Scoping Review of the Literature.

INTRODUCTION: Hospital-based antibiotic stewardship programs (ASPs) are an important strategy in combating antibiotic resistance. Four antibiotic stewardship interventions are recommended by the CDC as particularly well-designed to engage nurses. However, there is limited information on whether and how existing hospital-based ASPs reflect these practices. PURPOSE: To describe how nurses are being engaged in hospital ASPs and to what extent this overlaps with the CDC framework. METHODS: This scoping review included studies published in the last 10 years on engaging nurses in hospital-based ASPs. Three databases, PubMed, CINAHL, and Embase, were searched. RESULTS: The search yielded 195 unique articles. Ten articles were retained for review detailing how nurses are engaged. One CDC recommended intervention, initiating discussion of antibiotic treatment, appeared in nine studies. CONCLUSIONS: Although hospitals are engaging nurses in antibiotic stewardship programs, their selected approaches do not reflect the full breadth of the opportunities identified by the CDC. More detail as to how exactly nurses engage would also be a useful addition to the literature. IMPLICATIONS: More research is needed on nurse engagement on culturing or testing and penicillin allergy evaluation. Standardized measures should be collected and reported to measure the impact of engaging nurses in ASPs.

Epidemiology and Impact of Healthcare-Associated Infections in Trauma Patients: A National Data Analysis.

Background: Traumatic injuries are a leading cause of death and morbidity. Despite their comprising a small (<5%) segment of all hospitalizations, the length of stay (LOS) is above average; and the cost of care for the more than 20 million trauma inpatients nears $30 billion per year. Adding insult to injury, risk factors for health-care-associated infections (HAI), including invasive devices and comprised integrity, may be particularly pronounced in this population, potentially exacerbating the clinical and economic burden. Our aim was to determine the distribution, determinants, and burden of HAI after traumatic injury using LOS as a surrogate for health-care-related expense. Patients and Methods: This retrospective cohort study used the Trauma Quality Improvement Project (TQIP) database (2013-2016). Patients 16 to 89 years of age were included. Those who developed at least one of the following were counted as cases: Catheter-related central blood stream infection, catheter-related urinary tract infection, ventilator-associated pneumonia, surgical site infection, osteomyelitis, and severe sepsis. Outcomes included the hospital LOS, intensive care unit (ICU) days, and ventilator days. Uni-variable and propensity-matched analyses were conducted to determine differences among patients with and without an HAI. Results: Of 806,066 patients, 5.6% (n = 44,844) developed an HAI. A higher proportion of patients with HAI had co-morbid risk factors of chronicity and history of blood transfusion and rated higher on the Abbreviated Injury Scale than those without HAI. After matching, those with HAI also had significantly longer (3 × ) overall LOS, ICU LOS, and prolonged mechanical ventilation (p < 0.05). Conclusions: This updated epidemiology study of trauma patients showed the HAI burden to be higher than past estimates and disproportionate of all patient estimates. The associated economic burden of a longer ICU stay with a tripling of the LOS and longer mechanical ventilation demands responsible administrative policies and support for infection prevention programs and interventions.

Relationship among safety culture, nursing care, and Standard Precautions adherence.

Standard Precautions (SP) are an essential, although unmet, component of nursing care. Understanding conditions fostering the integration of SP within nursing workflow is imperative. This research describes the relationships among patient safety culture, adherence to SP, and missed nursing care.

Patient Safety Culture Survey in Pediatric Complex Care Settings: A Factor Analysis.

OBJECTIVES: Children with complex medical needs are increasing in number and demanding the services of pediatric long-term care facilities (pLTC), which require a focus on patient safety culture (PSC). However, no tool to measure PSC has been tested in this unique hybrid acute care-residential setting. The objective of this study was to evaluate the psychometric properties of the Nursing Home Survey on Patient Safety Culture tool slightly modified for use in the pLTC setting. METHODS: Factor analyses were performed on data collected from 239 staff at 3 pLTC in 2012. Items were screened by principal axis factoring, and the original structure was tested using confirmatory factor analysis. Exploratory factor analysis was conducted to identify the best model fit for the pLTC data, and factor reliability was assessed by Cronbach alpha. RESULTS: The extracted, rotated factor solution suggested items in 4 (staffing, nonpunitive response to mistakes, communication openness, and organizational learning) of the original 12 dimensions may not be a good fit for this population. Nevertheless, in the pLTC setting, both the original and the modified factor solutions demonstrated similar reliabilities to the published consistencies of the survey when tested in adult nursing homes and the items factored nearly identically as theorized. CONCLUSIONS: This study demonstrates that the Nursing Home Survey on Patient Safety Culture with minimal modification may be an appropriate instrument to measure PSC in pLTC settings. Additional psychometric testing is recommended to further validate the use of this instrument in this setting, including examining the relationship to safety outcomes. Increased use will yield data for benchmarking purposes across these specialized settings to inform frontline workers and organizational leaders of areas of strength and opportunity for improvement.

Impact of infectious exposures and outbreaks on nurse and infection preventionist workload.

BACKGROUND: Staff nurse and infection preventionist (IP) workload increases in response to exposures and outbreaks. Understanding the time burden associated with responding to specific pathogens may improve resource allocation. The purpose of this study was to evaluate workload increases reported by nurses and IPs in response to common exposures and outbreaks. METHODS: Surveys were distributed to nurses in a New York hospital network and to IPs who attended the 2018 Association for Professionals in Infection Control and Epidemiology annual conference or to IPs who were members of local Association for Professionals in Infection Control and Epidemiology chapters. Respondents were asked to rate their daily workload increase and to rank their most time-consuming activities in response to exposure and outbreak scenarios. RESULTS: A total of 150 nurses and 228 IPs responded. Among the nurses, >60-minute workload increases were reported for Clostridium difficile (76%), lice or scabies (46%), and influenza (45%). Among the IPs, >60-minute increases were reported for mumps or measles (66%), tuberculosis (64%), and C difficile (50%). Among the nurses, isolation precautions, patient and family education, and staffing changes were the most frequently reported time-consuming activities. Among the IPs, chart review, exposure list compiling, and preventive measures for exposures were the most frequently reported time-consuming activities. CONCLUSIONS: Organisms that are easier to treat and more difficult to spread, such as scabies or lice, can contribute substantially to nursing workload. Notably, three-quarters of the nurses and one-half of the IPs reported that C difficile adds >1 hour to their daily workload.

Dissemination and implementation science for infection prevention: A primer.

Dissemination and implementation science (D&I) is a rapidly growing area of investigation. Although many evidence-based guidelines for infection prevention are available, not all are systematically implemented into clinical practice. This evidence-to-practice gap has been linked to poor health outcomes. D&I science bridges the gap between research and everyday practice by providing a knowledge base about how health information, interventions, and new clinical practices and policies are translated for use in specific settings. D&I science can expedite and sustain the successful integration of evidence into practice to improve care delivery, population health, and health outcomes. This article offers an introductory overview of D&I and addresses issues such as variation in terminology, finding and appraising evidence, theories and models, implementation strategies, and the future of D&I. Examples from the infection prevention literature are presented throughout.

Missed Opportunities: The Development and Testing of Standard Precaution Case Vignettes.

Standard precautions are a recommended set of actions health care workers should take to prevent health care-associated infections and potentially infectious exposures. However, they are not reliably practiced, many opportunities are missed, and a substantial discrepancy between workers' stated performance and actual performance exists. This article presents findings from developing and testing standard precaution case scenarios to enhance nursing knowledge. Infusion nursing is high risk and entails highly complex care in dynamic settings. Challenges may exist when integrating this advanced care with fundamental standard precaution requirements. For this reason, findings from this study have implications for infusion nursing practice.

Impact of Patient Safety Culture on Missed Nursing Care and Adverse Patient Events.

BACKGROUND: A strong patient safety culture (PSC) may be associated with improved patient outcomes in hospitals. The mechanism that explains this relationship is underexplored; missed nursing care may be an important link. PURPOSE: The purpose of this study was to describe relationships among PSC, missed nursing care, and 4 types of adverse patient events. METHODS: This cross-sectional study employed primary survey data from 311 nurses from 29 units in 5 hospitals and secondary adverse event data from those same units. Analyses include analysis of variance and regression models. RESULTS: Missed nursing care was reported to occur at an occasional level (M = 3.44, SD = 0.24) across all 29 units. The PSC dimensions explained up to 30% of the variance in missed nursing care, 26% of quality of care concerns, and 15% of vascular access device events. Missed care was associated with falls (P < .05). CONCLUSIONS: Prioritized actions to enhance PSC should be taken to reduce missed nursing care and adverse patient outcomes.

Family Experiences and Perspectives on Infection Prevention in Pediatric Long-Term Care.

PURPOSE: Residents of pediatric long-term care facilities (pLTCF) are particularly vulnerable to healthcare-associated infections. The aims of this qualitative study were to (a) explore perspectives on infection prevention among families visiting children in pLTCF and (b) identify facilitators of and barriers to optimal hand hygiene. DESIGN AND METHODS: Semistructured, in-depth interviews with 10 family members visiting two New York City metropolitan area facilities were analyzed to identify themes. FINDINGS: "Everyone follows the rules" and "infections are inevitable" were primary themes. Participants reported "common sense" as a facilitator and "distraction" as a major barrier to prevention practices. CONCLUSION: Current education for visitors may be inadequate to improve infection prevention behaviors. CLINICAL RELEVANCE: Nurse-led education strategies for infection prevention should be tested and modified for families visiting pLTCF.

Understanding of safety monitoring in clinical trials by individuals with CF or their parents: A qualitative analysis.

BACKGROUND: Recruiting both pediatric and adult participants for clinical trials in CF is currently of paramount importance as numerous new therapies are being developed. However, recruitment is challenging as parents of children with CF and adults with CF cite safety concerns as a principal barrier to enrollment. In conjunction with the CF Foundation (CFF) Data Safety Monitoring Board (DSMB), a pilot brochure was developed to inform patients and parents of the multiple levels of safety monitoring; the CFF simultaneously created an infographic representing the safety monitoring process. This study explores the attitudes and beliefs of CF patients and families regarding safety monitoring and clinical trial participation, and elicits feedback regarding the educational materials. METHODS: Semi-structured interviews were conducted using a pre-tested interview guide and audio-recorded during routine CF clinic visits. Participants included 5 parents of children with CF <16years old; 5 adolescents and young adults with CF 16-21years old; and 5 adults with CF ≥22years old from pediatric and adult CF centers. The study team performed systematic text condensation analysis of the recorded interviews using an iterative process. RESULTS: Four major thematic categories with subthemes emerged as supported by exemplar quotations: attitudes toward clinical trials, safety values, conceptualizing the safety monitoring process, and priorities for delivery of patient education. Participant feedback was used to revise the pilot brochure; text was shortened, unfamiliar words clarified (e.g., "pipeline"), abbreviations eliminated, and redundancy avoided. CONCLUSIONS: Qualitative analysis of CF patient and family interviews provided insights into barriers to participation in clinical trials, safety concerns, perspectives on safety monitoring and educational priorities. We plan a multicenter study to determine if the revised brochure reduces knowledge, attitude and practice barriers regarding participation in CF clinical trials.

Perception of Patient Safety Culture in Pediatric Long-Term Care Settings.

INTRODUCTION: Patient safety culture (PSC) is an emerging construct in adult long-term care settings. No measures are validated to quantify PSC in pediatric long-term care (pLTC) settings despite the importance of safety for this vulnerable population. The study purposes are to (1) describe PSC in pLTC, (2) assess the relationship of PSC to facility recommendation and overall safety rating, and (3) test the stability and reliability of the PSC survey over time. METHODS: A modified Nursing Home PSC (NHSPSC) survey was administered to employees at three pLTC facilities over 3 years; data were summarized and compared over time. RESULTS: In all, 208 surveys were completed. Staff perceptions on "feedback and communication about incidents" and "overall perceptions of resident safety" were most positive and associated with responses of recommending the facility and high overall ratings for child safety (p < .05). CONCLUSIONS: The modified NHSPSC survey was reliable by Cronbach alpha and findings were consistent over time in these pLTC settings. This tool may be a useful adjunct to safety initiatives in pLTC. Knowledge derived from this survey can provide actionable information for consumers, pLTC employees, managers, and administrators.

Severity of Illness Measures for Pediatric Inpatients.

INTRODUCTION: Severity of illness (SOI) measures are commonly used in adults for comparison of treatment and outcomes in similar populations. Less is known about the psychometric properties of measures available to providers and healthcare systems caring for pediatric patients. The purpose of this study was to (1) identify SOI measures used for pediatric patients admitted to acute care hospitals and (2) compare the ability of two SOI measures to predict mortality and length of stay (LOS). METHODS: Twelve instruments were identified through literature search and one, the pediatric chronic complex condition (CCC), was retained. The CCC and the Charlson/Deyo comorbidity score were applied to an 8-year retrospective, multi-institutional data set using logistic and zero-truncated negative binomial regression models. RESULTS: Records from 199,001 children were examined. The CCC performed better for predicting mortality (odds ratio = 3.36; 95% confidence interval [CI]: 3.20-3.53) and LOS (incidence rate ratio = 2.24; 95% CI: 2.22-2.26). CONCLUSIONS: The CCC may be preferable for predicting outcomes among pediatric inpatients. Pediatric SOI measures are not extensively developed and tested nor widely and freely available. The use of the CCC can predict mortality and LOS to guide care, resource allocation, and research for the pediatric population.

National Testing of the Nursing-Kids Intensity of Care Survey for Pediatric Long-term Care.

PURPOSE: The purpose of this study is to test the Nursing-Kids Intensity of Care, a measure of the intensity of nursing care needs, defined as the quantity and type of direct and indirect care activities performed by caregivers in a national sample. DESIGN AND METHODS: A 40-item tool previously tested in a small sample was psychometrically tested on a sample of 116 children with complex medical conditions by 33 nurse raters across 11 pediatric sites. RESULTS: The Nursing-Kids Intensity of Care tool demonstrated components of usability, feasibility, inter-rater, test-retest and internal consistency reliability and construct validity in the national study sample. CONCLUSIONS: Additional testing to further establish psychometric sufficiency and expanded use to quantify the intensity of nursing care needs of children with complex medical conditions in pediatric long-term care settings is recommended. PRACTICE IMPLICATIONS: This novel measure could assist the nursing administrators, educators and staff of pediatric long-term care facilities assess the intensity of care needs of their residents.