Reducing surgical site infections at a pediatric academic medical center.

BACKGROUND: Surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, increased length of stay, and increased hospital costs. Cincinnati Children's Hospital Medical Center (CCHMC) used reliability science to dramatically reduce the rate of surgical site infections. METHODS: Key activities included the development and implementation of strategies to enhance the proportion of patients who receive timely antibiotic administration, a pediatric surgical site infection-prevention bundle, and procedure-specific pediatric surgical site infection-prevention bundles. Measures are presented in monthly reports and annotated control charts that are shared with the improvement team and organizational leadership and that are also posted on the hospital's patient safety intranet site. RESULTS: The Class I and II SSI rate decreased from 1.5 per 100 procedure days at baseline to 0.54 per 100 procedure days, a 64% reduction. The process has remained stable (within control limits) since August 2007. There were 33 fewer surgical site infections in fiscal year (FY) 2006 than in FY 2005, and 21 fewer in FY 2007 than in FY 2006. By December 2007, 91% of eligible same-day surgery patients received antibiotics within 60 minutes before a procedure, and 94% of patients undergoing inpatient surgery received antibiotics within 60 minutes prior to incision. DISCUSSION: Pediatric surgical patients can now expect a safer, more efficient experience with CCHMC's care system and reduced variation in care across CCHMC's surgeons and procedures. Sharing data on individual and collective provider performance was important in recruiting provider support. Examining data on any failures each day allowed assessment and correction, facilitating rapid-cycle improvement. Making the right thing to do the easy thing to do facilitated the behavior changes required.

Coughing, sneezing, and aching online: Twitter and the volume of influenza-like illness in a pediatric hospital.

This study investigates the relation of the incidence of georeferenced tweets related to respiratory illness to the incidence of influenza-like illness (ILI) in the emergency department (ED) and urgent care clinics (UCCs) of a large pediatric hospital. We collected (1) tweets in English originating in our hospital's primary service area between 11/1/2014 and 5/1/2015 and containing one or more specific terms related to respiratory illness and (2) the daily number of patients presenting to our hospital's EDs and UCCs with ILI, as captured by ICD-9 codes. A Support Vector Machine classifier was applied to the set of tweets to remove those unlikely to be related to ILI. Time series of the pooled set of remaining tweets involving any term, of tweets involving individual terms, and of the ICD-9 data were constructed, and temporal cross-correlation between the social media and clinical data was computed. A statistically significant correlation (Spearman ρ = 0.23) between tweets involving the term flu and ED and UCC volume related to ILI 11 days in the future was observed. Tweets involving the terms coughing (Spearman ρ = 0.24) and headache (Spearman ρ = 0.19) individually were also significantly correlated to ILI-related clinical volume four and two days in the future, respectively. In the 2014-2015 cold and flu season, the incidence of local tweets containing the terms flu, coughing, and headache were early indicators of the incidence of ILI-related cases presenting to EDs and UCCs at our children's hospital.

Atypical Mycobacterium furunculosis occurring after pedicures.

Mycobacterium fortuitum complex are rapidly-growing nontuberculous mycobacteria found ubiquitously in the environment including, water, soil, dust, and biofilms. M fortuitum has been reported to cause skin and soft-tissue infections in association with nail salon footbath use during pedicures. Four cases of M fortuitum complex furunculosis are reported that occurred after pedicures in the Cincinnati, Ohio/Northern Kentucky area. Dermatologists and clinicians should consider mycobacterial infections from the M fortuitum complex when patients present with nonhealing furuncles on the lower legs and should inquire about recent pedicures. Early recognition and institution of appropriate therapy are critical. Public health measures should be explored to protect against such infections, given the recent popularity of the nail care industry.

Herpes zoster in the first year of life following postnatal exposure to varicella-zoster virus: four case reports and a review of infantile herpes zoster.

BACKGROUND: Herpes zoster, a painful vesicular dermatomal eruption, is the result of reactivation of the varicella-zoster virus (VZV) from infected sensory ganglia. Traditionally, it is considered to be a disease of adults, in contrast to primary infection with VZV, which tends to occur mainly in children. OBSERVATIONS: We report 4 cases of infantile herpes zoster in healthy immunocompetent children, all of whom were exposed to primary varicella infection within the first few months of life. A review of 62 cases from the literature reveals that postnatally acquired herpes zoster is less common than intrauterine infection (31% [n = 19] vs 69% [n = 43]) and that there is a 1.5:1 male predominance. All dermatomes are equally affected. CONCLUSIONS: Although uncommon, herpes zoster can develop in immunocompetent children as young as a few weeks of age and should be considered in the differential diagnosis of vesicular eruptions in infants. Most frequently, it is the result of intrauterine VZV infection, but it can be secondary to postnatal exposure to VZV at an early age.

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care-associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams. METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians' compliance per day. RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months. CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care-associated infections.

Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene.

OBJECTIVE: To use quality-improvement (QI) methods to develop and test a multimodal intervention to improve hand-hygiene compliance among health care workers (HCWs) to >90%. METHODS: We used a quasi-experimental staggered intervention that was conducted on 2 similar general pediatric units within a 475-bed tertiary children's hospital. Compliance was defined as acceptable hand hygiene both before and after contact with the patient or the patient's care environment. Measurement of HCW hand-hygiene compliance was performed by covert observations made during routine patient care. Twelve months of preintervention data were collected. QI methods were used to test and implement interventions sequentially in each unit. Interventions addressed leadership support, improving HCW knowledge, hand-hygiene supply availability, and HCW behavior. RESULTS: Interventions began on unit A on November 10, 2008. Similar interventions were later tested on unit B starting March 23, 2009. By April 1, 2009, compliance increased on unit A (from 65% to 91%) and unit B (from 74% to 92%). Improvement on each unit occurred only after the interventions were introduced. Identifying HCWs who failed to perform hand hygiene and offering alcohol-based hand rub to them before patient contact resulted in the greatest improvement. Improvements were sustained on both units for 18 months. CONCLUSIONS: Use of QI methods to implement a multimodal intervention resulted in sustained improvement in hand-hygiene compliance. Real-time individual performance feedback or other high-reliability human-factor interventions seem to be necessary to reach and sustain high levels of hand-hygiene compliance.

Controversies in vaccine mandates.

Policies that mandate immunization have always been controversial. The controversies take different forms in different contexts. For routine childhood immunizations, many parents have fears about both short- and long-term side effects. Parental worries change as the rate of vaccination in the community changes. When most children are vaccinated, parents worry more about side effects than they do about disease. Because of these worries, immunization rates go down. As immunization rates go down, disease rates go up, and parents worry less about side effects of vaccination and more about the complications of the diseases. Immunization rates then go up. For teenagers, controversies arise about the criteria that should guide policies that mandate, rather than merely recommend and encourage, certain immunizations. In particular, policy makers have questioned whether immunizations for human papillomavirus, or other diseases that are not contagious, should be required. For healthcare workers, debates have focused on the strength of institutional mandates. For years, experts have recommended that all healthcare workers be immunized against influenza. Immunizations for other infections including pertussis, measles, mumps, and hepatitis are encouraged but few hospitals have mandated such immunizations-instead, they rely on incentives and education. Pandemics present a different set of problems as people demand vaccines that are in short supply. These issues erupt into controversy on a regular basis. Physicians and policy makers must respond both in their individual practices and as advisory experts to national and state agencies. The articles in this volume will discuss the evolution of national immunization programs in these various settings. We will critically examine the role of vaccine mandates. We will discuss ways that practitioners and public health officials should deal with vaccine refusal. We will contrast responses of the population as a whole, within the healthcare setting, and in the setting of pandemic influenza.

Risk factors associated with surgical site infection after pediatric posterior spinal fusion procedure.

OBJECTIVE: To identify risk factors associated with surgical site infection (SSI) after pediatric posterior spinal fusion procedure by examining characteristics related to the patient, the surgical procedure, and tissue hypoxia. DESIGN: Retrospective case-control study nested in a hospital cohort study. SETTING: A 475-bed, tertiary care children's hospital. METHODS: All patients who underwent a spinal fusion procedure during the period from January 1995 through December 2006 were included. SSI cases were identified by means of prospective surveillance using National Nosocomial Infection Surveillance system definitions. Forty-four case patients who underwent a posterior spinal fusion procedure and developed an SSI were identified and evaluated. Each case patient was matched (on the basis of date of surgery, +/-3 months) to 3 control patients who underwent a posterior spinal fusion procedure but did not develop an SSI. Risk factors for SSI were evaluated by univariate analysis and multivariable conditional logistic regression. Odds ratios (ORs), with 95% confidence intervals (CIs) and P values, were calculated. RESULTS: From 1995 to 2006, the mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%-6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.5-8.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2-10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.0-6.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5 degrees C) during surgery (OR, 0.4 [95% CI, 0.2-0.9]). An American Society of Anesthesiologists (ASA) score of greater than 2, obesity (ie, a BMI greater than the 95th percentile), antibiotic prophylaxis with clindamycin, and hypothermia were statistically significant in the multivariable model. CONCLUSION: An ASA score greater than 2, obesity, and antibiotic prophylaxis with clindamycin were independent risk factors for SSI. Hypothermia during surgery appears to provide protection against SSI in this patient population.

Pertussis vaccine effectiveness among children 6 to 59 months of age in the United States, 1998-2001.

BACKGROUND: Despite the dramatic pertussis decrease since the licensure of whole-cell pertussis (diphtheria-tetanus toxoids-pertussis [DTP]) vaccines in the middle 1940s, pertussis remains endemic in the United States and can cause illness among persons at any age; >11000 pertussis cases were reported in 2003. Since July 1996, in addition to 2 DTP vaccines already in use, 5 acellular pertussis (diphtheria-tetanus toxoids-acellular pertussis [DTaP]) vaccines were licensed for use among infants; 3 DTaP vaccines were distributed widely during the study period. Because of the availability of 3 DTaP and 2 DTP vaccines and the likelihood of the vaccines being used interchangeably to vaccinate children with the recommended 5-dose schedule, measuring the effectiveness of the pertussis vaccines was a high priority. OBJECTIVE: To measure the pertussis vaccine effectiveness (VE) among US children 6 to 59 months of age. DESIGN: We conducted a case-control study in the Cincinnati, Ohio, metropolitan area, Colorado, Idaho, and Minnesota. PARTICIPANTS: Confirmed pertussis cases among children 6 to 59 months of age at the time of disease onset, with onset in 1998-2001, were included. For each case subject, 5 control children were matched from birth certificate records, according to the date of birth and residence. OUTCOME MEASURES: A standardized questionnaire was used to obtain vaccination data from parents and providers. Parents/guardians were asked about demographic characteristics, child care attendance, the number of household members who stayed at the same home as the enrolled child for > or =2 nights per week, and cough illness of > or =2-week duration among these household members in the month before the case patient's cough onset. Pertussis vaccine doses among case children were counted as valid if they were received > or =14 days before the cough onset date ("valid period"). The age of the case patient (in days) at the end of the valid period was determined, and doses of vaccine for the matched control subjects were counted as valid if they were received by that age. Conditional logistic regression models were used to estimate the matched odds ratios (ORs) for pertussis according to the number of pertussis vaccine doses. The VE was calculated with the following formula: (1 - OR) x 100. Because the pertussis antigen components or amounts differed according to vaccine, the VE of 3 or 4 doses of DTP and/or DTaP was estimated according to the recorded vaccine manufacturer and vaccine type. RESULTS: All enrolled children (184 case subjects and 893 control subjects) had their vaccine history verified. The proportions of children who received 0, 1 or 2, 3, and > or =4 pertussis (DTP and/or DTaP) vaccine doses among case subjects were 26%, 14%, 26%, and 34% and among control subjects were 2%, 8%, 33%, and 57%, respectively. Compared with 0 doses, the unadjusted VE estimate for 1 or 2 pertussis doses was 83.6% (95% confidence interval [CI]: 61.1-93.1%), that for 3 doses was 95.6% (95% CI: 89.7-98.0%), and for > or =4 doses was 97.7% (95% CI: 94.7-99.0%). Among children who received 4 pertussis vaccinations, the risk of pertussis was slightly higher among those who received only 1 type of vaccine (either 4 DTP doses or 4 DTaP doses), compared with those who received a combination of DTP for doses 1 to 3 and DTaP for dose 4 (OR: 2.4; 95% CI: 1.1-5.2). Among children who received 3 or 4 DTaP vaccine doses, the risk of pertussis was slightly higher among those who received a DTaP vaccine with 4 pertussis antigen components (a vaccine no longer available), compared with those who received the DTaP vaccine with 2 pertussis antigen components (OR: 2.5; 95% CI: 1.1-5.8). Among children who received 4 doses, the risk of pertussis was 2.7 times higher for children who received dose 4 early (age of < or =13 months), compared with children who received dose 4 at an older age (age of > or =14 months) (95% CI: 1.1-6.8). For children 6 to 23 months of age, features of household structure were significant risk factors for pertussis. In a multivariate model, compared with living with an older parent (> or =25 years of age), not living with an "other" household member (a relative other than a parent or sibling or a nonrelated person), and not living with a sibling 6 to 11 years of age, the risk of pertussis for children 6 to 23 months of age was 6.8 times higher if they lived with a young parent (< or =24 years of age) (95% CI: 3.1-15.0), 2.5 times higher if they lived with an "other" household member (95% CI: 1.2-5.4), and 2.2 times higher if they lived with a sibling 6 to 11 years of age (95% CI: 1.2-4.3). Adjusting for these risk factors did not change the VE. Compared with control children, case children were significantly more likely to live with a household member (representing all age groups and relationships) who reported a recent cough illness with duration of > or =2 weeks (87 [52%] of 168 case subjects, compared with 79 [8%] of 860 control subjects). CONCLUSIONS: Any combination of > or =3 DTP/DTaP vaccine doses for children 6 to 59 months of age was highly protective against pertussis. However, there were differences according to vaccine type (DTaP or DTP) and DTaP manufacturer. Among children who received 4 pertussis vaccine doses, a combination of 3 DTP doses followed by 1 DTaP dose had a slightly higher VE than other combinations; among children who received 3 or 4 DTaP vaccine doses, 1 DTaP vaccine performed less well. The finding that pertussis dose 4 was more effective when given to children at > or =14 months of age might be confounded if health care providers were more likely to vaccinate children at 12 months of age because of a perceived risk of undervaccination and if these same children were also at higher risk for pertussis. Household members of any age group and relationship could have been the source of pertussis, and household structure was associated with risk for pertussis for children 6 to 23 months of age. In contrast to control children in the study, 26% of case children had never been vaccinated against pertussis. Unvaccinated children are at risk for pertussis and, in a community with other unvaccinated children, can lead to community-wide pertussis outbreaks. Parents need to be educated about the morbidity and mortality risks associated with Bordetella pertussis infection, and they need to be encouraged to vaccinate their children against pertussis on time and with the recommended number of vaccine doses for optimal protection.

Screening for neonatal herpes: physicians' descriptions of discussions with parents.

Screening for possible herpes simplex virus infection in neonates may raise feelings of anxiety and distress among parents and physicians. To elicit physicians' experiences of communicating with families when screening for neonatal herpes, we conducted a series of semi-structured interviews with 15 physicians from one paediatric institution, and coded the resulting audiotapes for common themes. These included how physicians prepared families for screening and treatment, how physicians managed stigma, and perceived parental reactions. Techniques for fostering good communication included being direct and honest and ensuring the time and place for discussion were appropriate; strategies for managing stigma included placing the diagnosis in epidemiological context, and discussing the potential severity of the disease. Physicians described many parental emotional reactions, some of which were herpes-specific, and suggested strategies to manage potential discomfort when discussing neonatal herpes with families. Future research can determine which strategies are most effective, which are associated with negative psychological outcomes, and how medical students and residents can be better trained to screen for this diagnosis.