Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Infection surveillance and control programs in the Department of Veterans Affairs nursing home care units: a preliminary assessment.

A survey was conducted to assess the capacity and current practices of the infection surveillance and control programs at the Department of Veterans Affairs' 130 nursing home care units (VA NHCUs) covering a total of 15,006 beds in 2003. All 130 VA NHCUs responded to the survey, although not all NHCUs answered every question. The majority of the VA NHCUs provided specialized services that might pose increased risks of infection. For every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection control room available. Each VA NHCU had an active ongoing infection surveillance and control program managed by highly educated infection control personnel (ICP), of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to the infection surveillance and control activities. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibiotic-resistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. We conclude that VA NHCUs have a considerable infrastructure and capacity for infection surveillance and control. This information can be used to develop a nationwide VA NHCU nosocomial infection surveillance system.

Healthcare-associated myiasis: prevention and intervention.

Healthcare-associated myiasis (maggot infestation) can have complications that go well beyond the medical consequences of the infestation for patients, their families, and facilities. Prevention of healthcare-associated myiasis requires effort on two fronts: minimizing patient risk factors and reducing fly populations in the healthcare environment. If myiasis occurs, intervention must be swift, thorough, and interdisciplinary. The first priority always is the well-being of the patient. Preservation and identification of the maggots can help determine the likely timing and circumstances that led to the infestation. Conditions favoring the infestation must be identified and then corrected. Free and rapid communication must be promoted. A single designated knowledgeable spokesperson to communicate with the patient, employees, and, as needed, the media will reduce miscommunication and hasten mitigation. Following the guidelines presented in this document, healthcare facilities should be able to reduce the likelihood of healthcare-associated myiasis and effectively intervene when such events occur.

Acute hepatitis B infection and hepatitis B surface antigen positivity reported in the Department of Veterans Affairs: occurrence in a population seeking medical assistance.

In the United States, reported acute hepatitis B infections steadily declined from 18,003 cases in 1991 to 8,036 cases in 2000. Despite this decline, hepatitis B is a significant concern to the Veterans Health Administration (VHA) of the Department of Veterans Affairs because of the need for care of veterans afflicted with this disease and the VHA health care workers at risk for occupational exposure to hepatitis B virus. On an annual basis from federal fiscal year (FY) 1991 through FY 2001, the VHA Infectious Diseases Program Office requested information from patient care sites regarding hepatitis B. The reported number of patients with acute hepatitis B ranged from 446 to 749 during this period. This translates into a case rate per 100,000 veterans served of 29.15 and 12.68 for FYs 1991 and 2001, respectively. The number of persons with a positive hepatitis B surface antigen test during this 11-year period ranged from 2,688 to 3,100, suggesting a sizeable pool from which occupational exposure may occur. The rate of decline in the cases of acute hepatitis B in the VHA is more than that seen nationally in the United States.

National Hepatitis C Surveillance Day in the Veterans Health Administration of the Department of Veterans Affairs.

Hepatitis C is a major public health and financial issue in health care. On March 17, 1999, a Veterans Health Administration (VHA) Hepatitis C Surveillance Day (HepCSD) was undertaken as an administrative tool to estimate the prevalence of hepatitis C antibody positivity in the population served by the VHA for purposes of resource needs allocation and cost projections. This was accomplished using blood from patients who were to have blood drawn for any other purpose. Data were gathered using a national electronic data-extraction system. Of 26,102 tests for hepatitis C virus antibody (HCVAb) performed that day, 1,724 were positive for HCVAb (6.6%). The mean age was 53.8 years, 58.7% were from the Vietnam era, 46% reported as white non-Hispanic, 29% reported as black non-Hispanic, and 97.4% were male. Compared with those who agreed to be tested and who were not seropositive for HCVAb and all persons having contact with the VHA on HepCSD, those who were HCVAb positive were more likely to be younger, black non-Hispanic, and to have served during the Vietnam era. The VHA has identified a target population for further screening and intervention efforts for hepatitis C.

Nursing home-associated infections in Department of Veterans Affairs community living centers.

BACKGROUND: Little is known about factors contributing to nursing home-associated infections (NHAIs). We conducted a survey of residents in 133 Department of Veterans Affairs community living centers to determine the roles of indwelling device use, bed locations, and treatment codes on NHAIs. METHODS: A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted on November 14, 2007. RESULTS: Among 10,939 residents, 575 had at least one NHAI, for a point prevalence rate of 5.3%. Urinary tract infection, skin infection, asymptomatic bacteriuria, and pneumonia were the most prevalent NHAIs. A total of 2687 residents had one or more indwelling devices; 290 of these also had an NHAI, for a prevalence of 10.8%. In contrast, the prevalence of NHAIs in residents without indwelling devices was 3.5% (P < .0001). Indwelling urinary catheters, percutaneous gastrostomy tubes, peripherally inserted central catheters, and suprapubic urinary catheters were the most commonly used devices. There were 4027 residents in designated units and 6912 residents in dispersed units. The rate of device use was 21.4% in the designated units and 26.4% in the dispersed units (P < .0001). The prevalence of NHAIs was 4.5% in the designated units and 5.7% in the dispersed units (P < .001). Rates of NHAIs and device use varied greatly among the various treatment codes; however, there was a positive correlation between the rates of NHAIs and device use. Stepwise logistic regression analysis of data from long-stay and short-stay skilled nursing care residents revealed that only the presence of an indwelling device, not length of stay or bed location, affected the rate of NHAIs. CONCLUSION: Indwelling device use, but not bed location or treatment code, was found to be associated with increased rate of NHAIs.

Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units.

BACKGROUND: The Department of Veterans Affairs (VA) is the largest single provider of long-term care in the United States. The prevalence of nursing home-associated infections (NHAIs) among residents of VA nursing home care units (NHCUs) is not known. METHODS: A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted in the VA's 133 NHCUs on November 9, 2005. RESULTS: From a total population of 11,475 NHCU residents, 591 had at least 1 NHAI for a point prevalence rate of 5.2%. Urinary tract infection, asymptomatic bacteriuria, pneumonia, skin infection, gastroenteritis, and soft tissue infection were most prevalent, constituting 72% of all NHAIs. A total of 2817 residents (24.5%) had 1 or more indwelling device. Of these 2817 residents with an indwelling device(s), 309 (11.0%) had 1 or more NHAI. In contrast, the prevalence of NHAIs in residents without an indwelling device was 3.3%. Indwelling urinary catheter, percutaneous gastrostomy tube, intravenous peripheral line, peripherally inserted central catheter, and suprapubic urinary catheter were most common, accounting for 79.3% of all devices used. CONCLUSION: There are effective infection surveillance and control programs in VA NHCUs with a point prevalence of NHAIs of 5.2%.

Laboratory reporting of Staphylococcus aureus with reduced susceptibility to vancomycin in United States Department of Veterans Affairs facilities.

A national survey was sent to all appropriate Veterans Health Administration (VA) medical facilities asking about the ability to test for Staphylococcus aureus with reduced susceptibility to vancomycin (SARV) (MICs >4 microg/mL). For those with this ability, a request was made for the number of patients having SARV isolated during a 1-year period. Nineteen patients from eight sites across the country had isolation of SARV. Of these, MicroScan (Dade Behring, Inc, MicroScan Division, West Sacramento, CA) technology was used for 17 patients, Vitek (Hazelwood, MO) was used for 1 of the remaining 2 patients, and E-test (AB Biiodisk North America, Inc, Piscataway, NJ) for the other. All patients with this organism had microbiology testing done onsite in the reporting VA facility's College of American Pathologists-approved laboratory. For comparison, similar data were obtained for a 1-year period 2 years prior to the current survey; seven patients from four sites were verified to have a SARV. Between the two survey periods the reported cases of SARV increased 170%, indicating a need for continued surveillance and potentially a need to initiate a collection of isolates for further analysis.