[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Hand hygiene is considered a critical factor in the prevention of health care-associated infections, and there have been many studies on ways to measure hand hygiene compliance. OBJECTIVE: Our objective was to evaluate the utility of estimating hand hygiene compliance using automated count technology versus direct human observation before and after a feedback intervention. We used a before and after quasi-experimental study over 30 weeks, in the setting of one 12-bed neurocare intensive care unit (NCICU) and one 15-bed cardiac intensive care unit (CCU) in a university, tertiary care hospital. METHODS: We assessed hand hygiene through a quasi-experimental study comparing estimated compliance using automated count technology and direct observation by a secret shopper with a feedback intervention at month 3. We used Poisson segmented regression and χ(2) tests to compare trends before and after the intervention. RESULTS: Over 30 weeks, we collected 424,682 dispenser counts and 338 hours of human observations that included 1,783 room entries. Electronic hand hygiene dispenser counts increased significantly in the post-intervention period relative to the pre-intervention period (average count/patient-day increased 22.7 in the NCICU and 7.3 in the CCU, both P < .001), but direct observation of compliance did not change significantly (percent compliant increased by 2.9% in the NCICU and decreased by 6.7% in the CCU, P = .47 and P = .07, respectively). CONCLUSION: Passive electronic monitoring of hand hygiene dispenser counts does not closely correlate with direct human observation and was more responsive than observation to a feedback intervention.
American journal of infection control 05/2012; 40(10). DOI:10.1016/j.ajic.2012.01.026 · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mandatory active surveillance culturing of all patients admitted to Veterans Affairs (VA) hospitals carries substantial economic costs. Clinical prediction rules have been used elsewhere to identify patients at high risk of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). We aimed to derive and evaluate the clinical efficacy of prediction rules for MRSA and VRE colonization in a VA hospital. Design and setting. Prospective cohort of adult inpatients admitted to the medical and surgical wards of a 119-bed tertiary care VA hospital.
Within 48 hours after admission, patients gave consent, completed a 44-item risk factor questionnaire, and provided nasal culture samples for MRSA testing. A subset provided perirectal culture samples for VRE testing.
Of 598 patients enrolled from August 30, 2007, through October 30, 2009, 585 provided nares samples and 239 provided perirectal samples. The prevalence of MRSA was 10.4% (61 of 585) (15.0% in patients with and 5.6% in patients without electronic medical record (EMR)-documented antibiotic use during the past year; P < .01). The prevalence of VRE was 6.3% (15 of 239) (11.3% in patients with and 0.9% in patients without EMR-documented antibiotic use; P < .01). The use of EMR-documented antibiotic use during the past year as the predictive rule for screening identified 242.8 (84%) of 290.6 subsequent days of exposure to MRSA and 60.0 (98%) of 61.0 subsequent days of exposure to VRE, respectively. EMR documentation of antibiotic use during the past year identified 301 (51%) of 585 patients as high-risk patients for whom additional testing with active surveillance culturing would be appropriate.
EMR documentation of antibiotic use during the year prior to admission identifies most MRSA and nearly all VRE transmission risk with surveillance culture sampling of only 51% of patients. This approach has substantial cost savings compared with the practice of universal active surveillance.
Infection Control and Hospital Epidemiology 10/2010; 31(12):1230-5. DOI:10.1086/657335 · 4.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Although Contact Precautions have been shown to reduce transmission of multidrug-resistant organisms, adverse effects have been reported with this intervention. Some have found that patients placed on Contact Precautions are visited less often or for a shorter duration by healthcare personnel (HCP). However, others have found that HCP who care for patients on Contact Precautions are more likely to be compliant with hand hygiene. Objective: Determine the association between Contact Precautions and HCP behavior including frequency of patient visits, time spent in the patient room and compliance with infection control precautions in a cohort of patients both on and off Contact Precautions. Methods: We completed a prospective cohort study of HCP behavior from June 2009 though November 5, 2009 in two intensive care units (Cardiac ICU and Neurocare ICU) at the University of Maryland Medical Center, Baltimore MD. A standardized data extraction sheet was used to record behavior and infection control compliance. To minimize the Hawthorne effect all observations were completed by a single observer (AY) who by design was not a member of the infection control team. Each observation period lasted one hour and every HCP visit was counted. Each observed ICU room was randomly selected each day and periods of observation occurred between 6am and 3pm. HCP were considered compliant with hand hygiene if they used alcohol hand rub or soap/water on exit. Bivariate analyses were performed using the Fisher's exact test, Student t-test or the Wilcoxon Rank Sum test using SAS v9.1. Results: 231 HCP-patient visits were observed during 107 hours of observation. 72 visits during 33 observed hours of patients on Contact Precautions and 159 visits during 74 observed hours of non-isolated patients. Overall, hand hygiene compliance was 36% on entry, 54% on exit, and 58% on either entry or exit. Compliance with Contact Precautions was 55% and time to don protective equipment in compliant individuals had a mean of 50 seconds. The number of HCP visits/hour was the same for patients on Contact Precautions vs. non-isolated patients (mean 2.18 vs. 2.19, p=0.97). The average minutes the HCP spent in the room was similar for patients on Contact Precautions vs. non-isolated patients (mean 17.1 vs 15.3 minutes, p=0.89). HCP were far more likely to be compliant with hand hygiene if caring for patients on Contact Precautions (67% vs 49%, p=0.03). Conclusions: While there has been debate concerning the benefits of Contact Precautions for reducing transmission, we found no evidence that Contact Precautions reduce the frequency of HCP visits nor does it alter the time that HCP spend in the room caring for patients. Contact Precautions was associated with improved hand hygiene compliance among HCP. Nonetheless new methods to improve compliance with both Contact Precautions and recommended hand hygiene practices are needed.
Fifth Decennial International Conference on Health-Care Related Infections 2010; 03/2010
[Show abstract][Hide abstract] ABSTRACT: Background: Although Contact Precautions have been shown to reduce transmission of multidrug-resistant organisms, adverse psychological effects have been reported including frustration, boredom, generally negative feelings towards isolation as well as depression and anxiety.
Objective: The current study estimates the point prevalence of depression and anxiety using a validated self-assessment questionnaire, the Hospital Anxiety and Depression Scale (HADS). HADS was designed as a measure to screen for anxiety and depression in hospitalized adults.
Methods: We conducted a prospective cohort study of general medical, surgical admissions to a Department of Veterans Affairs hospital from February to November, 2009. Veterans were approached within 48 hours of admission for enrollment in a larger study of risk factors for methicillin-resistant Staphylococcus aureus (MRSA). At time of enrollment, demographic, risk factor questions and HADS were collected. Univariate, bivariate and regression analyses were completed in SAS version 9.1.
Results: 113 sequential patients completed HADS at time of admission (17 on Contact Precautions and 96 patients not on Contact Precautions). Veterans on Contact Precautions were slightly older than non-Contact Precautions veterans (mean=72.0, 95% confidence interval (CI): 65.4-78.7) vs. (mean=63.3, 95% CI: 60.7-65.8). Veterans on isolation had non-significantly lower educational levels.
Unadjusted analyses showed no significant differences in depression (mean 6.5 Contact Precautions vs. mean 5.6 not, p = 0.30) or anxiety (mean 7.8 Contact Precautions vs. mean 7.9 not, p = 0.89) within 48 hours of admission.
When adjusting for age, sex and education level, there was a trend towards higher depressive symptoms in the Contact Precautions group (ß=1.91, p = 0.08). According to the resulting model, a patient with average age, sex and education level would have a mean HAD depression score of 7.55 if on Contact Precautions compared to a mean of 5.65 if not on Contact Precautions.
No significant differences were seen in levels of anxiety symptoms from Contact Precautions (ß=1.31, p = 0.30). Younger age, however, was a strong independent predictor of anxiety scores (p < 0.01) and younger age remained the only significant predictor of HADS anxiety scores when looking at isolation, age, sex and education level. Age was not an independent predictor of depressive scores (p = 0.95).
Conclusions: Patients initially placed on Contact Precautions may have higher depressive symptoms than patients not on Contact Precautions. Younger age was a much better predictor of anxiety than Contact Precautions. However, with only 17 patients in Contact Precautions, power for this study was limited. Future studies should include longitudinal tracking of depression and anxiety symptoms to determine if these symptoms change over the length of the hospital stay.
Fifth Decennial International Conference on Health-Care Related Infections 2010; 03/2010