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The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Measuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome.
To evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures.
SETTING AND PARTICIPANTS
A total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates.
We calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test.
Mean sampling accuracy ranged 84%–97% for 1 day per month, 91%–98% for 1 day per week, 92%–98% for 7 consecutive days per month, and 96%–99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%–99% of unit-months and within 5% of actual rates in 74%–97% of unit-months.
Sampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates.
To develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved and analyze effects of implementation progress on outcome measures.
We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on the Comprehensive Unit-based Safety Program (CUSP) and clinical interventions for use in guiding data collection via telephone interviews.
We conducted interviews with leaders of improvement teams from units participating in the two-state VAP prevention initiative.
We collected data from 43 hospital units as they implemented actions for the VAP initiative and performed descriptive analyzes of the data with comparisons across the 2 states.
Early in the VAP prevention initiative, most units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress (in particular, barriers related to workload and time issues). We modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified.
These assessments provided important new knowledge regarding the implementation science of quality improvement projects, including feedback during implementation, and give a better understanding of which factors most affect implementation.
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
Ventilator-associated pneumonia (VAP) is among the most lethal of all healthcare-associated infections. Guidelines summarize interventions to prevent VAP, but translating recommendations into practice is an art unto itself.
Summarize strategies to enhance adoption of VAP prevention interventions.
We conducted a systematic literature review of articles in the MEDLINE database published between 2002 and 2012. We selected articles on the basis of specific inclusion criteria. We used structured forms to abstract implementation strategies and inserted them into the “engage, educate, execute, and evaluate” framework.
Twenty-seven articles met our inclusion criteria. Engagement strategies included multidisciplinary teamwork, involvement of local champions, and networking among peers. Educational strategies included training sessions and developing succinct summaries of the evidence. Execution strategies included standardization of care processes and building redundancies into routine care. Evaluation strategies included measuring performance and providing feedback to staff.
We summarized and organized practical implementation strategies in a framework to enhance adoption of recommended evidence-based practices. We believe this work fills an important void in most clinical practice guidelines, and broad use of these strategies may expedite VAP reduction efforts.
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days.
Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3.
Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study.
Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.
To evaluate the impact of postprescription review of broad-spectrum antimicrobial (study-ABX) agents on rates of antimicrobial use.
Quasi-experimental before-after study.
Five academic medical centers.
Adults receiving at least 48 hours of study-ABX.
The baseline, intervention, and follow-up periods were 6 months each in 2 units at each of 5 sites. Adults receiving at least 48 hours of study-ABX entered the cohort as case-patients. During the intervention, infectious-diseases physicians reviewed the cases after 48 hours of study-ABX. The provider was contacted with alternative recommendations if antimicrobial use was considered to be unjustified on the basis of predetermined criteria. Acceptance rates were assessed 48 hours later. The primary outcome measure was days of study-ABX per 1,000 study-patient-days in the baseline and intervention periods.
There were 1,265 patients in the baseline period and 1,163 patients in the intervention period. Study-ABX use decreased significantly during the intervention period at 2 sites: from 574.4 to 533.8 study-ABX days/1,000 patient-days (incidence rate ratio [IRR], 0.93; 95% confidence interval [CI], 0.88-0.97; P = .002) at hospital В and from 615.6 to 514.4 study-ABX days/1,000 patient-days (IRR, 0.83; 95% CI, 0.79-0.88; P < .001) at hospital D. Both had established antimicrobial stewardship programs (ASP). Study-ABX use increased at 2 sites and stayed the same at 1 site. At all institutions combined, 390 of 1,429 (27.3%) study-ABX courses were assessed as unjustified; recommendations to modify or stop therapy were accepted for 260 (66.7%) of these courses.
Postprescription review of study-ABX decreased antimicrobial utilization in some of the study hospitals and may be more effective when performed as part of an established ASP.
Seasonal influenza is a significant cause of morbidity and mortality in the United States each year. Healthcare worker (HCW) influenza vaccination is associated with both decreased absenteeism among employees and improved outcomes among patients. However, HCW influenza vaccine uptake remains suboptimal. The objective of this study was to characterize HCWs' understanding of and response to a stringent vaccination policy.
Design, Setting, and Participants.
A survey of 928 hospital staff at a tertiary academic medical center in Baltimore during the 2008-2009 influenza season.
Of those surveyed, 75% (n = 695) completed the survey; 623 respondents reported regular patient contact, and 91% of those reported vaccination in the current influenza season. However, only 60% reported consistently receiving the vaccine every year. Of those who were vaccinated, 8% (n = 48) reported being vaccinated for the first time during that influenza season. A significant proportion (42%) of respondents were unaware of the major change in hospital policy regarding vaccination. Influences on the decision to be vaccinated varied significantly between those who are regularly vaccinated and those with inconsistent vaccination habits. Attitudes toward hospital policy varied significantly by race and clinical role.
Although 91% of respondents with regular patient contact reported being vaccinated for influenza in the 2008–2009 season, only 60% reported consistent annual vaccination. Misinformation regarding hospital policies is widespread. Improvements in vaccination rates will likely require multifaceted, targeted efforts focused on specific influences on less adherent groups. The identified variability in influences on the decision to be vaccinated suggests possible targets for future interventions.
We collected serial blood samples from children in the intensive care unit who underwent daily bathing with 2% Chlorhexidine gluconate (CHG)-impregnated cloths. Low concentrations of CHG were detected in a few blood samples, indicating absorption through intact skin. There was no suggestion that CHG accumulated in the blood with repeated exposures.
Clostridium difficile-associated disease (CDAD) is responsible for increased morbidity and a substantial economic burden. Incidences of CDAD, including those with a severe course of illness, have been increasing rapidly.
To evaluate the excess mortality, increased length of stay (LOS) in the hospital, and additional costs associated with CDAD.
A retrospective matched cohort study.
Adult patients admitted to a large tertiary care hospital between January 2000 and October 2005.
Adult patients were tested with a C. difficile laboratory assay at admission or 72 hours after admission. Infected patients had lor more positive assay results and were individually matched to 1 uninfected patient who had negative assay results, by exposure time, age, ward, and at least 2 measurements for comorbidity and severity of illness.
The incidence rate of CDAD among adult patients increased from 0.57 cases per 1,000 patient-days at risk before 2004 to 0.88 cases per 1,000 patient-days at risk after 2004 (P < .001). The 630 infected patients had a mortality rate of 11.9%; the 630 uninfected patients had a mortality rate of 15.1% (P = .02). After adjustment in the multivariate analysis, we found that the LOS for infected patients was 4 days longer than that for uninfected patients (P < .001). If CDAD occurred after 2004, the additional LOS increased to 5.5 days. The direct cost associated with CDAD was $306 per case; after year 2004, it increased to $6,326 per case.
There may be no excess mortality among patients with CDAD, compared with patients without it, but the economic burden of CDAD is increasing. By 2004, CDAD-associated medical expenditures approached $1,000,000 per year at our institution alone.
To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review.
Prospective intervention to identify and modify inappropriate antimicrobial therapy.
A 1,000-bed, tertiary care teaching hospital.
Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours.
We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and “reserve” antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC.
Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 (“target the pathogen”), 1% into step 4 (“access experts”), 3% into steps 7 and 8 (“treat infection, not colonization or contamination”), 18% into step 9 (“say ‘no’ to vancomycin”), and 26% into step 10 (“stop treatment when no infection”). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback.
Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.
A comprehensive influenza vaccination campaign improved vaccination rates among healthcare workers with direct patient care responsibilities from 45% during the 2003-2004 influenza season to 80% during the 2004-2005 season. A strategy of weekly feedback to unvaccinated employees was the most important factor in enhancing the rate of vaccination acceptance and was particularly effective among the nursing staff.
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