Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown.

We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion.

After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection.

The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial.

To develop common indicators, relevant to both EU member states and the United States, that characterize and allow for meaningful comparison of antimicrobial stewardship programs among different countries and healthcare systems.

Modified Delphi process.

A multinational panel of 20 experts in antimicrobial stewardship.

Potential indicators were rated on the perceived feasibility to implement and measure each indicator and clinical importance for optimizing appropriate antimicrobial prescribing.

The outcome was a set of 33 indicators developed to characterize the infrastructure and activities of hospital antimicrobial stewardship programs. Among them 17 indicators were considered essential to characterize an antimicrobial stewardship program and therefore were included in a core set of indicators. The remaining 16 indicators were considered optional indicators and included in a supplemental set.

The integration of these indicators in public health surveillance and special studies will lead to a better understanding of best practices in antimicrobial stewardship. Additionally, future studies can explore the association of hospital antimicrobial stewardship programs to antimicrobial use and resistance.

Infect Control Hosp Epidemiol 2016:1–11

To identify differences in organizational culture and better understand motivators to implementation of abundle intervention to control Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC).

Mixed-methods study.

Four long-term acute care hospitals (LTACHs) in Chicago.

LTACH staff across 3 strata of employees (administration, midlevel management, and frontline clinical workers).

Qualitative interviews or focus groups and completion of a quantitative questionnaire.

Eighty employees (frontline, 72.5%; midlevel, 17.5%; administration, 10%) completed surveys and participated in qualitative discussions in August 2012. Although 82.3% of respondents felt that quality improvement was a priority at their LTACH, there were statistically significant differences in organizational culture between staff strata, with administrative-level having higher organizational culture scores (ie, more favorable responses) than midlevel or frontline staff. When asked to rank the success of the KPC control program, mean response was 8.0 (95% confidence interval, 7.6–8.5), indicating a high level of agreement with the perception that the program was a success. Patient safety and personal safety were reported most often as personal motivators for intervention adherence. The most convergent theme related to prevention across groups was that proper hand hygiene is vital to prevention of KPC transmission.

Despite differences in organizational culture across 3 strata of LTACH employees, the high degree of convergence in motivation, understanding, and beliefs related to implementation of a KPC control bundle suggests that all levels of staff may be able to align perspectives when faced with a key infection control problem and quality improvement initiative.

Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff.

Evaluation of a mixed qualitative and quantitative methodology (“trilogic evaluation model”).

Six hospitals that joined the campaign before June 2006.

Three strata of staff (executive leadership, midlevel, and frontline) at each hospital.

Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability.

The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

Infect Control Hosp Epidemiol 2012;33(2):135-143

To assess healthcare personnel (HCP) perceptions regarding implementation of sensor-based electronic systems for automated hand hygiene adherence monitoring.

Using a mixed-methods approach, structured focus groups were designed to elicit quantitative and qualitative responses on familiarity, comfort level, and perceived impact of sensor-based hand hygiene adherence monitoring

A university hospital, a Veterans Affairs hospital, and a community hospital in the Midwest.

Focus groups were homogenous by HCP type, with separate groups held for leadership, midlevel management, and frontline personnel at each hospital.

Overall, 89 HCP participated in 10 focus groups. Levels of familiarity and comfort with electronic oversight technology varied by HCP type; when compared with frontline HCP, those in leadership positions were significantly more familiar with (P<.01) and more comfortable with (P<.01) the technology. The most common concerns cited by participants across groups included lack of accuracy in the data produced, such as the inability of the technology to assess the situational context of hand hygiene opportunities, and the potential punitive use of data produced. Across groups, HCP had decreased tolerance for electronic collection of spatial-temporal data, describing such oversight as Big Brother.

While substantial concerns were expressed by all types of HCP, participants' recommendations for effective implementation of electronic oversight technologies for hand hygiene monitoring included addressing accuracy issues before implementation and transparent communication with frontline HCP about the intended use of the data.

To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistant Staphylococcus aureus (MRSA) prevention program.

Before-after intervention study

An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospital

Allpatientsadmittedtothe study units

We implemented an MRSA infection control program that consisted of the following 4 elements: (1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; (2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; (3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and (4) use of an industrial systems-engineering approach, the Toyota Production System, to facilitate consistent and reliable adherence to the infection control program.

The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001).

Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.

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.

To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs.

Observational study.

Intensive care unit in a Veterans Affairs hospital.

HCWs.

There were 767 patient encounters observed (48.6% involved nurses, 20.6% involved physicians, and 30.8% involved other HCWs); 39.8% of encounters involved patients placed under contact precautions. HCW contact with either the patient or surfaces in the patient's environment occurred during all encounters; direct patient contact occurred during 439 encounters (57.4%), and contact with environmental surfaces occurred during 710 encounters (92.6%). The median duration of encounters was 2 minutes (range, <1 to 51 minutes); 33.6% of encounters lasted 1 minute or less, with no significant occupation-associated differences in the median duration of encounters. Adherence with hand hygiene practices was correlated with the duration of the encounter, with overall adherences of 30.0% after encounters of ≤1 minute, 43.4% after encounters of >1 to ≤2 minutes, 51.1% after encounters of >3 to ≤5 minutes, and 64.9% after encounters of >5 minutes (P < .001 by the x2 for trend). In multivariate analyses, longer encounter duration, contact precautions status, patient contact, and nursing occupation were independently associated with adherence to hand hygiene recommendations.

In this study, adherence to hand hygiene practices was lowest after brief patient encounters (ie, <2 minutes). Brief encounters accounted for a substantial proportion of all observed encounters, and opportunities for hand contamination occurred during all brief encounters. Therefore, improving adherence after brief encounters may have an important overall impact on the transmission of healthcare-associated pathogens and may deserve special emphasis in the design of programs to promote adherence to hand hygiene practices.

To compare the cumulative incidence of infections acquired in the pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU).

Estimation of the cumulative incidence of infections with data obtained from the Pediatric Prevention Network (PPN) point-prevalence survey and observed rates from the National Nosocomial Infections Surveillance (NNIS) system.

Ten hospitals participated in both the PPN survey and NNIS system.

All patients present on the PPN survey dates (August 4, 1999, or February 1, 2000) in the NICUs or PICUs of the PPN hospitals were included in the survey. Point prevalences for PICU-acquired and for NICU-acquired infections at these hospitals were calculated from the survey data. The cumulative incidence rates were estimated from the point prevalence rates using a standard formula and a standard method for calculating the time to recovery (ie, on the basis of the assumption that discontinuance of antimicrobial therapy indicates recovery from infection); alternate methods to judge the time to recovery from infection were also explored.

The average cumulative incidence of intensive care unit-acquired infection for NICUs and PICUs combined (all units), as measured by NNIS, was 14.1 cases per 100 patients; in comparison, the prevalence was 14.06 cases for 100 patients (median difference, —0.95 cases per 100 patients; 95% confidence interval, —4.6 to 5.0 cases per 100 patients), and the estimated cumulative incidence using the standard method of calculating the time to recovery was 13.8 cases per 100 patients (median difference, —1.5 cases per 100 patients; 95% confidence interval, —9.1 to 2.9 cases per 100 patients). Estimates of cumulative incidence using alternate methods for calculation of time to recovery did not perform as well (range, 4.9-100.9 cases per 100 patients). The average incidence density for all units, as measured by the NNIS system, was 6.8 cases per 1,000 patient-days, and the estimate of incidence density using the standard method of calculating the time to recovery was 3.6 cases per 1,000 patient-days (median difference, 4.3 cases per 1,000 patient-days; 95% confidence interval, 0.9 to 9.2 cases per 1,000 patient-days). Estimated incidence densities using alternate methods for determining recovery time correlated closely with observed incidence densities.

In this patient population, the simple point prevalence provided the best estimate of cumulative incidence, followed by use of a standard formula and a standard method of calculating the time to recovery. Estimation of incidence density using alternate methods performed well. The standard formula and method may provide an even better estimate of cumulative incidence than does simple prevalence in general populations.

To assess the efficacy of parental education and use of parents as nursing assistants on reducing nosocomial infections.

Prospective study.

Active surveillance for nosocomial infections was performed on two wards. On ward A, parents were educated about infection control practices and assisted nursing staff with routine tasks, so that nursing personnel could focus their efforts on procedures with higher risk of infection. Parental assistance was not sought on ward B, the comparison ward.

From October 1990 through September 1991, 1,081 patients were admitted to wards A (470) or B (611). The overall nosocomial infection rate was 7.1 per 100 admissions; the nosocomial infection rate was significantly higher on ward B than ward A (63/611 vs 14/470; P<.001). Multivariate analysis identified risk factors for nosocomial infection on the two wards as age <2 years (P=.01), malnutrition (P=.005), duration of hospitalization (P<.001), ward B hospitalization (P=.003), and ward cleanliness score (P=.009); the distribution of patients with these factors was similar on the two wards.

Our data suggest that parental infection control education and recruitment to relieve nursing staff of routine low-risk procedures are economical and easily implemented measures to reduce nosocomial infections in hospitals with limited personnel resources in the developing world.

To determine the type of media preferred for continuing medical education (CME) and to assess the factors that affect physician preferences for CME in general and on the special topic of antimicrobial resistance.

A voluntary survey of the membership of the Society for Healthcare Epidemiology of America, Inc. (SHEA).

SHEA in collaboration with other medical societies and with technical assistance from the Centers for Disease Control and Prevention, designed and mailed the survey to its membership. The survey included questions about media used, preferred, and of interest to try for CME delivery in general and on the topic of antimicrobial resistance in specific. The survey also included demographic and general questions, such as work environment, percentage of time in direct patient care, and experience treating patients with antimicrobial-resistant pathogens.

225 SHEA members completed the survey. The majority of physicians were in clinical practice (59%) and worked in a hospital (57%). The median year of graduation from medical school was 1979 (range, 1951-1999). CME subject matter (46%) was ranked as the most important factor affecting media preference. Journal articles (52%) were the most frequently used educational medium; local grand rounds (53%) and regional meetings (53%) were the most preferred media. CD-ROM (56%) and the Internet (46%) were selected as media of greatest interest to try. On the topic of antimicrobial resistance, the most frequently used and the preferred medium was journal articles (67% and 87%, respectively). Most (94%) had received an educational update on current antimicrobial resistance issues within the past year. Stratification of the data by graduation date revealed no significant differences in the medical education media used most (F=0.59, degrees of freedom [df]=4, P=.6715) or preferred by SHEA members in general or on the topic of antimicrobial resistance (F=1.99, df=4, P=.0982).

This study provides an understanding of how physicians learn, prefer to learn, and implement best practices for optimal patient outcomes in decreasing the spread of antimicrobial resistance.