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Background Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. Methods Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary—an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. Results Median (interquartile range) cardiopulmonary bypass duration was 132 (91–192) minutes, and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (–24 minutes) and high-risk (–27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. Conclusion Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.

Background Pneumonia is the most prevalent healthcare-associated infection after coronary artery bypass grafting (CABG), but the relative effectiveness of strategies to reduce its incidence remains unclear. We evaluated the relationship between healthcare-associated infection recommendations and risk of pneumonia after CABG. Methods Pneumonia prevention practice recommendations were developed based on literature review and analysis of semistructured interviews with key health care personnel across centers with low ( 6.1%) rates of pneumonia. These practices were implemented among 2482 patients undergoing CABG from 2016 to 2017 across 18 centers. The independent effect of each practice in reducing pneumonia was assessed using multivariable logistic regression, adjusting for baseline risk and center. A composite (bundle) score was calculated as the number of practices (0 to 4) each patient received. Results Recommended pneumonia prevention practices included lung protective ventilation management, early extubation, progressive ambulation, and avoidance of postoperative bronchodilator therapy. Pneumonia occurred in 2.4% of patients. Lung protective ventilation (adjusted odds ratio [ORadj], 0.45; 95% confidence interval [CI], 0.22-0.92), ambulation (ORadj, 0.08; 95% CI, 0.04-0.17), and postoperative ventilation of less than 6 hours (ORadj, 0.47; 95% CI, 0.26-0.87) were significantly associated with lower odds of pneumonia. Postoperative bronchodilator therapy (ORadj, 4.83; 95% CI, 2.20-10.7) was significantly associated with higher odds. Risk-adjusted rates of pneumonia, operative mortality, and intensive care unit length of stay were lower in patients with higher bundle scores (all P-trend Conclusions These pneumonia prevention recommendations may serve as effective targets for avoiding postoperative healthcare-associated infections.

The coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic.We conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis.A total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes.Early on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.

Background Caring for patients in contact precautions can be challenging. In this pilot study, we sought to understand, using qualitative and visual methods, how nurses provide care for patients in contact precaution rooms and to identify potential breakdowns in practice that could increase risk of disease transmission. Methods Qualitative data were collected while shadowing 4 nurses on 2 medical/surgical units at a university medical center between September and October 2016. Observers documented nurses' movements in handwritten fieldnotes. Fieldnote data were analyzed using a descriptive approach with visual depiction to map care delivery in precaution and non-precaution rooms. Results Nurses moved between non-precaution rooms, completing 1-4 tasks per room entry, over the course of several brief room entries and exits. In contrast, nurses rarely entered contact precaution rooms to complete only a few tasks, generally completing ≥10 tasks per room entry. Although hand hygiene on room entry/exit was consistently performed, a breakdown in practice occurred in precaution rooms as nurses tended to move between tasks and contact with the environment without performing hand hygiene. Conclusions Differences in how nurses structure their work in contact precaution rooms may contribute to risk of infectious disease transmission. Understanding and addressing the challenges specific to how nurses work is a critical part of infection prevention in today's hospital environment.

Introduction Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes. Methods Incident reports filed during fiscal year 2015–2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test. Results Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes. Conclusion It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Background Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. Methods Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach. Results Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover. Conclusions Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Objective To develop a natural language processing pipeline to extract positively asserted concepts related to the presence of an indwelling urinary catheter in hospitalized patients from the free text of the electronic medical note. The goal is to assist infection preventionists and other healthcare professionals in determining whether a patient has an indwelling urinary catheter when a catheter-associated urinary tract infection is suspected. Currently, data on indwelling urinary catheters is not consistently captured in the electronic medical record in structured format and thus cannot be reliably extracted for clinical and research purposes. Materials and methods We developed a lexicon of terms related to indwelling urinary catheters and urinary symptoms based on domain knowledge, prior experience in the field, and review of medical notes. A reference standard of 1595 randomly selected documents from inpatient admissions was annotated by human reviewers to identify all positively and negatively asserted concepts related to indwelling urinary catheters. We trained a natural language processing pipeline based on the V3NLP framework using 1050 documents and tested on 545 documents to determine agreement with the human reference standard. Metrics reported are positive predictive value and recall. Results The lexicon contained 590 terms related to the presence of an indwelling urinary catheter in various categories including insertion, care, change, and removal of urinary catheters and 67 terms for urinary symptoms. Nursing notes were the most frequent inpatient note titles in the reference standard document corpus; these also yielded the highest number of positively asserted concepts with respect to urinary catheters. Comparing the performance of the natural language processing pipeline against the human reference standard, the overall recall was 75% and positive predictive value was 99% on the training set; on the testing set, the recall was 72% and positive predictive value was 98%. The performance on extracting urinary symptoms (including fever) was high with recall and precision greater than 90%. Conclusions We have shown that it is possible to identify the presence of an indwelling urinary catheter and urinary symptoms from the free text of electronic medical notes from inpatients using natural language processing. These are two key steps in developing automated protocols to assist humans in large-scale review of patient charts for catheter-associated urinary tract infection. The challenges associated with extracting indwelling urinary catheter-related concepts also inform the design of electronic medical record templates to reliably and consistently capture data on indwelling urinary catheters.

Background Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS. Methods We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement. Results A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues. Conclusions Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.

Catheter-associated urinary tract infection (CAUTI) surveillance is labor intensive, generally involving manual medical record review. We developed a prototype automated report through iterative design. Surveys and qualitative interviews were administered to key stakeholders to assess the report design. We found that different provider types expressed different needs regarding report content and format. Therefore, determining the primary audience for reporting data on CAUTI a priori is critical to developing useful reports, particularly as this process becomes standardized and automated.

Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

Implementing polymerase chain reaction (PCR) technology in the context of infection prevention and control (IPC) at Centre Hospitalier Universitaire (CHU) de Quebec necessitated organisational change involving new infection prevention and control (IPC) procedures, the organisation of hospital services and attribution of new roles within a network of actors, at the macro, meso and micro levels. Understanding how the adoption of IPC technology can transform healthcare practices and outcomes for patients will remain a challenge as long as the process lacks a theoretical basis. This paper discusses a conceptual framework that will make it possible to understand the dynamics involved in implementing practice change. To identify the outcomes of such a process, both from the point of view of the nursing staff and that of patients, an integrated model was developed based on the Translating Research Into Practice (TRIP) model and on the Actor-Network Theory (ANT). The TRIP-ANT model provides a basis for exploring the complexity of implementing technology in the context of IPC and illustrates the dynamic nature of healthcare organisation in the real world. It identifies how new technology integration can translate into different responses to change and into the practices of a network of actors involved directly or indirectly in the new intra- and inter-organisational processes surrounding the handling of IPC practices. Furthermore, this model could also be applied to other innovations in healthcare organisations.

SummaryBackground Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome. Methods This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated. Results Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01–3.76]) and PICC gauge (HR 2.21 [95%CI 1.04–4.70] and HR 3.56 [95%CI 1.31–9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis. Conclusions Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.

BACKGROUND In November 2019, Centers for Medicare & Medicaid Services (CMS) will require skilled nursing facilities (SNFs) to have an infection preventionist (IP) with “specialized training.” Meeting this requirement may prove difficult for many SNFs due to staff turnover, lack of resources and increasing patient acuity. The purpose of this study was to better understand SNF readiness for meeting the challenges ahead. METHODS In 2018, data were collected through a survey administered to 12 SNFs. These SNFs participated in the pilot phase of larger project designed to reduce healthcare-associated infections (HAIs) by enhancing relationships between SNFs and hospitals. The survey included facility-based questions of services provided and their current infection prevention program; IP experience and education; and communication between SNFs and hospitals. Following the survey, qualitative data were collected through semi-structured interviews at 4 SNFs and analyzed using a descriptive approach. RESULTS The 12 SNFs varied in size and services provided. Over half of the 12 IPs had “five years or less” experience in infection prevention. All of the IPs had other responsibilities such as staff education/development, occupational health, or assistant director of nursing. Ten months into the 12-month pilot year, 7 of the 12 IPs had left their IP position. The SNFs remained enrolled in the project, with the project team engaging the SNF IP in their new role and acquainting them to project-related resources. Our qualitative analysis revealed that these meetings met a critical need for new IPs. One of the interviewees noted that the “mentorship” offered by the project was vital to continue existing IP efforts at the SNF. CONCLUSIONS Limited IP experience and turnover will pose a significant challenge for SNFs in trying to meet CMS mandates. Strategies should encourage relationships with experienced IPs to assist SNFs in training and retaining IPs.

The widespread use of peripherally inserted central catheters (PICCs) has transformed the care of medical and surgical patients. Whereas intravenous antibiotics, parenteral nutrition, and administration of chemotherapy once necessitated prolonged hospitalization, PICCs have eliminated the need for such practice. However, PICCs may not be as innocuous as once thought; a growing body of evidence suggests that these devices also have important risks. This review discusses the origin of PICCs and highlights reasons behind their rapid adoption in medical practice. We evaluate the evidence behind 2 important PICC-related complications—venous thrombosis and bloodstream infections—and describe how initial studies may have led to a false sense of security with respect to these outcomes. In this context, we introduce a conceptual model to understand the risk of PICC-related complications and guide the use of these devices. Through this model, we outline recommendations that clinicians may use to prevent PICC-related adverse events. We conclude by highlighting important knowledge gaps and identifying avenues for future research in this area.

Background The catheter-associated urinary tract infection (CAUTI) measure recommended by the National Healthcare Safety Network (NHSN) accounts for the risk of infection in patients with an indwelling urinary catheter, but might not adequately reflect all efforts aimed to enhance patient safety by reducing urinary catheter use. Methods We used computer-based Monte Carlo simulation to compare the NHSN-recommended CAUTI rate (CAUTIs per 1,000 catheter-days) with the proposed “population CAUTI rate” (CAUTIs per 10,000 patient-days). We simulated 100 interventions with a wide range of effects on catheter utilization and CAUTI risk in patients with catheters, and then compared the 2 measures before and after intervention across the simulated interventions. Results Out of our 100 simulated interventions, 93 yielded reductions in CAUTI; however, in 25 (27%) of these 93 simulations, the NHSN CAUTI rate increased after the intervention. In addition, among the 68 simulations in which both the NHSN and the population CAUTI rates decreased, the percent decreases in the population CAUTI rate were consistently greater than those in the NHSN rate. Conclusion The population CAUTI rate—CAUTIs per 10,000 patient-days—should be calculated along with the NHSN rate, particularly in settings where interventions lead to substantial reductions in catheter placement. We suspect that this population CAUTI rate may eventually emerge as a primary outcome for hospital-based quality improvement interventions for reducing urinary catheter utilization, especially those focusing on avoiding urinary catheter placement.

Catheter-associated urinary tract infection, 1 of the hospital-acquired conditions targeted for reduction by the US government, is challenging to prevent. We therefore developed a self-assessment tool (a catheter-associated urinary tract infection prevention guide to patient safety) based on extensive qualitative evaluations. We describe the rationale, features, and utility of such a quality improvement tool.

Preventing catheter-associated urinary tract infection (CAUTI) is an important patient safety issue worldwide. In addition to understanding the required technical elements, addressing the socio-adaptive or behavioural elements of CAUTI prevention is also critical to ensure effective implementation and reduce the risk of patient harm.

Background & Aims Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. Methods We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000−2013 at 133 facilities. Results The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09−1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. Conclusions In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Article-at-a-Glance Background Catheter-associated urinary tract infection (CAUTI), a frequent health care–associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization. In addition, a long-term research project is being conducted to evaluate the current initiative and to identify practical strategies to ensure the effective use of proven infection prevention and patient safety practices. Overview of the Bladder Bundle Initiative in Michigan The bladder bundle as conceived by MHA Keystone HAI focuses on preventing CAUTI by optimizing the use of urinary catheters with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. Collaboration Between Researchers and State wide Patient Safety Organizations A synergistic collaboration between patient safety researchers and a statewide patient safety organization is aimed at identifying effective strategies to move evidence from peer-reviewed literature to the bedside. Practical strategies that facilitate implementation of the bundle will be developed and tested using mixed quantitative and qualitative methods. Discussion Simply disseminating scientific evidence is often ineffective in changing clinical practice. Therefore, learning how to implement these findings is critically important to promoting high-quality care and a safe health care environment.

Article-at-a-Glance Background As of October 2008, hospitals in the United States no longer receive Medicare reimbursement for certain types of health care–associated infection (HAI), thereby heightening the need for effective prevention efforts. The mere existence of evidence-based practices, however, does not always result in the use of such practices because of the complexities inherent in translating evidence into practice. A qualitative study was conducted to determine the barriers to implementing evidence-based practices to prevent HAI, with a specific focus on the role played by hospital personnel. Methods In-depth phone and in-person interviews were conducted between October 2006 and September 2007 with 86 participants (31 physicians) including chief executive officers, chiefs of staff, hospital epidemiologists, infection control professionals, intensive care unit directors, nurse managers, and frontline physicians and nurses, in 14 hospitals. Findings Active resistance to evidence-based practice change was pervasive. Successful efforts to overcome active resisters included benchmarking infection rates, identifying effective champions, and participating in collaborative efforts. Organizational constipators—mid- to high-level executives who act as insidious barriers to change—also increased the difficulty in implementing change. Recognizing the presence of constipators is often the first step in addressing the problem but can be followed with including the organizational constipator early in group discussions to improve communication and obtain buy-in, working around the individual, and terminating the constipator's employment. Discussion Two types of personnel—active resistors and organizational constipators—impeded HAI prevention activities, and several approaches were used to overcome those barriers. Hospital administrators and patient safety leaders can use the findings to more successfully structure activities that prevent HAI in their hospitals.

Infection control professionals and hospital epidemiologists are accustomed to using quantitative research. Although quantitative studies are extremely important in the field of infection control and prevention, often they cannot help us explain why certain factors affect the use of infection control practices and identify the underlying mechanisms through which they do so. Qualitative research methods, which use open-ended techniques, such as interviews, to collect data and nonstatistical techniques to analyze it, provide detailed, diverse insights of individuals, useful quotes that bring a realism to applied research, and information about how different health care settings operate. Qualitative research can illuminate the processes underlying statistical correlations, inform the development of interventions, and show how interventions work to produce observed outcomes. This article describes the key features of qualitative research and the advantages that such features add to existing quantitative research approaches in the study of infection control. We address the goal of qualitative research, the nature of the research process, sampling, data collection and analysis, validity, generalizability of findings, and presentation of findings. Health services researchers are increasingly using qualitative methods to address practical problems by uncovering interacting influences in complex health care environments. Qualitative research methods, applied with expertise and rigor, can contribute important insights to infection prevention efforts.

OBJECTIVE To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs). PARTICIPANTS AND METHODS Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs. RESULTS The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P =.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P P =.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices. CONCLUSION Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.

The increasing prevalence of diabetes and prediabetes makes the cost of diabetes care a pressing concern. Nurses in all settings play a critical role in helping to reduce the cost of diabetes not only for individual patients but ultimately for the health care system. This article focuses on four main issues related to the economic impact of diabetes for patients and health systems: (1) overall estimates of the direct and indirect costs of diabetes and its associated complications, (2) the impact of cost on diabetes care and health outcomes, (3) the ways in which federal- and state-mandated insurance for persons with diabetes is being used to promote more cost-effective and high-quality diabetes care, and (4) the use of cost-effectiveness analysis to evaluate interventions designed to prevent diabetes or diabetes-related complications.

Purpose To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control, intermediate cardiovascular outcomes, satisfaction with care, and resource utilization. Methods We conducted a randomized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A 1C (HbA 1C ) levels ≥7.5%. Two nurse practitioner case managers worked with patients and their primary care providers, monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts, collaborative goal setting, and treatment algorithms. Control patients received educational materials and usual care from their primary care providers. Results At the conclusion of the study, both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA 1C level (9.3% vs. 9.2%; difference=0.1%; 95% confidence interval: −0.4% to 0.7%; P = 0.65). There was also no evidence that the intervention resulted in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy. However, intervention patients were substantially more satisfied with their diabetes care, with 82% rating their providers as better than average compared with 64% of patients in the control group ( P = 0.04). Conclusion An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes. The type of patients targeted for intervention, organizational factors, and program structure are likely critical determinants of the effectiveness of case management. Health systems must understand the potential limitations before expending substantial resources on case management, as the expected improvements in outcomes and downstream cost savings may not always be realized.

Article-at-a-Glance Background Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined. Methods Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use. Results Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record–based measures but would have required about 50% fewer chart reviews. Conclusions Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.

BACKGROUND/OBJECTIVES: Professional and practice standards specify that infection control professionals (ICPs) acquire and maintain current knowledge and skills, critically appraise published evidence and then apply this knowledge towards infection prevention and control and epidemiology. Since evidence-based health care is taking on increasing importance we surveyed a nationwide sample of ICPs on their reading habits to discern which and how often various media are utilized. METHODS: As part of a larger study, IC Coordinators (ICCs) at 797 hospitals in the U.S., including all VA Medical Centers and a randomized, stratified sample of non-VA hospitals were mailed an 11-page evidence-based practice survey. Recipients were asked which of several peer-reviewed journals and others such as “throwaway” periodicals they subscribe to, perception of quality for each, and rank order on the extent to which these provided useful practice information. Frequency of responses was analyzed using SAS [ver.9.1, Cary, NC]. RESULTS: The survey response rate was 74.3%. Respondents spend a mean of 3.6 hours/week reading journals or periodicals. Resources identified as most helpful included the CDC website (51.7%), APIC Text (10.8%) and APIClist (8.4%). Proportion of subscribers was highest for American Journal of Infection Control (AJIC; 83.6%), Infection Control Today (71.5%) and Managing Infection Control (54.2%). The top three journals ranked on a scale of 1-10 for quality were Infection Control & Hospital Epidemiology (ICHE; 8.0), AJIC (7.5), and New England Journal of Medicine (7.4). Of peer-reviewed journals, AJIC (85.1%) and ICHE (71.8%) were deemed most helpful sources of practice information. For non-peer-reviewed, Morbidity and Mortality Weekly Report (85.1%) and Hospital Infection Control (61.3%) were ranked at the top. Using an average of mean rank scores based on a four point rating, ICCs indicated that non-peer-reviewed periodicals are the most commonly utilized (63.0%), followed by other sources [e.g. CDC website, professional conferences, networking; (61.6%)], and lastly peer-reviewed scientific journals (40.9%). CONCLUSIONS: Non-peer-reviewed periodicals such as throwaways do not meet objective scoring criteria for evidence-based practice, nonetheless we found they are the source of information used most frequently by ICPs.

Despite strong medical evidence and policy initiatives supporting the use of daily interruption of sedation in mechanically ventilated patients, compliance remains suboptimal. We sought to identify new barriers to daily interruption of sedation.We conducted 5 focus groups of intensive care unit physicians, nurses, and respiratory therapists during a 2-month period to identify attitudes, barriers, and motivations to perform a daily interruption of sedation. Each focus group was audiotaped, and the transcripts were analyzed using qualitative methods to identify recurrent themes.There was wide consensus on the importance of daily interruptions of sedation; however, practitioners usually performed sedation interruption for 1 of 5 distinct reasons: minimizing the dose of sedation, performing a neurologic examination, facilitating ventilator weaning, reducing intensive care unit length of stay, and assessing patient pain. Participants rarely espoused more than 1 main reason, and there was no shared understanding of why one might do a daily interruption of sedation. This lack of shared understanding led to different patients being selected and diverse approaches to carrying out the DIS.Despite apparent consensus, lack of shared understanding of the rationale for an intervention may lead to divergent practice patterns and failure to implement standardized, evidence-based practice.