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Objective:To describe pathogen distribution and rates for central-line–associated bloodstream infections (CLABSIs) from different acute-care locations during 2011–2017 to inform prevention efforts.Methods:CLABSI data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) were analyzed. Percentages and pooled mean incidence density rates were calculated for a variety of pathogens and stratified by acute-care location groups (adult intensive care units [ICUs], pediatric ICUs [PICUs], adult wards, pediatric wards, and oncology wards).Results:From 2011 to 2017, 136,264 CLABSIs were reported to the NHSN by adult and pediatric acute-care locations; adult ICUs and wards reported the most CLABSIs: 59,461 (44%) and 40,763 (30%), respectively. In 2017, the most common pathogens were Candida spp/yeast in adult ICUs (27%) and Enterobacteriaceae in adult wards, pediatric wards, oncology wards, and PICUs (23%–31%). Most pathogen-specific CLABSI rates decreased over time, excepting Candida spp/yeast in adult ICUs and Enterobacteriaceae in oncology wards, which increased, and Staphylococcus aureus rates in pediatric locations, which did not change.Conclusions:The pathogens associated with CLABSIs differ across acute-care location groups. Learning how pathogen-targeted prevention efforts could augment current prevention strategies, such as strategies aimed at preventing Candida spp/yeast and Enterobacteriaceae CLABSIs, might further reduce national rates.

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Background A large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes; however, current literature including the frontline perspective of staff working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility level factors may have contributed to the impact of COVID-19 on Certified Nursing Assistants (CNAs) and Environmental Services (EVS) staff working in nursing homes. Methods Based on a simple random sample from the National Healthcare Safety Network (NHSN), 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member for participation in a voluntary focus group over Zoom. Facility characteristics were obtained via NHSN and publicly available sources; participant demographics were collected via SurveyMonkey during registration and polling during focus groups. Qualitative information was coded using NVIVO and Excel. Results Throughout April 2021, 23 focus groups including 110 participants from 84 facilities were conducted homogenous by participant role. Staffing problems were a recurring theme reported. Participants often cited the toll the pandemic took on their emotional well-being, describing increased stress, responsibilities, and time needed to complete their jobs. The lack of consistent and systematic guidance resulting in frequently changing infection prevention protocols was also reported across focus groups. Conclusions Addressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Additionally, access to mental health resources could help nursing home staff cope with the emotional burden of the COVID-19 pandemic. These frontline staff members provided invaluable insight and should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning.

Background: The Targeted Assessment for Prevention (TAP) strategy is a quality improvement framework created by the Centers for Disease Control and Prevention (CDC) to facilitate the reduction of healthcare-associated infections (HAIs). TAP facility assessments are a component of the TAP strategy and are completed by staff across the facility to help identify perceptions of and target infection prevention gaps. We have described the gaps most commonly reported by facilities completing TAP facility assessments for catheter-associated urinary tract infections (CAUTIs) and central-line–associated bloodstream infections (CLABSIs). Methods: TAP CAUTI and CLABSI assessments were completed by acute-care facilities across the nation, with CDC technical assistance, from December 2014 to August 2019. Similar questions across 2 versions of CAUTI assessments and 3 versions of CLABSI assessments were combined. Analysis was limited to facilities with ≥10 assessments. Infection prevention gaps were defined as ≥33% respondents answering Unknown, ≥33% respondents answering “no,” or ≥50% of respondents answering “no” and “unknown” or “never” and “rarely” “sometimes” “unknown.” The analysis was completed at the facility level, and the gaps most commonly reported across facilities were identified. Results: In total, 1,942 CAUTI assessments from 42 facilities in 12 states and 1,623 CLABSI assessments from 29 facilities in 11 states were included for analysis. The mean numbers of assessments per facility were 46.2 for CAUTIs and 56.0 for CLABSIs. Across both CAUTIs and CLABSIs, commonly reported perceptions about infection prevention gaps included lack of physician and nurse champions for prevention activities, failure to conduct competency assessments, and inconsistency in select device insertion practices (Fig. 1). For CAUTIs, lack of practices to facilitate timely removal of urinary catheters were also commonly reported, with one-third of facilities reporting inconsistency in use of alerts for catheter removal, 78.6% reporting lack of physician response to these alerts, and 90.5% reporting deficiencies in removing unnecessary catheters in the postanesthesia care unit. For CLABSIs, 79.3% of facilities reported failure to replace central lines within 48 hours after emergent insertion, and 62.1% reported that feedback was not provided to staff on central-line device utilization ratios. Conclusion: For both assessments, absence of CAUTI and CLABSI prevention champions, failure to conduct competency assessments, and inconsistency in performing device insertion practices were commonly reported across facilities. These common gaps have and will continue to inform the development of tools and resources to improve infection prevention practices as well as help to better target the implementation of interventions.Funding: NoneDisclosures: None

A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers.

Although critical to prevent healthcare-associated infections, hand hygiene (HH) compliance is poor in resource-limited settings. In 2012, three Kenyan hospitals began onsite production of alcohol-based handrub (ABHR) and HH promotion. Our aim is to determine the impact of local production of ABHR on HH compliance and perceptions of ABHR. We observed 25,738 HH compliance opportunities and conducted 15 baseline and post-intervention focus group discussions. Hand Hygiene compliance increased from 28% (baseline) to 38% (post-intervention, p = 0.0003). Healthcare workers liked the increased accessibility of ABHR, but disliked its smell, feel, and sporadic availability. Onsite production and promotion of ABHR resulted in modest HH improvement. Enhancing the quality of ABHR and addressing logistical barriers could improve program impact.

The prevention of central line-associated bloodstream infections in patients in hospital critical care units has been a target of efforts by the Centers for Disease Control and Prevention (CDC) since the 1960s. We developed a historical economic model to measure the net economic benefits of preventing these infections in Medicare and Medicaid patients in critical care units for the period 1990-2008-a time when reductions attributable to federal investment resulted primarily from CDC efforts-using the cost perspective of the federal government as a third-party payer. The estimated net economic benefits ranged from $640 million to $1.8 billion, with the corresponding net benefits per case averted ranging from $15,780 to $24,391. The per dollar rate of return on the CDC's investments ranged from $3.88 to $23.85. These findings suggest that investments in CDC programs targeting other health care-associated infections also have the potential to produce savings by lowering Medicare and Medicaid reimbursements.

Objectives. We evaluated capacity built and outcomes achieved from September 1, 2009, to December 31, 2011, by 51 health departments (HDs) funded through the American Recovery and Reinvestment Act (ARRA) for health care–associated infection (HAI) program development. Methods. We defined capacity for HAI prevention at HDs by 25 indicators of activity in 6 categories: staffing, partnerships, training, technical assistance, surveillance, and prevention. We assessed state-level infection outcomes by modeling quarterly standardized infection ratios (SIRs) for device- and procedure-associated infections with longitudinal regression models. Results. With ARRA funds, HDs created 188 HAI-related positions and supported 1042 training programs, 53 surveillance data validation projects, and 60 prevention collaboratives. All states demonstrated significant declines in central line–associated bloodstream and surgical site infections. States that implemented ARRA-funded catheter-associated urinary tract infection prevention collaboratives showed significantly greater SIR reductions over time than states that did not (P = .02). Conclusions. ARRA–HAI funding substantially improved HD capacity to reduce HAIs not targeted by other national efforts, suggesting that HDs can play a critical role in addressing emerging or neglected HAIs.

Objective.To identify differences in organizational culture and better understand motivators to implementation of abundle intervention to control Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC).Design.Mixed-methods study.Setting.Four long-term acute care hospitals (LTACHs) in Chicago.Participants.LTACH staff across 3 strata of employees (administration, midlevel management, and frontline clinical workers).Methods.Qualitative interviews or focus groups and completion of a quantitative questionnaire.Results.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.Conclusions.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.

INTRODUCTION Aligned with the goals of the DHHS Action Plan to Prevent Healthcare Associated Infections (HAIs), in 2009 the Centers for Disease Control and Prevention (CDC) awarded cooperative agreements to 51 state and territorial health departments for purposes of developing and implementing strategies to reduce HAIs. These cooperative agreements through the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) were supported by the American Recovery and Reinvestment Act (ARRA). OBJECTIVES To systematically describe the perceptions of CDC public health analysts who delivered technical assistance (TA) to state health departments as part of the ELC cooperative agreement supported by ARRA to develop, implement, and/or expand HAI prevention programs. RESEARCH DESIGN Eight semistructured interviews using a standardized script were administered. Interviews were audio recorded; responses were transcribed, thematically coded, and analyzed using a qualitative immersion approach. SUBJECTS This study included CDC staff who provided TA to grantees of the ELC cooperative agreement supported by ARRA from September 2009 to December 2011. RESULTS Four convergent themes were identified, creating a framework of activities for the delivery of TA: acting as a liaison, facilitating training, providing administrative and program management support, and sharing/disseminating information to states. Having a liaison and providing informational resources to states were perceived as critical components of TA for HAI program sustainability. CONCLUSIONS Findings provide a framework of core TA activities required to build and sustain capacity in state HAI prevention programs through the cooperative agreement structure. This categorization of themes can be used to assist other agencies and entities in planning for and provision of TA when utilizing cooperative agreements.

Background Better understanding of medical students' perceptions, attitudes, and knowledge about antimicrobial prescribing practices could facilitate more effective education of these future prescribers. Methods A 24-item electronic survey on antimicrobial prescribing and education was administered to fourth-year medical students at the University of Miami, the Johns Hopkins University, and the University of Washington (January-March 2012). Results Three hundred seventeen of 519 (61%) students completed the survey; 92% of respondents agreed that strong knowledge of antimicrobials is important in their careers, and 90% said that they would like more education on appropriate use of antimicrobials. Mean correct knowledge score (11 items) was 51%, with statistically significant differences between study sites and sources of information used to learn about antimicrobials. Only 15% had completed a clinical infectious diseases rotation during medical school; those who had done so rated the quality of their antimicrobial education significantly higher compared to those who had not (mean, 3.93 vs 3.44, on a 5-point scale; P = .0003). There were no statistically significant associations between knowledge scores and having had an infectious diseases clinical elective. Only one-third of respondents perceived their preparedness to be adequate in some fundamental principles of antimicrobial use. Conclusions Differences exist between medical schools in educational resources used, perceived preparedness, and knowledge about antimicrobial use. Variability in formative education could frame behaviors and prescribing practices in future patient care. To help address the growing problem of antimicrobial resistance, efforts should be undertaken to ensure that our future doctors are well educated in the principles and practices of appropriate use of antibiotics and antimicrobial stewardship.

OBJECTIVESTo 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.DESIGNModified Delphi process.PARTICIPANTSA multinational panel of 20 experts in antimicrobial stewardship.METHODSPotential indicators were rated on the perceived feasibility to implement and measure each indicator and clinical importance for optimizing appropriate antimicrobial prescribing.RESULTSThe 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.CONCLUSIONSThe 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

Although guidelines currently recommend prevention practices to decrease in-hospital transmission of infections, increasing adherence to the practices remains a challenge. This study assessed the effect of a multicenter methicillin-resistant Staphylococcus aureus (MRSA) prevention initiative on changes in employees' knowledge, attitudes, and practices.Two cross-sectional surveys were distributed at baseline (October 2006) and follow-up (July 2007) at 17 medical centers participating in the Veterans' Administration (VA) MRSA initiative.Surveys were completed by 1362 employees at baseline and 952 employees at follow-up (representing 57% and 56% of eligible respondents, respectively). Respondents included physicians (9%), nurses (38%), allied health professionals (30%), and other support staff (24%). Of the 5 knowledge items, the mean proportion answered correctly increased slightly from baseline to follow-up (from 71% to 73%; P = .07). The percentage of respondents who believed that MRSA was a problem on their unit increased over time (from 56% to 65%; P.001). Respondents also reported increased comfort with reminding other staff about proper hand hygiene (from 61% to 70%; P.001) and contact precautions (from 63% to 70%; P.002). The percentage of respondents reporting at least one barrier to proper hand hygiene decreased over time (from 25% to 20%; P = .003).In this multicenter study of VA employees, implementation of a MRSA quality improvement initiative was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention.

Objective.To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs.Design.Observational study.Setting.Intensive care unit in a Veterans Affairs hospital.Participants.HCWs.Results.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 ≤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.Conclusions.In this study, adherence to hand hygiene practices was lowest after brief patient encounters (ie

Background Patient safety is of concern to consumers, health professionals, policymakers, insurers, and researchers. Objective Assess the perceptions of health care providers regarding the impact of parts of the health care system on patient safety, barriers to patient safety, and strategies to improve patient safety. Methods Statewide survey mailed in May 2001. Participants rated the impact of 10 parts of the health care system on patient safety, selected barriers to patient safety that they thought should be priorities, and selected the best strategies for improving patient safety. Results Of random samples of 1310 physicians, 1310 pharmacists, and 2620 nurses licensed by the state of Iowa, 5075 providers were eligible and 2388 responded (47%). Provider education, norms and values, patient and family characteristics, and continuity of care were rated as having a major impact on patient safety by at least 70% of each provider group. A general lack of consensus exists among providers about which barriers to patient safety should be priorities and which strategies would best improve the system. However, a majority of providers agreed that educating patients about their role in health care and sharing information between providers and across settings of care are important strategies for improving patient safety. Conclusion In areas in which providers agree on the best strategies, broader, system-wide interventions that include physicians, pharmacists, and nurses in multiple settings may be implemented to improve patient safety. Health care organizations and providers must get patients more involved in their care by asking them to help define roles, design educational materials, and develop useful methods of sharing information across settings.

Antimicrobial use contributes to the development of emergence and dissemination of antimicrobial-resistant bacteria among intensive care unit (ICU) patients. There are few published data on antimicrobial use in neonatal (NICU) and pediatric ICU (PICU) patients.Personnel at 31 Pediatric Prevention Network hospitals participated in point prevalence surveys on August 4, 1999 (summer) and February 8, 2000 (winter). Data collected for all NICU and PICU inpatients included demographics, antimicrobials and indications for use and therapeutic interventions.Data were reported for 2647 patients in 29 NICUs (827 patients in summer; 753 in winter) and 35 PICUs (512 patients in summer; 555 in winter). PICU patients were more likely than NICU patients to be receiving antimicrobials on the survey date [758 of 1070 (70.8%) versus 684 of 1582 (43.2%), P0.0001]. NICU patients were receiving a higher median number of antimicrobials (2 versus 1, P0.0001). The most common agents among NICU patients were gentamicin, ampicillin and vancomycin; the most common agents among PICU patients were cefazolin, vancomycin and cefotaxime. Use of aminoglycosides, aminopenicillins and topical antibacterials was significantly more common in NICU patients; first, second and third generation cephalosporins, extended spectrum penicillins, sulfonamides, fluoroquinolones, antianaerobic agents, systemic antifungals and systemic antivirals were more common in PICU patients.This is the first U.S. national multicenter description of antimicrobial use in NICUs and PICUs and demonstrates the high prevalence of antimicrobial use among these patients. Assessment strategies targeting antimicrobial use in pediatrics are needed.

Background There has been no recent assessment of public attitudes and opinions concerning risk of bloodborne virus transmission during health care. Methods Seven items in the 2000 annual Healthstyles survey were used to assess current attitudes and opinions about health care providers infected with human immunodeficiency virus (HIV) and the risk of bloodborne virus transmission during health care in a sample of approximately 3000 US households. Results Of the 2353 respondents, 89% agreed that they want to know whether their doctor or dentist is infected with HIV; 82% agreed that disclosure of HBV or HCV infection in a provider should be mandatory. However, 47% did not believe that HIV-infected doctors were more likely to infect patients than doctors infected with HBV or HCV. Opinions were divided on whether HIV-infected providers should be able to care for patients as long as they use good infection control: only 38% thought that infected providers should be allowed to provide patient care. Conclusions These findings suggest that improved public education and risk communication on health care-associated bloodborne infections is needed.

Background Antimicrobial resistance (AR) is a threat to hospitalized children, and more information is needed to motivate physicians to adopt evidence-based practices such as those in the Centers for Disease Control and Prevention's (CDC) Campaign to Prevent Antimicrobial Resistance. Methods The framework of the Health Belief Model (HBM) was used to assess personal perceptions and cues to action related to the prevention of AR in 3 national focus groups in August 2003. Results Twenty-five physicians who treat hospitalized children participated; all reported that they had cared for a patient with an antimicrobial-resistant organism. Physicians perceived that AR was more of a problem nationally (92%) than in their institution (76%) or practice (60%) and reported that issues such as nursing shortage, cost of health care, and lack of specialty services presented more of a challenge to the care of hospitalized children than AR. Reported preferences of cues to action included journal articles (80%), infectious disease experts (76%), and colleagues (52%). Conclusions The HBM provides insight into physicians' perceptions about AR and preferred cues to action, which yield valuable information concerning the modes, methods, and messengers to intervene on problems such as antimicrobial resistance in hospitalized children.

The CDC introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs.To assess the preventability of VAEs.We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance among 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining eight units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, Sequential Organ Failure Assessment score, and comorbidity index.We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator day but significant decreases in VAE risk per episode of mechanical ventilation (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.42-0.97) and infection-related ventilator-associated complications (OR, 0.35; 95% CI, 0.17-0.71) but not pneumonias (OR, 0.51; 95% CI, 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates.Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registered with www.clinicaltrials.gov (NCT 01583413).

Patients on hemodialysis, particularly those dialyzed through central lines, are at risk of acquiring bloodstream infections. Strategies to prevent bloodstream infections in patients on dialysis include educating patients about infection prevention, although patients’ perspectives on this topic are not known. During focus groups conducted to explore these issues, patients reported that education on infection prevention should begin early in the process of dialysis, and that patients should be actively engaged as partners in infection prevention.

During late April 2009, the first cases of 2009 pandemic influenza A (H1N1) (pH1N1) in Illinois were reported. On-going, sustained local transmission resulted in an estimated 500,000 infected persons. We conducted a mixed method analysis using both quantitative (surveillance) and qualitative (interview) data; surveillance data was used to analyze demographic distribution of hospitalized cases and follow-up interview data was used to assess health seeking behavior. Invitations to participate in a telephone interview were sent to 120 randomly selected Illinois residents that were hospitalized during April-December 2009. During April-December 2009, 2,824 pH1N1 hospitalizations occurred in Illinois hospitals; median age (interquartile range) at admission was 24 (range: 6-49) years. Hospitalization rates/100,000 persons for blacks and Hispanics, regardless of age or sex were 2-3 times greater than for whites (blacks, 36/100,000 (95% Confidence Interval ([95% CI], 33-39)); Hispanics, 35/100,000 [95%CI,32-37] (; whites, 13/100,000[95%CI, 12-14); p

Objective: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.Design:A voluntary survey of the membership of the Society for Healthcare Epidemiology of America, Inc. (SHEA).Methods: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.Results: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).Conclusions: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.

The use of intravascular catheters is associated with increased risk of bloodstream infections, principally caused by coagulase-negative staphylococci. This “Reality Check” session, held at die 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections, focused on the question of whether, and in what manner, vancomycin should be used for the prophylaxis of these infections.

Antimicrobial resistance, including vancomycin resistance in enterococci (VRE), is a growing problem in healthcare facilities. This “Reality Check” session focused on the question of whether we should try to detect and isolate patients colonized or infected with VRE.

Background: The rapid emergence of both new infections and new technologies has revolutionized health care during the past 50 years. Increased use of the Internet has enabled health care professionals to educate, interact, and collaborate throughout the world in ways never before possible. Increased use of vancomycin has been associated with the emergence of organisms with decreased susceptibility to vancomycin, such as Enterococcus and staphylococcal species. The purpose of this article is to describe our experience using Internet technology to assess vancomycin use at children’s hospitals in the United States. Methods: A Web-based evaluation was developed and distributed on the Internet to 57 Pediatric Prevention Network hospitals. The evaluation was structured to collect summary statistics on vancomycin use and admissions data by service for 1997 and 1998. Results: Twenty-four hospitals were able to provide archived vancomycin use and patient admissions data; completed evaluations were returned from 15 hospitals (62.5% response rate). Personnel at 6 (40%) hospitals completed the evaluation directly on the Internet. Conclusions: In our study, Internet technology facilitated a more efficient evaluation of vancomycin use, but fewer than half of the personnel at Pediatric Prevention Network hospitals completed the evaluation directly on the Internet. It is unclear whether personnel at these hospitals were limited in Internet access, support, or understanding. Efforts should be directed to educate health care personnel on the advantages of the Internet. Furthermore, many of the pharmacy databases used in our assessment were not standardized across hospitals nor systematically validated. Understanding that limitations still remain—within the source of the data studied, the health care system sampled, and the Internet tools available—is essential because the Internet offers health care professionals today a tool both to protect patients and to improve quality throughout the world. (AJIC Am J Infect Control 2000;28:459-64)

Background: Nosocomial infections have been recognized as a source of morbidity and mortality throughout the world for several decades. In the United States, an estimated 2.1 million nosocomial infections occur annually in acute care hospitals alone. Infection surveillance and control programs (ISCPs) play a vital role in addressing this problem, but no national studies have described the status and composition of these programs since the 1970s. Methods: In January 1997, a voluntary survey was sent by mail to members of the Association for Professionals in Infection Control and Epidemiology, Inc. Only one response per facility was requested. The survey asked for information for the years 1992 to 1996 (study period), and questions pertained to characteristics of the health care facility in which the respondent worked, characteristics of the ISCP and its personnel, and the overall level of administration support for infection control activities. Results: Completed questionnaires were received from personnel at 187 health care facilities located in 40 states and the District of Columbia. The majority (76.5%) of responding facilities were nongovernment owned, and 57.2% were classified as general acute care facilities. The number of licensed beds at these facilities remained stable throughout the study period, but all other measures of facility size and activity (eg, number of patient days and number of nurses) decreased by as much as 28.9%. In 1992, ISCPs were most likely to be organizationally located in the Nursing Department, but by 1996, many had been transferred to departments of Medical Records, Quality Assurance, or Risk Management. Throughout the course of the study period, the number of facilities performing surveillance for health care–associated infections in outpatient settings increased by 44.0%, from 100 to 144. In 1996, only 47.6% of facilities had a hospital epidemiologist (HE), and HEs devoted a median of 15% or less of their time to infection control activities. For the most part, HEs were trained in infectious diseases, and few had certification in infection control. Infection control professionals (ICPs) were much more common than were HEs (ICPs were reported at 97.9% of respondents' facilities in 1996), and they spent the majority (80% in 1996) of their time on infection control activities. During the course of the study period, increasing numbers of facilities had ICPs who had certification in infection control. Furthermore, most respondents did not report a change over time in the level of administration support for infection control activities. Conclusions: Health care delivery has changed dramatically during the past 20 years. This study presents an updated description of ISCPs in the United States. Our results illustrate several changing parameters, such as departmental shifts and increased outpatient surveillance, that reflect adjustments in health care priorities during the study period. As the transformation of the health care system continues, continued evaluation of the status of ISCPs on a national level will be necessary. Diligent monitoring, proactive measures, and collaboration between infection control organizations and government agencies will be vital for the prevention and control of health care–associated infections in the future. (AJIC Am J Infect Control 2000;28:392-400)

The infectious diseases community shares a wide consensus about the need for control of antimicrobial use. However, current practices toward this goal remain controversial. This “Reality Check” session assessed attendees of the 4th Decennial Conference regarding their knowledge and practices about control of antimicrobial use in hospitals.

Objective: The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use. Methods: A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children's Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use. Results: Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients. Conclusions: Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population. (AJIC Am J Infect Control 1999;27:482-7)

A 19-item survey instrument was designed and mailed by the Infectious Diseases Society of America to its membership to determine the media preferred by infectious diseases physicians for continuing medical education on general topics and on antimicrobial resistance. The objective of the survey was to offer the developers of educational programs knowledge on which to base more-effective ways to deliver educational materials to physicians in this specialty.

In September 2009, federal funding for health care–associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states—including state health department employees, representatives from partner organizations, and health care facility employees—were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

We surveyed acute care facilities in Florida to assess components of and barriers to sustained antimicrobial stewardship programs (ASPs). Most respondents with and without ASPs are doing some stewardship-related activities to improve antimicrobial use. Collaborative efforts between facilities and health departments are important to providing better resources for ASPs.

CONTEXT: Public health has an important and critical role in responding to emerging multidrug-resistant organisms, such as carbapenem-resistant Entembacteriaceae. The Centers for Disease Control and Prevention developed a survey as a tool for state health departments to determine carbapenem-resistant Enterobacteriaceae prevalence within their region. OBJECTIVE: This report summarizes an assessment of the health department experience with the survey, their perceived roles and responsibilities in responding to an emerging health care-associated pathogen, and potential barriers to public health engagement of acute care facilities in response activities. DESIGN: Key informant interviews consisting of open-ended and 5-point Likert scale questions were conducted. PARTICIPANTS: Interviewees represented state health departments that administered the survey and select states that did not. RESULTS: Of 11 states interviewed, 7 (64%) had administered the survey to acute care facilities. Despite similar competing priorities and concerns about administering the survey, different perspectives emerged among the 11 states; those that administered the survey regarded it as a learning opportunity, whereas other states emphasized concerns about survey logistics and other public health demands. All 11 states perceived the prevention of an emerging pathogen to be a public health priority, but the degree of their action depended on availability of resources and existing relationships with infection preventionists. Health departments had less interaction with other hospital personnel (eg, facility leadership) and limited knowledge of the roles and associated responsibilities of other health care partners (eg, Quality Improvement Organizations). CONCLUSIONS: Although considered a public health priority, response efforts to emerging J Public Health Management Practice, 2013, 00(00), 1–6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins pathogens were reported to vary among state health departments. A better understanding is needed of the factors that motivate and facilitate state health departments to engage in a public health activity despite the challenges of competing priorities and limited resources. Efforts should also focus on improving the relationship between health departments and hospital leadership and other health care partners.

Surveys are one of the most frequent modes of observation and measurement. Survey research can be exploratory, descriptive, and/or explanatory. Modes of survey administration vary and include face-to-face, telephone, mail, and Internet. There are numerous considerations that that must be taken into account when designing and conducting a survey. Deciding what information is needed and why is important when developing questions for a survey; it is essential to define the purpose of the survey and to be as specific as possible in terms of the data to be collected. Response rate varies by target audience and is influenced by a number of factors such as incentives, survey length, and perceived burden. From question development to survey construction, the goal is to minimize measurement error with systematic planning and execution.

Background.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.Design.Evaluation of a mixed qualitative and quantitative methodology (“trilogic evaluation model”).Setting.Six hospitals that joined the campaign before June 2006.Participants.Three strata of staff (executive leadership, midlevel, and frontline) at each hospital.Results.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.Conclusions.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 Epidemiol2012;33(2):135-143

To formatively evaluate the Hand Hygiene Saves Lives video and explore the perceptions and expectations of health care providers and laypersons regarding hand hygiene (HH), health care-associated infections, and patient empowerment using the Health Belief Model as a framework.Four focus groups were conducted in February 2008 among laypersons (n = 18) and health care providers (n = 17). Qualitative data were coded for themes, and quantitative Likert scales ranging from 1 (not at all) to 5 (very) were analyzed using SPSS.Health care-associated infections were perceived to be somewhat common (mean, 3.4) and HH as very important (mean, 4.9). Laypersons reported being significantly more likely to ask their nurses (2.5 versus 4.3; P = 0.001) and physicians (3.3 versus 4.3; P = 0.010) to perform HH after viewing the video. The video's target audience was perceived to be families (42.0%) or patients (39.1%) and the message to be the importance of HH (45.5%) or creating comfort about asking (24.2%).Empowering patients using tools such as a video may be an important patient safety advance to improve HH in health care settings and prevent health care-associated infections.

Objective.To assess healthcare personnel (HCP) perceptions regarding implementation of sensor-based electronic systems for automated hand hygiene adherence monitoring.Design.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 monitoringSetting.A university hospital, a Veterans Affairs hospital, and a community hospital in the Midwest.Participants.Focus groups were homogenous by HCP type, with separate groups held for leadership, midlevel management, and frontline personnel at each hospital.Results.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 (PPConclusions.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.

We surveyed faculty and residents to assess attitudes, perceptions, and knowledge about antimicrobial use and resistance. Most respondents were concerned about resistance when prescribing antibiotics and agreed that antibiotics are overused, that inappropriate use is professionally unethical, and that others, but not themselves, overprescribe antibiotics. Antimicrobial stewardship programs should capitalize on these perceptions.

Background Previous research demonstrates that organizational culture (OC) and knowledge, attitudes, and practices of health care personnel are associated with the overall success of infection control programs; however, little attention has been given to the relationships among these factors in contributing to the success of quality improvement programs. Methods Cross-sectional surveys assessing OC and knowledge, attitudes, and practices related to methicillin-resistant Staphylococcus aureus (MRSA) were distributed to 16 medical centers participating in a Veterans Affairs MRSA prevention initiative in 2 time periods. Factor analysis was performed on the OC survey responses, and factor scores were generated. To assess associations between OC and knowledge, attitudes, and practices of health care personnel, regression analyses were performed overall and then stratified by job type. Results The final analyzable sample included 2,314 surveys (43% completed by nurses, 9% by physicians, and 48% by other health care personnel). Three OC factors emerged accounting for 53% of the total variance: “Staff Engagement,” “Overwhelmed/Stress-Chaos,” and “Hospital Leadership.” Overall, higher Staff Engagement was associated with greater knowledge scores, better hand hygiene practices, fewer reported barriers, and more positive attitudes. Higher Hospital Leadership scores were associated with better hand hygiene practices, fewer reported barriers, and more positive attitudes. Conversely, higher Overwhelmed/Stress-Chaos scores were associated with poorer reported prevention practices, more barriers, and less positive attitudes. When these associations were stratified by job type, there were significant associations between OC factors and knowledge for nurses only, between OC factors and practice items for nurses and other health care personnel, and between OC factors and the barriers and attitudes items for all job types. OC factors were not associated with knowledge and practices among physicians. Conclusions Three OC factors—Staff Engagement, Overwhelmed/Stress-Chaos, and Hospital Leadership—were found to be significantly associated with individual health care personnel knowledge, attitudes, and self-reported practices regarding MRSA prevention. When developing a prevention intervention program, health care organizations should not only focus on the link between OC and the knowledge, attitudes, and practices of health care personnel, but also target programs based on health care personnel type to maximize their effectiveness.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade, including in Asian/Pacific Islanders (A/PIs).We conducted ethnographic interviews in O'ahu and Kaua'i, Hawai'i, with 10 Asian/Pacific Islanders identified as having a history of CA-MRSA infections.Most (7/10) thought skin infections were not a new problem in Hawai'i. Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies and store- bought solutions. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after concern from family, unbearable pain, and/or other symptoms of illness.Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined. If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.

To describe the key strategies and potential pitfalls involved with implementing the Department of Veterans Affairs (VA) Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a qualitative evaluation, we conducted in-depth interviews with MRSA Prevention Coordinators at 17 VA ß sites at 2 time points during program implementation.

Background and objectives: Nephrogenic systemic fibrosis (NSF) is a disorder that can affect patients with renal dysfunction exposed to a gadolinium-based contrast agent (GBCA). Given the unique role nephrologists play in caring for patients at risk to develop NSF, this study surveyed their perceptions and practices regarding NSF. Design, setting, participants, & measurements: An internet-based, cross-sectional survey of clinical nephrologists in the United States was performed. Perceptions and self-reported practices regarding NSF and local facility policies were assessed concerning GBCA use in renal dysfunction. Results: Of the 2310 eligible nephrologists e-mailed to participate in the survey, 171 (7.4%) responded. Respondents spent 85% of their time in direct patient care and 83% worked in private practice; 59% had cared for a patient with NSF. Although over 90% were aware of the morbidity and mortality associated with NSF, 31% were unaware of an association with specific GBCA brand and 50% believed chronic kidney disease stage 3 patients were at risk to develop NSF. Changes in facility policies concerning GBCA use in renal dysfunction were widespread (>90%). Most nephrologists (56%) felt that enacted policies were appropriate, yet 58% were uncertain if the changes had benefited patients. Conclusions: These results indicate that nephrologists are generally familiar with the risk factors and consequences of NSF, but their perceptions do not always align with current evidence. Local policy changes in GBCA use are pervasive. Most nephrologists are comfortable with these policy changes but have mixed feelings regarding their effectiveness.

The 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections provided a unique forum to assess opinions regarding current infection control controversies. The “Reality Check” sessions were a special portion of the conference where attendees expressed their opinions on these issues and heard varying viewpoints from noted experts. Using an Audience Response System (ARS), individual audience members cast their votes during seven different sessions. Although systems such as the ARS have been used during other conferences, there are no published accounts to date describing audience viewpoints on infection control topics. An overview of the “Reality Check” sessions follows.

Healthcare-associated infections are a major cause of morbidity and mortality. Dramatic changes in the delivery of healthcare during the past decade have changed the definition of healthcare-associated infections. Healthcare delivery changes include a reduction in the number of general hospital beds, an increase in the proportion of patients who are in intensive care units, a larger proportion of surgical procedures performed as outpatient procedures, a marked increase in patients cared for in outpatient settings, and an increase in the delivery of healthcare in the home setting. These changes have blurred the border between hospital- and community-acquired infections, increased the challenge of controlling transmission of antimicrobial-resistant pathogens, and complicated clinicians' treatment decisions. Data from the National Nosocomial Infections Surveillance system show that between the periods of 1993-1997 and 1998, infections caused by vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative staphylococci, and imipenem- or quinolone-resistant Pseudomonas aeruginosa have significantly increased. In addition, we have witnessed the emergence of vancomycin-intermediate resistant S aureus and the community transmission of MRSA. If we are to turn the tide on the continued emergence of antimicrobial-resistant pathogens, we will need to enhance and expand our infection control programs in all settings in which healthcare is provided and improve the appropriateness of antimicrobial use.

Objective.To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistantStaphylococcus aureus(MRSA) prevention program.Design.Before-after intervention studySetting.An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospitalPatients.Allpatientsadmittedtothe study unitsIntervention.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.Results.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).Conclusions.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.

Background To reduce the incidence of phlebotomy-related percutaneous injuries (PIs), factors that contribute to these injuries must be identified. This study examined institutional phlebotomy practices, policies, perceptions, and culture to identify facilitators and barriers that appear to have the greatest impact in preventing injuries. Methods During site visits at study hospitals, observational data were collected during the performance of phlebotomy. In addition, interviews and focus groups were conducted with hospital personnel involved in phlebotomy procedures. Results Nine hospitals participated in the study. A total of 126 phlebotomy procedures were observed. Health care personnel chose devices with safety features for the majority of observed procedures (n = 122, 97%). Recommended phlebotomy practices for handling needles after use were observed in 42% to 92% of procedures. Adherence varied by type of device, occupation, and facility PI rate. In the 23 interviews and 9 focus groups, participants identified factors that facilitated PI prevention such as the availability and use of devices with safety mechanisms, adherence to recommended safe needle-handling practices, and institutional phlebotomy training. Conclusion The quantitative and qualitative data indicate that a wide array of factors can affect phlebotomy-related practices and perceptions. Prevention of PIs may require comprehensive, multifaceted intervention efforts to improve the safety culture and reduce PIs and exposure to bloodborne pathogens in health care facilities.

To guide development of infection control education, we conducted a pilot needs assessment to determine current infection control knowledge, identify potential gaps between knowledge and practice, and identify perceived training needs among a varied group of health care personnel. A total of 23 health care personnel from various disciplines and health care settings completed the self-administered Web-based survey. Differences in knowledge and self-identified training needs were found among disciplines. Future research may well focus on further exploring specific needs of different disciplines. These results will be used to inform topics to cover in infection control curricula for clinicians, public health professionals, and allied health personnel.