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SURGICAL SUITES: Guidelines on best practices to prevent surgical site infections

The number of unresolved issues in this guideline reveals substantial gaps that warrant future research.” (page E6)

Best practices in avoiding surgical site infections were studied by the Centers for Disease Control and Prevention with the assistance of the Healthcare Infection Control Practices Advisory Committee.  This guideline is based on the full text review of nearly 900 journal articles and studies.  The guideline is organized according to specific surgical practices – for example the efficacy of wearing a space suit during orthopedic surgery – and assigns each practice a rating on a continuum as to whether the practice is highly recommended, unresolved, or somewhere in between.  The rating on the space suits, for instance, is that it is unresolved.

Source: Berrios-Torres, S.I., and others. (2017, May 3). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection 2017. JAMA Surgery. Click here: http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

MRSA: 1.2 percent of hospital stays in California (2013)

In 2013, there were over 3.1 million inpatient stays in California hospitals, according to the California State Inpatient Database – which includes information on patients of all ages.  This study examines characteristics of those patients who had a hospital stay associated with Methicillin-resistant Staphylococcus aureas (MRSA).  Here are some of the findings:

  • 1.2 percent of California hospital stays involved MRSA
  • 1 in 100 California hospital stays involved MRSA
  • Over 40 percent of the MRSA was associated with cellulitis or skin ulcers
  • Only 8 percent of hospitalized patients with MRSA acquired their MRSA in a hospital
  • Another 41.9 percent of hospitalized patient with MRSA acquired their MRSA in the community after contact with some type of health care facility

Source: Sutton, J.P., and Steiner, C.A. (2016, Oct.). Hospital-, health care-, and community-acquired MRSA: Estimates from California hospitals, 2013. Healthcare Cost and Utilization Project Statistical Brief, 212.  Click here: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb212-MRSA-Hospital-Stays-California-2013.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OBSTETRICS: 1 million deliveries in U.S. hospitals studied

Statistics on over one million deliveries at 355 U.S. hospitals in 2008 and 2009 were studied based on Premier, Inc.’s Perspective database.  This provides a fascinating large-scale look at the obstetrics population in the U.S.  Let’s take a look (I’ve rounded the following numbers off and combined some categories from those given in the original article.)

How old are maternity patients?

  • About half are in their 20s
  • About 10 percent are teenage mothers

What kind of insurance do they have?

  • 42 percent managed care
  • 42 percent Medicaid
  •   8 percent commercial – indemnity
  •   3 percent self pay
  •   6 percent other

How many patients…

  • Delivered by C-section this time? 39 percent
  • Have had a previous C-section?  18 percent
  • Are of advanced maternal age?  16 percent
  • Are delivering prematurely?  8 percent
  • Are obese?  4 percent

What was the median length of stay?

  • 2 days for vaginal delivery
  • 3 days for C-section

What was the hospital risk-adjusted infection rate?

  • 4.1 percent of all deliveries were complicated by infection

The authors found that “risk-adjusted infection rates following childbirth vary considerably across hospitals, and that key structural and organizational hospital features explain only a modest amount of this variation.”

Source: Goff, S.L., Pekow, P.S., and others. (2013, June). Patterns of obstetric infection rates in a large sample of U.S. hospitals. American Journal of Obstetrics & Gynecology, 208(6). Author manuscript free here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670964/pdf/nihms-443021.pdf  Posted by AHA Resource Center (312) 422.2050, rc@aha.org

INFECTION CONTROL: Staffing benchmarks per 100 beds

This was a study of data provided in 2011 by 975 U.S. hospitals participating in the National Healthcare Safety Network (NHSN).  The objective of this large-scale survey was to study the structure of the hospitals’ infection prevention and control programs.

Infection Preventionists (IP) Staffing Metrics

  • 1.2 infection preventionists / 100 hospital beds (average found in this study)
  • 1.0 infection preventionist / 250 hospital beds (had been recommended in a 1985 study)
  • 0.8 to 1.0 infection preventionist / 100 hospital beds (recommendations of a study published in 2002)

Use of Hospitalists and Intensivists (remember — this is as of 2011)

  • 84 percent of the nearly 1000 hospitals in this survey reported having hospitalists
  • 49 percent reported having intensivists

There are also two detailed Tables of data about the use of evidence-based infection control policies in the adult intensive care units of these hospitals.  For example, 100 percent of the 20 hospitals with burn units reported having a policy for maximal barrier precautions.

Source: Stone, P.W., Pogorzelska-Maziarz, M., and others. (2014, Feb.). State of infection prevention in US hospitals enrolled in NHSN. American Journal of Infection Control, 42(2), 94-99.  Retrieved from author manuscript http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951506/pdf/nihms540286.pdf  Posted by AHA Resource Center (312) 422-2003, rc@aha.org

HEALTH CARE ASSOCIATED INFECTIONS: Gowning and gloving needed for ALL ICU patients? Maybe not.

Whether the practice of gowning and gloving should be expanded beyond the current Centers for Disease Control recommendations to include staff caring for ALL patients in intensive care units was studied in this large-scale randomized trial.  The researchers collected data from 20 participating hospitals in 2012 to see if universal gowning and gloving would be found to reduce the acquisition of MRSA or VME (antibiotic-resistant infections).  There was no compelling statistical evidence that universal gowning and gloving should be used for all patients in ICUs to achieve this objective.

Source: Harris, A.D., Belton, B., and others.  Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.  JAMA, Oct. 4, 2013 [published online before print].  Click here for access to article: http://jama.jamanetwork.com/article.aspx?articleID=1746112&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst10%2F04%2F2013.  There is also an editorial and a video!  Posted by AHA Resource Center (312) 422-2050, rc@aha.org




HOSPITAL INFECTIONS: How many people enter the room?

The number of people who enter a patient’s hospital room, the length of time that  they are in the room, and what they touch when they are there were recorded in this observational study conducted in three hospitals.   Here are some of the findings (these are medians):

  • 5 room entries per hour (adult patients)
  • 8.5 room entries per hour (pediatric patients)
  • 3 to 3.5 different people entering the room per hour
  • 3 minutes spent in the room

There is also an interesting breakdown of what is touched in the room according to the type of person doing the touching — for example, nonclinical staff primarily touch the patient’s environment only.  Physicians are the most likely to touch nothing in the room.  The authors commented that the having numbers of people in and out of the patients’ rooms can have benefits for patients, in that patient needs can be more quickly identified, but that there is also the possibility that the patients may be at higher risk of contracting a health care-associated infection (HAI).

Source: Cohen, B., and others.  Frequency of patient contact with health care personnel and visitors: implications for infection prevention.  The Joint Commission Journal on Quality and Patient Safety;38(12):560-565, Dec. 2012.  Click here for text:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3531228/pdf/nihms421967.pdf  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Private rooms help reduce hospital acquired infections

The Canadian Standards Association has issued standards aligned with US recommendations in that new hospital construction should have single patient rooms.  In Canada, over half of hospital beds are in wards of four or more per room, and hospitals charge more for semiprivate or private rooms than for wards, a price differential that totals an estimated $200 million or more in Ontario alone.  An interesting observation, coming from Roger Ulrich, an international hospital design expert:

  • “…the operational costs of running a hospital for 30 years are at least 15 times higher than the initial capital costs.”

The arguments in favor of single patient rooms are summarized in this series of brief articles.  Among these are patient safety, patient preference (an estimated 90 percent of patients think that having other patients in the room is a significant source of stress), and the ability to run the hospital at a higher occupancy rate. 

Sources:  Stall, N.  Private rooms: a choice between infection and profit.  CMAJ. Canadian Medical Association Journal;184(1):24-25, Jan. 10, 2012.  Click here for full text: http://www.cmaj.ca/content/184/1/24.full.pdf ; Stall, N.  Private rooms: the fiscal advantage.  CMAJ. Canadian Medical Association Journal;184(1):E47-E48, Jan. 10, 2012.  Click here for full text: http://www.cmaj.ca/content/184/1/E47.full.pdf ; Stall, N.  Private rooms: evidence-based design in hospitals.  CMAJ. Canadian Medical Association Journal;184(2):162-163, Feb. 7, 2012. Click here for full text: http://www.cmaj.ca/content/184/2/162.full.pdf  Canadian Standards Association.  CSA Z8000: Canadian Health Care Facilities: Planning, Design and Construction, 2011.   A copy can be purchased here: http://shop.csa.ca/en/canada/landing-pages/z8000-canadian-health-care-facilities/page/z8000/  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org