The vicissitudes of prospective multihospital surveillance studies: the Israeli Study of Surgical Infections.
Explore the source record for details and available documents.
Cross-Sectional Studies↗
Biomedical subjects
R W Haley
Publications and source records attributed to R W Haley.
The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system. An empirical determination from a nationally representative sample.
To clarify the financial incentives for hospitals to prevent nosocomial infections, we analyzed 9423 nosocomial infections identified in 169 526 admissions selected randomly from the adult admissions to a random sample of US hospitals. By classifying each admission into a baseline diagnosis related group (DRG) (after first excluding all diagnoses of nosocomial infection) and a final DRG (after including these diagnoses), we found that only 5% to 18% of nosocomial infections would have caused the admission to be reclassified to a higher-paying DRG, depending on the extent to which physicians recorded nosocomial infection diagnoses in patients' medical records. The extra payment from the reclassification, averaged over all nosocomial infections, would have been no more than $93 per infection (in 1985 reimbursement rates), constituting only 5% of the hospitals' costs for treating these infections. Thus, at least 95% of the cost savings obtained from preventing nosocomial infections represents financial gains to the hospital.
Adult↗
Fever in hospitalized patients. With special reference to the medical service.
Fever (oral temperature of 38 degrees C or more on two or more consecutive days) during the hospital stay of 4,065 patients admitted to Grady Memorial Hospital during an 11-week period was studied. At least one episode of fever occurred in 1,194 patients (29 percent). Rates of fever were highest on medical and surgical services. Review of 341 episodes of fever in 302 patients on the medical service identified a single potential cause in 56 percent. Multiple factors were present in 26 percent, and no potential causes were found in 18 percent. Of 390 factors identified, 44 percent were community-acquired infections, 9 percent were nosocomial infections, 20 percent possibly involved infection, and 26 percent were noninfectious processes. Fever is a frequent finding in hospitalized patients. Both infectious and noninfectious processes play important roles. Determining the cause of fever is complicated by the multiplicity of possible causes.
Cross Infection↗
Factors which influence the risk of wound infection in trauma patients.
Surgical wound infections following traumatic injury remain a source of morbidity and mortality. A simple system for estimating the risk of infectious complications was evaluated in 949 trauma patients requiring operative therapy. The majority of cases were caused by penetrating trauma (784). Truncal, neck, and extremity procedures were included. The overall wound infection rate was 7%. Infection rates were related to amount of bacterial contamination and mechanism of injury. Age, type of antibiotics, and delay time from injury to operation were not risk factors for any injury type. Wound classification, shock, blood loss, number of organs injured, and operative time were significant risk factors, but had different effects on infection rate related to injury type. Multivariate analysis revealed no significant infectious risk factors for stabwounds. Significant factors were wound class (p = 0.02) and shock (p = 0.001) for gunshot wounds, wound class (p = 0.03) and number of organs injured (p = 0.01) for blunt trauma, and blood loss (p = 0.01) for shotgun wounds. This classification system can be used to review outcome and compare trauma patient populations for infectious morbidity in a more uniform fashion.
Adult↗
Surveillance by objective: a new priority-directed approach to the control of nosocomial infections. The National Foundation for Infectious Diseases lecture.
Explore the source record for details and available documents.
Cross Infection↗
Update from the SENIC project. Hospital infection control: recent progress and opportunities under prospective payment.
From a survey of all U.S. hospitals in 1976 and of a random sample in 1983, we found that the intensity of infection surveillance and control activities greatly increased, and the percentage of hospitals with an infection control nurse per 250 beds increased from 22% to 57%. The percentage with a physician trained in infection control remained low (15%), and there was a drop in the percentages of hospitals doing surgical wound infection surveillance (from 90% down to 79%) and reporting surgeon-specific rates to surgeons (from 19% down to 13%). There was an increase in the percentage of hospitals with programs shown to be effective in preventing urinary tract infections, bacteremias, and pneumonias, but not surgical wound infections. The percentage of nosocomial infections being prevented nationwide appears to have increased from 6% to only 9%, whereas 32% could be prevented if all hospitals adopted the most effective programs.
Cross Infection↗
How frequent are outbreaks of nosocomial infection in community hospitals?
A statistical algorithm was used to identify potentially important clusters among nosocomial infections reported each month by 7 community hospitals. Epidemiologic review and on-site investigations distinguished outbreaks of clinical disease from factitious clusters. In 1 year, 8 outbreaks were confirmed. They involved 82 patients--approximately 2% of patients with nosocomial infections and 0.09% of all discharges. One true outbreak occurred for every 12,000 discharges--at least 1 outbreak per year for the average community hospital. Five (63%) outbreaks were recognized independently by the hospitals' infection control personnel. Four (50%) resolved spontaneously; the hospitals' own control measures were necessary in 2; and 2 resolved only after an outside investigation. Organized surveillance appears necessary to detect some outbreaks, and control measures are needed to stop many. Since, however, outbreaks account for such a small proportion of nosocomial infections, infection control programs should be sufficiently staffed and managed so that most of the effort is directed toward the surveillance and control of endemic infection problems, but with adequate resources remaining to respond to outbreaks when they occur.
Cross Infection↗
The nationwide nosocomial infection rate. A new need for vital statistics.
From a random sample of patients and hospitals and extrapolation ratios derived from the best available sources of data, the authors estimate that the nationwide nosocomial infection rate among the 6,449 acute-care US hospitals in 1975-1976 was 5.7 nosocomial infections per 100 admissions and that over 2 million nosocomial infections occurred in a 12-month period in these hospitals. Nosocomial urinary tract infections constituted 42% of the infections, surgical wound infections 24%, nosocomial pneumonia 10%, nosocomial bacteremia 5%, and nosocomial infections at all other sites 19%. If adjustments are made for the accuracy of the diagnostic method, the increasing nationwide secular trend, and the number of nosocomial infections in nursing homes, however, as many as 4 million nosocomial infections per year may now be occurring. This greatly exceeds previous estimates and calls for timely and accurate vital statistics on the problem.
Adult↗
Increased recognition of infectious diseases in US hospitals through increased use of diagnostic tests, 1970-1976.
To assess the influence of physicians' diagnostic practices on the recognition of nosocomial infections, the authors analyzed data collected on 339,044 patients selected randomly from admissions in 1970 and 1975-1976 to 338 randomly selected hospitals representative of all acute-care US hospitals. Eight rates representing the frequency of cultures or chest x-rays among patients with or without signs of infection were calculated. These varied widely among hospitals, were highest in teaching hospitals and in the Northeast, but increased more among small hospitals and in the South and West. Rates of performing urine cultures and reporting colony counts were highly correlated with observed rates of nosocomial urinary tract infection. Analogous measures were moderately correlated with observed bacteremia rates and pneumonia rates but were only weakly associated with surgical wound infection rates. These data indicate that the nationwide increase in the use of these diagnostic tests increased the recognition of infectious diseases in US hospitals.
Cost Control↗
The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
In a representative sample of US general hospitals, the authors found that the establishment of intensive infection surveillance and control programs was strongly associated with reductions in rates of nosocomial urinary tract infection, surgical wound infection, pneumonia, and bacteremia between 1970 and 1975-1976, after controlling for other characteristics of the hospitals and their patients. Essential components of effective programs included conducting organized surveillance and control activities and having a trained, effectual infection control physician, an infection control nurse per 250 beds, and a system for reporting infection rates to practicing surgeons. Programs with these components reduced their hospitals' infection rates by 32%. Since relatively few hospitals had very effective programs, however, only 6% of the nation's approximately 2 million nosocomial infections were being prevented in the mid-1970s, leaving another 26% to be prevented by universal adoption of these programs. Among hospitals without effective programs, the overall infection rate increased by 18% from 1970 to 1976.
Adult↗
Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination.
To predict the likelihood that a patient will develop a surgical wound infection from several risk factors, the authors used information collected on 58,498 patients undergoing operations in 1970 to develop a simple multivariate risk index. Analyzing 10 risk factors with stepwise multiple logistic regression techniques, they developed a model combining information on four of the risk factors to predict a patient's probability of getting a surgical wound infection. Then, with information collected on another sample of 59,352 surgical patients admitted in 1975-1976, the validity of this index as a predictor of surgical wound infection risk was verified. With the simplified index, a subgroup, consisting of half the surgical patients, can be identified in whom 90% of the surgical wound infections will develop. By the inclusion of factors measuring the risk due to the patient's susceptibility as well as that due to the level of wound contamination, the simplified index predicts surgical wound infection risk about twice as well as the traditional classification of wound contamination (Goodman-Kruskal G = 0.67 vs. 0.36, p less than 0.0001). Use of this new index might substantially increase the efficiency of routine surgical wound infection surveillance and control.
Abdomen↗
A new approach to the isolation of hospitalized patients with infectious diseases: alternative systems.
A new guideline developed by the Centers for Disease Control suggests that hospitals adopt one of two alternative isolation systems: the category system or the disease-specific system. The older category system has been modified to reflect current knowledge; for example, the category of protective isolation has been deleted, new categories for contact precautions and tuberculosis precautions have been added, the specific precautions indicated in the other categories have been substantially modified, and many infections have been assigned to new categories. The disease-specific system, a newly developed approach, lists the specific isolation precautions indicated for each infectious disease. Whereas the revised category system offers greater simplicity in practice, the disease-specific system minimizes unnecessary precautions. Both systems allow patient-care personnel more decision-making authority in determining which precautions to apply.
Centers for Disease Control and Prevention, U.S.↗
Benzyl alcohol poisoning.
Explore the source record for details and available documents.
Benzyl Alcohol↗
Comparison of surveillance and control activities of infection control nurses and infection control laboratorians in United States hospitals, 1976-1977.
To study the impact of the professional background of infection control personnel, we compared the characteristics and activities of 107 infection control nurses (ICNs) with those of 13 infection control laboratorians (ICLs), all in hospitals with 300 beds or more. Although the two groups performed similarly in many respects. ICNs spent more time teaching, whereas ICLs spent more time and appeared more proficient in investigating outbreaks. Staff nurses at hospitals with ICNs found the infection control person more visible on the wards and more available for discussing infection control matters. ICNs appeared less hesitant to speak up to personnel not following correct handwashing techniques. ICNs and ICLs appear to offer different skills that should be considered when filling different infection control positions.
Analysis of Variance↗
The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit.
Understaffing and overcrowding in the neonatal nursery are thought to contribute to the spread of infectious diseases among neonates, although little scientific documentation exists to support the view. In the present investigation of recurring epidemics in one nursery, the incidence rate of clustered staphylococcal infection was 16 times higher after periods when the infant:nurse ratio exceeded 7, seven times higher after periods when the infant census exceeded 33, three times higher in the summer months, and 1.5 times higher in the absence of bathing with hexachlorophene. All four factors were significantly associated with infection in a multivariate statistical model which predicted the occurrence of infection well (goodness-of-fit chi 2 = 6.08; df = 9; P = 0.73). These results support the contention that staphylococcal outbreaks periodically resulted when, in the presence of overcrowding, serious understaffing made frequent handwashing between infant contacts difficult. Elimination of these problems appears to be important in reducing cross infection in the nursery.
Baths↗
The emergence of methicillin-resistant Staphylococcus aureus infections in United States hospitals. Possible role of the house staff-patient transfer circuit.
Infections with methicillin-resistant strains of Staphylococcus aureus appear to be occurring with increasing frequency in some U.S. hospitals about a decade after a similar increase in Britain and other countries. In the United States, clustered methicillin-resistant S. aureus infections reported in scientific journals and in three hospital surveys have been almost entirely in large, tertiary referral hospitals affiliated with medical schools. Among 63 hospitals regularly reporting infections from 1974 to 1981 in the National Nosocomial Infections Study, the increase in methicillin-resistant S. aureus infections was entirely due to substantial increases in only four hospitals, all of which were large, tertiary referral centers affiliated with medical schools. The predominance of methicillin-resistant S. aureus infections in these large hospitals may be due to the large numbers of patients at high risk of infection and to the interhospital spread of the organism by the transfer of infected patients and house staff from similar hospitals or from nursing homes.
Cross Infection↗
Operating room practices for the control of infection in U. S. hospitals, October 1976 to July 1977.
We estimated the frequency of selected infection control practices in the operating room from a nationwide survey of hospitals. Our survey confirmed that, in many hospitals, practices which have not received scientific or budgetary scrutiny have become part of the perioperative routine. Almost half of the hospitals reported using nonrecommended tacky, or disinfectant, mats at the entrance to operating rooms, and more than three-fourths were performing nonrecommended environmental cultures in the operating room at a cost ranging from $2,000 to $20,000 per year. When routine nose and throat cultures were taken of operating room personnel, we found an obvious pecking order, rather than a scientific rationale for culturing. In almost all instances, we found wide variations in practice among hospitals. This nonuniformity may be due to such factors as lack of a convincing scientific basis for evaluating the relative efficacy of alternative practices, the strong influence of industry marketing, the individual preferences of surgeons and operating room supervisors and the lack of completeness and agreement of statements from various scientific and professional organizations.
Bacteriological Techniques↗
The Employee Health Service and Infection Control in US hospitals, 1976-1977. II. Managing employee illness.
To assess the methods being used in US hospitals to prevent the spread of contagious illnesses from hospital employees to patients, we analyzed information obtained in the SENIC Project (Study on the Efficacy of Nosocomial Infection Control) from interviews with hospital officials and staff nurses. In general, staff nurses and their first-line supervisors appeared to be unfamiliar with some published recommendations outlining when an illness or exposure should exclude them temporarily from patient contact. The infection control nurse had authority to exclude employees in fewer than half of the hospitals. Although employees would be financially penalized in less than 10% of hospitals for missing work on account of a contagious illness, staff nurses in larger hospitals were more reluctant to consult the employee health service if they believed they would lose pay.
Absenteeism↗