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Sanjay Saint

Publications and source records attributed to Sanjay Saint.

At least 73 records · Page 4Linked to original sources
PubMed2004

The use of systematic reviews and meta-analyses in infection control and hospital epidemiology.

Systematic review is a type of research that attempts to identify and summarize all of the evidence related to a specific research question. It can be thought of as a "pause" in the process of conducting research in a particular area, in which the following questions are asked: Based on all of the available evidence, what do we know about this specific question so far, and what future studies should be conducted to clarify areas of uncertainty? The systematic review arose as an alternative to the traditional narrative review-which allows authors to pick and choose the studies they discuss and the depth at which they discuss them-a process prone to bias. By adhering to a prospectively defined protocol that specifies how studies should be identified, evaluated, and statistically combined (the statistical process is a component of systematic review and is called "meta-analysis"), systematic reviews reduce the bias inherent to traditional narrative reviews. Systematic reviews are an increasingly common form of published research, and several of the approximately 1000 such studies that are published annually focus on topics important to infection control professionals. Consequently, it is essential that infection control professionals and hospital epidemiologists be able to understand and evaluate the quality of this useful research design. This article discusses the essential elements of a systematic review, provides a framework for evaluating the quality of such an article, and will help the infection control professional and hospital epidemiologist in determining whether the results of such reviews should change clinical practice.

Cross Infection↗
PubMed2004

Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review.

BACKGROUND: Catheter-related infections cause increased morbidity, mortality, and health care costs. Infection control experts advocate using maximal sterile barriers to reduce the incidence of these infections. Low compliance rates suggest that clinicians are not convinced or are not aware that available data support adopting this more cumbersome, time-consuming, and relatively more expensive technique. Accordingly, we conducted a systematic, evidence-based review of the medical literature to determine the value of maximal sterile barriers. DATA SOURCES: We used multiple computerized databases, reference lists of identified articles, and queries of prominent investigators. STUDY SELECTION: We selected studies comparing infectious outcomes using maximal sterile barriers versus using less stringent sterile barrier techniques during central venous catheter insertion. DATA SYNTHESIS: We found only 3 primary research studies. Although each study suggests maximal sterile barriers may reduce infectious complications, the evidence supporting this conclusion is incomplete. The only randomized controlled trial limited enrollment to ambulatory oncology patients. These 3 studies differed notably in their patient populations, research designs, and health care settings. CONCLUSION: The medical literature suggests maximal sterile barriers are advantageous in at least one setting and may be useful in others. While we believe the available evidence does support the use of maximal sterile barriers during routine insertion of central venous catheters, prospective studies and economic analyses would better clarify its value.

Bacteremia↗
PubMed2004

What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?

OBJECTIVE: To examine the effects of internal medicine specialty and physician experience on inpatient resource use and clinical outcomes on an academic general medicine service. DESIGN: A 1-year retrospective cohort study. SETTING: The University of Michigan Hospitals, Ann Arbor, Michigan. PATIENTS: Two thousand six hundred seventeen admissions to the general medicine service from July 2001 to June 2002, excluding those for whom data were incomplete (n = 18). MEASUREMENTS AND MAIN RESULTS: Length of stay (LOS) and total hospital costs were used to measure resource utilization. Hospital mortality and 14-day and 30-day readmission rates were used to measure clinical outcomes. Adjusted mean LOS was significantly greater for rheumatologists (0.56 days greater; P =.002) and endocrinologists (0.38 days greater; P =.03) compared to general internists. Total costs were lower for general internists compared to endocrinologists ($1100 lower; P =.01) and rheumatologists ($431 lower; P =.07). Hospitalists showed a trend toward reduced LOS compared to all other physicians (0.31 days lower; P =.06). The top two deciles of physicians stratified by recent inpatient general medical experience showed significantly reduced LOS compared to all other physicians (0.35 days lower; P =.04). No significant differences were seen in readmission rates or in-hospital mortality among the various physician groups. CONCLUSIONS: General internists had lower lengths of stay and costs compared to endocrinologists and rheumatologists. Hospitalists showed a trend toward reduced LOS compared to all other physicians. Recent inpatient general medicine experience appears to be a determinant of reduced inpatient resource use.

Academic Medical Centers↗
PubMed2003

Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine.

The use of chlorhexidine gluconate solution for vascular catheter insertion site care reduces the risk of catheter-related bloodstream infection by one-half, compared with povidone iodine. Our objective was to evaluate the cost-effectiveness of chlorhexidine gluconate versus povidone iodine. We used data from randomized, controlled trials, meta-analyses, and epidemiologic studies to construct a decision analysis model. We estimated that use of chlorhexidine, rather than povidone, for central catheter site care resulted in a 1.6% decrease in the incidence of catheter-related bloodstream infection, a 0.23% decrease in the incidence of death, and savings of 113 dollars per catheter used. For peripheral catheter site care, the results were similar, although the differences were smaller. The results were found to be robust on multivariate sensitivity analyses. Use of chlorhexidine gluconate in place of the current standard solution for vascular catheter site care is a simple and cost-effective method of improving patient safety in the hospital setting.

Anti-Infective Agents, Local↗
PubMed2003

Prevention of ventilator-associated pneumonia: an evidence-based systematic review.

BACKGROUND: Ventilator-associated pneumonia is a common cause of morbidity in critically ill patients. Interventions beneficial to the prevention of ventilator-associated pneumonia would therefore have a significant impact on the care of these patients. PURPOSE: To perform a literature review and synthesis of methods for prevention of ventilator-associated pneumonia. DATA SOURCES: MEDLINE (1966-2001), the Cochrane Library, and bibliographies of retrieved articles. STUDY SELECTION: Studies were required to be prospective and controlled in design and to evaluate clinically important or surrogate outcomes. Surrogate outcomes were required to have a direct link to clinically important outcomes supported by the literature. DATA EXTRACTION: Data on patients, definitions, study design, and outcomes were abstracted and graded by using preestablished criteria. DATA SYNTHESIS: The preventive practices with the strongest supportive evidence were semi-recumbent positioning, sucralfate instead of H2-antagonists for stress ulcer prophylaxis, and selective digestive tract decontamination. Aspiration of subglottic secretions and oscillating beds may be useful in select populations. There is no evidence to support specific methods of enteral feeding or increased frequency of ventilator circuitry changes. CONCLUSIONS: After evaluation of potential benefits and risks, the authors recommend considering several specific interventions to reduce the incidence of ventilator-associated pneumonia: semi-recumbent positioning in all eligible patients, sucralfate rather than H2-antagonists in patients at low to moderate risk for gastrointestinal tract bleeding, and aspiration of subglottic secretions and oscillating beds in select patient populations. Selective digestive tract decontamination is not recommended because routine use may increase antimicrobial resistance.

Anti-Bacterial Agents↗
PubMed2003

Do physicians examine patients in contact isolation less frequently? A brief report.

BACKGROUND: Patients who are hospitalized and infected with multidrug-resistant bacteria are usually placed in contact isolation, which requires hospital personnel to gown and glove before patient examination. Contact isolation with active culture surveillance appears beneficial in preventing the spread of drug-resistant infections; however, contact isolation may impede the ability to examine patients as a result of the additional effort required to gown and glove. We assessed whether patients who are hospitalized and placed under contact precautions are examined less often by second- and third-year medical residents (ie, senior medical residents), and attending physicians during morning rounds. METHOD: We conducted a prospective cohort study on the inpatient medical services at 2 university-affiliated medical centers. We directly observed senior medical residents and attending physicians during morning rounds, and recorded the contact precaution status of the patient and whether they were examined by either physician. RESULTS: Of a total of 139 patients, 31 (22%) were in contact isolation. Senior medical residents examined 26 of 31 patients (84%) in contact isolation versus 94 of 108 patients (87%) not in contact isolation (relative risk, 0.96; 95% confidence interval, 0.81-1.14; P =.58). In comparison, attending physicians examined 11 of 31 patients (35%) in contact isolation versus 79 of 108 patients (73%) not in contact isolation (relative risk, 0.49; 95% confidence interval, 0.30-0.79; P <.001). DISCUSSION: Attending physicians are about half as likely to examine patients in contact isolation compared with patients not in contact isolation.

Academic Medical Centers↗
PubMed2003

Biofilms and catheter-associated urinary tract infections.

Urinary catheter-related infections are commonly seen in several different patient populations and lead to substantial morbidity. The overall health care costs caused by these infections are sizable given how often urinary catheters are used in acute care settings, extended care facilities, and in persons with injured spinal cords. Recent attention has appropriately focused on biofilm development on the catheter surface because biofilm has important implications for the pathogenesis, treatment, and prevention of catheter-related infection. Because the most important risk factor for infection is duration of catheterization, indwelling urethral catheterization should be avoided or at least limited whenever possible. Additional methods to prevent this infection include aseptic insertion and maintenance use of a closed drainage system, anti-infective catheters in patients at high-risk for infection, and systemic antibiotics in select patients. Alternative urinary collection strategies may be appropriate in certain patient groups. Specifically, condom catheters should be considered in men likely to be adherent with this urinary collection method, suprapubic catheters should be considered in patients requiring long-term indwelling drainage, and intermittent catheterization seems appropriate in patients with injured spinal cords. Future research should focus on additional methods for preventing this common infection.

Biofilms↗
PubMed2003

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

BACKGROUND: Mandatory disclosure of medical errors has been advocated to improve patient safety. Many resist mandatory disclosure policies because of concerns about increasing malpractice exposure. It has been countered that malpractice liability actually decreases when there is full disclosure of medical errors. A comprehensive literature search was conducted to determine what is known about the impact of full disclosure on malpractice liability. METHODS: Electronic searches of multiple databases were supplemented with hand searches of bibliographies and communication with recognized experts in the field. RESULTS: Screening the titles, abstracts, and, in many cases, the full articles from more than an estimated 5,200 citations resulted in identification of one published study directly examining malpractice liability when a policy of full disclosure was implemented. DISCUSSION: Despite extensive literature on the impact of disclosure on malpractice liability, few well-designed studies have focused on the real-world impact on the volume and cost of suits following implementation of a full disclosure policy. Many articles examine why patients sue their doctors, suggesting that some lawsuits may be averted by disclosure, but the articles do not allow us to estimate the additional suits that would be created by disclosure. Additional studies addressing the effect of disclosure on malpractice liability are needed.

Compensation and Redress↗
PubMed2003

What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?

OBJECTIVE: Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, "Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?" DESIGN/PARTICIPANTS: The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association's Masterfile were surveyed (adjusted response rate = 52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N = 339). MEASUREMENTS AND MAIN RESULTS: We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout. CONCLUSIONS: Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.

Adult↗
PubMed2003

The optimal use of diagnostic testing in women with acute uncomplicated cystitis.

Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician's responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with >or=1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.

Acute Disease↗
PubMed2003

Which antimicrobial impregnated central venous catheter should we use? Modeling the costs and outcomes of antimicrobial catheter use.

BACKGROUND: Catheter-related bloodstream infections are costly and associated with substantial morbidity and mortality. Trials suggest that central venous catheters impregnated with minocycline/rifampin, although more expensive, are clinically superior to chlorhexidine/silver sulfadiazine impregnated catheters. It remains unclear whether minocycline/rifampin catheters are cost-effective for all high-risk patients or only those requiring longer-term catheterization. METHODS: We developed a series of decision models with patient-level clinical trial data to determine whether minocycline/rifampin catheters are cost-effective for patients requiring various durations of catheterization. We calculated incremental cost-effectiveness ratios for patients catheterized for durations ranging from 1 to 25 days. RESULTS: The data were too sparse to estimate cost-effectiveness for patients catheterized less than 8 days. The probability that minocycline/rifampin catheters were cost-effective compared with chlorhexidine/silver sulfadiazine catheters in patients catheterized for 8 days was 91%. The probability that the minocycline/rifampin catheters in patients catheterized 13 days or longer resulted in cost savings was more than 95%. CONCLUSIONS: Our analysis suggests that central venous catheters coated with minocycline/rifampin are cost-effective for patients catheterized for at least 1 week and lead to overall cost savings when patients are catheterized for 2 weeks or longer. Policies for the use of antimicrobial catheters in high-risk patients should reflect patients' expected duration of catheterization.

Anti-Infective Agents↗
PubMed2003

Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis.

OBJECTIVE: Since the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters. DATA SOURCE: Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents. DATA ABSTRACTION: Two independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality. DATA SYNTHESIS: A total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00-4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92-3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50-3.41). CONCLUSIONS: Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

Bacteremia↗