National Healthcare Safety Network Hospitals Research Articles

Rates of urinary catheter-associated urinary tract infection in Saudi MOH hospitals: a 2-year multi-centre study

Background: The published rates of catheter-associated urinary tract infection (CAUTI) in Saudi Arabia were derived from single-centre studies or nationally non-representative studies. Objectives: The aim of this study was to estimate CAUTI rates and urinary catheter utilisation (UCU) ratios in 99 Saudi Ministry of Health (MOH) hospitals from all regions. Methods: A prospective surveillance study was conducted in 15 different types of intensive care units (ICUs) between January 2018 and December 2019. The data were entered into the Health Electronic Surveillance Network (HESN) programme. The methods of the US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) centre for infection control were used. Results: During 2 years of surveillance covering 919,615 patient-days and 573,720 urinary catheter days, a total of 965 CAUTI events were identified. The overall MOH CAUTI rate was 1.68 (95%confidence interval (CI) 1.58–1.79) per 1,000 urinary catheter days, and the overall UCU was 0.624 (95%CI 0.623–0.625). CAUTI rates were highest in paediatric medical (5.73) and adult medical (2.02) ICUs. UCU were highest in neurosurgical (0.795) and medical surgical (0.743) ICUs. CAUTI standardised infection ratios across different ICUs in Saudi MOH hospitals were 16% lower than NHSN hospitals, 47% lower than GCC hospitals and 69% lower than International Nosocomial Infection Control Consortium (INICC) hospitals. Urinary catheter standardised utilisation ratios across different ICUs in Saudi MOH hospitals were 15% higher than NHSN hospitals, 9% higher than INICC hospitals and 13% lower than GCC hospitals. Conclusions: The current study is a unique national CAUTI benchmark that can potentially help in the fight against healthcare-associated infection.

Rates of Ventilator Associated Pneumonia in Saudi Ministry of Health Hospitals; A Two-year Multi-Center Study

BACKGROUND: Although the rates of ventilator associated pneumonia (VAP) have been estimated in Saudi Arabia, however national surveillance data for VAP has never been reported earlier. OBJECTIVES: To estimate VAP rates and ventilator utilization ratios in 105 Ministry of health (MOH) hospitals and to benchmark them with International Standards. METHODS: It was a prospective surveillance study in 15 different types of intensive care units (ICUs) between January 2018 and December 2019. The data were entered into the health electronic surveillance network (HESN) program. The methods of US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) center for infection control were used. RESULTS: During two years of surveillance covering 1,469,658 patient-days and 569,961 ventilator-days, a total 1,694 VAP events were identified. The overall MOH VAP rate was 2.97 (95% confidence 2.83-3.11) per 1000 ventilator-days and the overall ventilator utilization ratio was 0.39 (95% confidence 0.387- 0.389). VAP rates were highest in adult medical (4.40), pediatric cardiothoracic (3.64), and adult medical surgical ICUs (3.61). VAP standardized infection ratio across all types of ICUs in MOH hospitals were 29% lower than GCC hospitals, 78% lower than International Nosocomial Infection Control Consortium (INICC) hospitals, and 191% higher than NHSN hospitals. Ventilator standardized utilization ratio in all types of ICUs in MOH hospitals were 19% lower than GCC hospitals, 32% higher than INICC hospitals, and 50% higher than NHSN hospitals. CONCLUSIONS: Using huge standardized data, the current report can serve as a unique national VAP benchmark, fostering a culture of competitiveness between the hospitals and regions.

Burden of central-line-associated bloodstream infections in 106 Ministry of Health hospitals of Saudi Arabia: a 2-year surveillance study

Background: Although the Saudi Ministry of Health (MOH) is managing the majority of inpatient bed capacity in Saudi Arabia, surveillance data for central-line-associated bloodstream infections (CLABSI) have never been reported at a national level. Objectives: To estimate unit-specific CLABSI rates along with central line utilization ratios in MOH hospitals. Additionally, to benchmark such rates and ratios with recognized regional and international benchmarks. Methods: A prospective surveillance study was conducted in 106 MOH hospitals between January 2018 and December 2019. The data from 14 different types of intensive care units (ICUs) were entered into the Health Electronic Surveillance Network (HESN) program. The surveillance methodology was similar to the methods of the US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) Center for Infection Control. Results: During the 2 years of surveillance in ICU setting covering 1,475,177 patient-days and 475,913 central line-days, a total of 1,542 CLABSI events were identified. The overall CLABSI rate was 3.24 (95% confidence interval [CI], 3.08–3.40) per 1,000 central line-days, and the overall central line utilization ratio was 0.32 (95% CI, 0.322–0.323). CLABSI-standardized infection ratios in HESN hospitals were very similar (1.01) to GCC hospitals, but 3.2 times higher than NHSN hospitals and 36% lower than International Nosocomial Infection Control Consortium (INICC) hospitals. Central-line-standardized utilization ratio in MOH hospitals was 15–30% lower than the three benchmarks. Conclusions: The overall CLABSI rate was 3.24 per 1,000 central line-days, and the overall central line utilization ratio was 0.32. MOH CLABSI rates were very similar to GCC hospitals, but higher than NHSN hospitals and lower than INICC hospitals. MOH central line utilization is slightly lower than the three benchmarks.

Rates of central line-associated bloodstream infection in tertiary care hospitals in 3 Arabian gulf countries: 6-year surveillance study.

The objective of this study was to compare central line-associated bloodstream infection (CLABSI) rates in Gulf Cooperation Council (GCC) states with those of the U.S. National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC) using pooled data from 6 hospitals in 3 GCC countries. The overall CLABSI rate was 3.1 per 1,000 central line days. After adjusting for differences in intensive care unit types, the risk of CLABSI in GCC hospitals was 146% higher than NHSN hospitals but 33% lower than INICC hospitals.

Validation of NHSN Annual Hospital Survey Questions: Do Responses Differ Depending on the Professional Completing the Survey?

BackgroundFacilities enrolled in the National Healthcare Safety Network (NHSN) provide annual information on their antibiotic stewardship programs (ASPs) via a mandatory survey. The survey contains 12 questions that explore uptake of CDC’s Core Elements for Hospital ASPs. Respondents (typically Infection Preventionists) are advised to seek input from pharmacist and physician ASP champions, but the professional completing the survey and the extent of input provided by ASP program personnel are unknown. A separate survey provided an opportunity to assess ASP responses reported to NHSN.MethodsIndividuals from 446 academic and community hospitals participating in the Vizient list-serve were surveyed in March 2016. The Vizient survey included the 12 ASP questions in the 2015 NHSN survey. Vizient responses were compared with NHSN survey responses to assess differences in reported uptake of core elements based on the professional completing the survey.Results189 of the 211 hospitals completing the Vizient survey were successfully matched to NHSN hospitals. The majority of respondents were pharmacists; 83% were either Directors of Pharmacy or clinical pharmacists of which 48% and 61% reported assisting with the NHSN survey, respectively. Reported implementation of all 7 elements in this subset of 189 hospitals was 58.2% in the Vizient survey compared with 54.5% in NHSN. Results differed by respondent position and core element surveyed. Clinical pharmacists in the Vizient survey reported higher rates of core element adherence than Directors of Pharmacy (Figure 1). The position of survey respondents varied by hospital size. Of hospitals with less than 250 beds, 87.5% of surveys were completed by Directors of Pharmacy, whereas 77.1% of surveys were completed by clinical pharmacists in hospitals with ≥250 beds.ConclusionOverall similarities between NHSN and Vizient survey results indicate that ASP questions based on CDC’s Core Elements are interpreted in similar ways and answered consistently when analyzed overall. However, individual core element responses may differ based on position of respondent, ASP familiarity, ASP infrastructure, and/or hospital bed size. CDC is exploring improved wording of the survey questions to help further improve consistency in responses.Disclosures All authors: No reported disclosures.

Ventilator-associated pneumonia rates in critical care units in 3 Arabian Gulf countries: A 6-year surveillance study

Data estimating the rates of ventilator-associated pneumonia (VAP) in critical patients in Gulf Cooperation Council (GCC) countries are very limited. The aim of this study was to estimate VAP rates in GCC hospitals and to compare rates with published reports of the U.S. National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC). VAP rates and ventilator utilization between 2008 and 2013 were calculated from aggregate VAP surveillance data using NHSN methodology pooled from 6 hospitals in 3 GCC countries: Saudi Arabia, Oman, and Bahrain. The standardized infection ratios of VAP in GCC hospitals were compared with published reports of the NHSN and INICC. A total of 368 VAP events were diagnosed during a 6-year period covering 76,749 ventilator days and 134,994 patient days. The overall VAP rate was 4.8 per 1,000 ventilator days (95% confidence interval, 4.3-5.3), with an overall ventilator utilization of 0.57. The VAP rates showed a wide variability between different types of intensive care units (ICUs) and were decreasing over time. After adjusting for the differences in ICU type, the risk of VAP in GCC hospitals was 217% higher than NHSN hospitals and 69% lower than INICC hospitals. The risk of VAP in ICU patients in GCC countries is higher than pooled U.S. VAP rates but lower than pooled rates from developing countries participating in the INICC.

Central line–associated blood stream infections in pediatric intensive care units: Longitudinal trends and compliance with bundle strategies

Knowing the temporal trend central line-associated bloodstream infection (CLABSI) rates among U.S. pediatric intensive care units (PICUs), the current extent of central line bundle compliance, and the impact of compliance on rates is necessary to understand what has been accomplished and can be improved in CLABSI prevention. This is a longitudinal study of PICUs in National Healthcare Safety Network hospitals and a cross-sectional survey of directors and managers of infection prevention and control departments regarding PICU CLABSI prevention practices, including self-reported compliance with elements of central line bundles. Associations between 2011-2012 PICU CLABSI rates and infection prevention practices were examined. Reported CLABSI rates decreased during the study period, from 5.8 per 1,000 line days in 2006 to 1.4 in 2011-2012 (P<.001). Although 73% of PICUs had policies for all central line prevention practices, only 35% of those with policies reported ≥95% compliance. PICUs with ≥95% compliance with central line infection prevention policies had lower reported CLABSI rates, but this association was statistically insignificant. There was a nonsignificant trend in decreasing CLABSI rates as PICUs improved bundle policy compliance. Given that few PICUs reported full compliance with these policies, PICUs increasing their efforts to comply with these policies may help reduce CLABSI rates.

Activity of Commonly Used Antimicrobial Prophylaxis Regimens against Pathogens Causing Coronary Artery Bypass Graft and Arthroplasty Surgical Site Infections in the United States, 2006–2009

Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens. Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime), β-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity. There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitive Staphylococcus aureus (23%), methicillin-resistant S. aureus (18%), coagulase-negative staphylococci (17%), and Enterococcus species (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures), β-lactam (12%), and extended-spectrum (8%) regimens was 41%-45%, 47%-96%, and 81%-96%, respectively. Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.

Activity of Commonly Used Antimicrobial Prophylaxis Regimens against Pathogens Causing Coronary Artery Bypass Graft and Arthroplasty Surgical Site Infections in the United States, 2006–2009

Background.Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens.Methods.Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime),β-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity.Results.There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitiveStaphylococcus aureus(23%), methicillin-resistantS. aureus(18%), coagulase-negative staphylococci (17%), andEnterococcusspecies (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures),β-lactam (12%), and extended-spectrum (8%) regimens was 41%–45%, 47%–96%, and 81%—96%, respectively.Conclusion.Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.

Impact of Medicare's Payment Policy on Mediastinitis Following Coronary Artery Bypass Graft Surgery in US Hospitals

The Centers for Medicare and Medicaid Services (CMS) implemented a policy in October 2008 to eliminate additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) surgery. To evaluate the impact of this policy on mediastinitis rates, using Medicare claims and National Healthcare Safety Network (NHSN) prospective surveillance data. We used an interrupted time series design to compare mediastinitis rates before and after the policy, adjusted for secular trends. Billing rates came from Medicare inpatient claims following 638,761 CABG procedures in 1,234 US hospitals (January 2006-September 2010). Prospective surveillance rates came from 151 NHSN hospitals in 29 states performing 94,739 CABG procedures (January 2007-September 2010). Logistic regression mixed-effects models estimated trends for mediastinitis rates. We found a sudden drop in coding for index admission mediastinitis at the time of policy implementation (odds ratio, 0.36 [95% confidence interval (CI), 0.23-0.57]) and a decreasing trend in coding for index admission mediastinitis in the postintervention period compared with the preintervention period (ratio of slopes, 0.83 [95% CI, 0.74-0.95]). However, we saw no impact of the policy on infection rates as measured using NHSN data. Our results were not affected by changes in patient risk over time, heterogeneity in hospital demographics, or timing of hospital participation in NHSN. The CMS policy of withholding additional Medicare payment for mediastinitis on the basis of claims-based evidence of infection was associated with changes in coding for infections but not with changes in actual infection rates during the first 2 years after policy implementation.

Wide variation in adoption of screening and infection control interventions for multidrug-resistant organisms: A national study

We performed a survey of National Healthcare Safety Network hospitals in 2008 to describe adoption of screening and infection control policies aimed at multidrug-resistant organisms (MDRO) in intensive care units (ICUs) and identify predictors of their presence, monitoring, and implementation. Four hundred forty-one infection control directors were surveyed using a modified Dillman technique. To explore differences in screening and infection control policies by setting characteristics, bivariate and multivariable logistic regression models were constructed. In total, 250 hospitals participated (57% response rate). Study ICUs (n = 413) routinely screened for methicillin-resistant Staphylococcus aureus (59%); vancomycin-resistant Enterococcus (22%); multidrug-resistant, gram-negative rods (12%); and Clostridium difficile (11%). Directors reported ICU policies to screen all admissions for any MDRO (40%), screen periodically (27%), utilize presumptive isolation/contact precautions pending a screen (31%), and cohort colonized patients (42%). Several independent predictors of the presence and implementation of different interventions including mandatory reporting and teaching status were identified. This study found wide variation in adoption of MDRO screening and infection control interventions, which may reflect differences in published recommendations or their interpretation. Further research is needed to provide additional insight on effective strategies and how best to promote compliance.

Central line bundle implementation in US intensive care units and impact on bloodstream infections.

BackgroundCentral line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs.Methodology/Principal FindingsIn this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%.Conclusions/SignificanceIn NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies.

Neonatal rates and risk factors of device-associated bloodstream infection in a tertiary care center in Saudi Arabia

In a prospective surveillance study, we examine the risk of device-associated bloodstream infection (BSI) in a neonatal intensive care unit at Riyadh, Saudi Arabia, during 2006 and 2007. The incidence per 1000 device-days was 8.2 for central line-associated BSI and 10.5 for umbilical catheter-associated BSI. Both rates were higher with more umbilical catheter and less central line utilization ratios compared with those reported by the American National Healthcare Safety Network hospitals. Concurrent with implementation of more strict infection control practices, BSI rates declined over the course of the study. Prolonged device duration was an independent risk factor for device-associated BSI.