Infection control interventions in small rural hospitals with limited resources: results of a cluster-randomized feasibility trial

Antimicrobial Resistance and Infection Control

Kurt B Stevenson⁴  Katie Searle²  Grace Curry²  John M Boyce⁵  Stephan Harbarth¹  Gregory J Stoddard²  Matthew H Samore³ 

[1] Service de Prévention et Contrôle de l'Infection, Hôpitaux Universitaires de Genève, CH-1211 Geneva 14, Switzerland

[2] University of Utah School of Medicine, Salt Lake City, UT, USA

[3] Informatics, Decision Enhancement, and Analytic Science (IDEAS) Center, VA Salt Lake City Health Care System, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA

[4] The Ohio State University Medical Center, N-1122 Doan Hall 410 West 10th Avenue, Columbus, OH 43210, USA

[5] Yale-New Haven Hospital, New Haven, CT, USA

关键词: MRSA;    Clinical trial;    Transmission;    United States;    Epidemiology;    Hand hygiene;   

Others  :  790554
DOI  :  10.1186/2047-2994-3-10

 received in 2013-03-19, accepted in 2013-10-25,  发布年份 2014

【 摘 要 】

Background

There are few reports on the feasibility of conducting successful infection control (IC) interventions in rural community hospitals.

Methods

Ten small rural community hospitals in Idaho and Utah were recruited to participate in a cluster-randomized trial of multidimensional IC interventions to determine their feasibility in the setting of limited resources. Five hospitals were randomized to develop individualized campaigns to promote HH, isolation compliance, and outbreak control. Five hospitals were randomized to continue with current IC practices. Regular blinded observations of hand hygiene (HH) compliance were conducted in all hospitals as the primary outcome measure. Additionally, periodic prevalence studies of patient colonization with resistant pathogens were performed. The 5-months intervention time period was compared to a 4-months baseline period, using a multi-level logistic regression model.

Results

The intervention hospitals implemented a variety of strategies. The estimated average absolute change in “complete HH compliance” in intervention hospitals was 20.1% (range, 7.8% to 35.5%) compared to −3.1% (range −6.3% to 5.9%) in control hospitals (p = 0.001). There was an estimated average absolute change in “any HH compliance” of 28.4% (range 17.8% to 38.2%) in intervention hospitals compared to 0.7% (range −16.7 to 20.7%) in control hospitals (p = 0.010). Active surveillance culturing demonstrated an overall prevalence of MRSA carriage of 9.7%.

Conclusions

A replicable intervention significantly improved hand hygiene as a primary outcome measure despite barriers of geographic distance and lack of experience with study protocols. Active surveillance culturing identified unsuspected reservoirs of MRSA colonization and further promoted IC activity.

【 授权许可】

   
2014 Stevenson et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med 2003, 348:2635-2645.
• [2]Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams JL, Schuster MA, McGlynn EA: The quality of ambulatory care delivered to children in the United States. N Engl J Med 2007, 357:1515-1523.
• [3]Woolf SH: The meaning of translational research and why it matters. JAMA 2008, 299:211-213.
• [4]Westfall JM, Mold J, Fagnan L: Practice-based research–“Blue Highways” on the NIH roadmap. JAMA 2007, 297:403-406.
• [5]Dougherty D, Conway PH: The “3T’s” road map to transform US health care: the “how” of high-quality care. JAMA 2008, 299:2319-2321.
• [6]Khoury MJ, Gwinn M, Yoon PW, Dowling N, Moore CA, Bradley L: The continuum of translation research in genomic medicine: how can we accelerate the appropriate integration of human genome discoveries into health care and disease prevention? Genet Med 2007, 9:665-674.
• [7]Centers for Disease Control and Prevention: Guideline for isolation precautions in hospitals. Part II. Recommendations for isolation precautions in hospitals. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996, 24:32-52.
• [8]Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee: 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007, 35:S65-S164.
• [9]Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee: Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007, 35:S165-S193.
• [10]Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000, 356:1307-1312.
• [11]Boyce JM, Pittet D: Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002, 23:S3-S40.
• [12]Boyce JM, Pittet D: Guideline for hand hygiene in health-care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002, 51:1-45. quiz
• [13]Pittet D: Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001, 7:234-240.
• [14]Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, Tsao PN: Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004, 25:742-746.
• [15]Lam BC, Lee J, Lau YL: Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004, 114:e565-e571.
• [16]Tomic V, Svetina Sorli P, Trinkaus D, Sorli J, Widmer AF, Trampuz A: Comprehensive strategy to prevent nosocomial spread of methicillin-resistant Staphylococcus aureus in a highly endemic setting. Arch Intern Med 2004, 164:2038-2043.
• [17]Trick WE, Weinstein RA, DeMarais PL, Tomaska W, Nathan C, McAllister SK, Hageman JC, Rice TW, Westbrook G, Jarvis WR: Comparison of routine glove use and contact-isolation precautions to prevent transmission of multidrug-resistant bacteria in a long-term care facility. J Am Geriatr Soc 2004, 52:2003-2009.
• [18]Moscovice I, Stensland J: Rural hospitals: trends, challenges, and a future research and policy analysis agenda. J Rural Health 2002, 18(Suppl):197-210.
• [19]Ricketts TCI, Heaphy PE: Hospitals and rural America. West J Med 2000, 173:418-422.
• [20]Grayson ML, Jarvie LJ, Martin R, Johnson PD, Jodoin ME, McMullan C, Gregory RH, Bellis K, Cunnington K, Wilson FL, Quin D, Kelly AM, Hand Hygiene Study Group and Hand Hygiene Statewide Roll-out Group, Victorian Quality Council: Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008, 188:633-640.
• [21]Anderson DJ, Miller BA, Chen LF, Adcock LH, Cook E, Cromer AL, Louis S, Thacker PA 2nd, Sexton DJ: The network approach for prevention of healthcare-associated infections: long-term effect of participation in the Duke Infection Control Outreach Network. Infect Control Hosp Epidemiol 2011, 32:315-322.
• [22]Stevenson KB, Murphy CL, Samore MH, Hannah EL, Moore JW, Barbera J, Houck P, Gerberding JL: Assessing the status of infection control programs in small rural hospitals in the western United States. Am J Infect Control 2004, 32:255-261.
• [23]Britt MR, Burke JP, Nordquist AG, Wilfert JN, Smith CB: Infection control in small hospitals-prevalence surveys in 18 institutions. JAMA 1976, 236:1700-1703.
• [24]Britt MR: Infectious diseases in small hospitals. Prevalence of infections and adequacy of microbiology services. Ann Intern Med 1978, 89:757-760.
• [25]Stevenson KB, Searle K, Stoddard GJ, Samore M: Methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci in rural communities, western United States. Emerg Infect Dis 2005, 11:895-903.
• [26]Ricketts TC, Johnson-Webb KD, Taylor P: Definitions of rural: A Handbook for Health Policy Makers and Researchers. Washington DC: Federal Office of Rural Health Policy, Health Resources and Services Administration, US DHHS; 1998.
• [27]Murray DM, Varnell SP, Blitstein JL: Design and analysis of group-randomized trials: a review of recent methodological developments. Am J Public Health 2004, 94:423-432.
• [28]Godwin M, Ruhland L, Casson I, MacDonald S, Delva D, Birtwhistle R, Lam M, Seguin R: Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Med Res Methodol 2003, 3:28. BioMed Central Full Text
• [29]Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM, Farr BM, SHEA: SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 2003, 24:362-386.
• [30]Boyce JM: MRSA patients: proven methods to treat colonization and infection. J Hosp Infect 2001, 48(Suppl A):S9-S14.
• [31]National Committee for Clinical Laboratory Standards: Performance Standards for Antimicrobial Susceptibiity Testing . Approved Standard M100-S12. Wayne, PA: National Committee for Clinical Laboratory Standards; 2002.
• [32]Jernigan JA, Titus MG, Gröschel DH, Getchell-White S, Farr BM: Effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus. Am J Epidemiol 1996, 143:496-504.
• [33]Karchmer TB, Durbin LJ, Simonton BM, Farr BM: Cost-effectiveness of active surveillance cultures and contact/droplet precautions for control of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2002, 51:126-132.
• [34]Farr BM, Jarvis WR: Would active surveillance cultures help control healtcare-related methicillin-resistant Staphylococcus aureus infections? Infect Control Hosp Epidemiol 2002, 23:65-68.
• [35]Chambers HF: The changing epidemiology of Staphylococcus aureus? Emerg Infect Dis 2001, 7:178-182.
• [36]Moran GJ, Amii RN, Abrahamian FM, Talan DA: Methicillin-resistant Staphylococcus aureus in community-acquired skin infections. Emerg Infect Dis 2005, 11:928-930.