A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

Background: Government-directed policy plays an important role in the regulation and supervision of healthcare quality. Effective implementation of these policies has the potential to significantly improve clinical practice and patient outcomes, including the prevention of healthcare-associated infections. A systematic review of research describing the implementation of government-directed policy in the hospital setting was performed with the aim to identify policy intervention characteristics that influence implementation. Methods: A systematic search of four electronic databases was undertaken to identify eligible articles published between 2007 and 2017. Studies were included if published in the English language and described the implementation of government-directed policy in a high-income country hospital setting. Data on policy and implementation were extracted for each article and interpretive syntheses performed. Results: A total of 925 articles were retrieved and titles and abstracts reviewed, with 69 articles included after review of abstract and full text. Qualitative synthesis of implementation data showed three overarching themes related to intervention characteristics associated with implementation: clarity; infrastructure; and alignment. Conclusion: Better understanding and consideration of policy intervention characteristics during development and planning will facilitate more effective implementation although research describing implementation of government-directed policy in the hospital setting is limited and of variable quality. The findings of this study provide guidance to staff tasked with the development or implementation of government-directed policy in the hospital setting, infection prevention and control professionals seeking to maximise the impact of policy on practice and improve patient outcomes.</p

Predictors of use of infection control precautions for multiresistant gram-negative bacilli in Australian hospitals: Analysis of a national survey

Introduction Despite the global expansion of extended spectrum β-lactamase-harboring Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE), only limited research on the infection control management of patients with these organisms is available. Methods We present a national survey of infection control practices amongst adult acute-care hospitals in Australia, for ESBL-E, CRE, and the emerging threat of patients with overseas health care contact. Results In total, 97 health services responded, representing 9% of all eligible hospitals. The proportion of hospitals that reported use of contact precautions (CP) was 96% (93 out of 97) for ESBL-E, 81% (79 out of 97) for CRE, and 72% (48 out of 67) for patients transferred from an international hospital. For ESBL-E hospitals frequently employed risk-stratification to limit the use of CP (40 out of 97; 41%). On multivariate analysis predictors of a strategy to limit use of CP for ESBL-E were government funding (odds ratio, 4.8; P =.003) and a metropolitan location (odds ratio, 3.2; P =.014); predictors of any use of CP for CRE were location in an Australian state with a specific legislation on CRE (P =.030) and the presence of a written policy on CRE (P =.011). Conclusions Infection control management of multiresistant gram-negative bacilli varied considerably across the Australian hospitals surveyed. A lower rate of reported CP use for CRE than for ESBL-E was unexpected and indicates a vulnerability in some Australian hospitals. Multivariate analysis revealed various drivers influencing infection control practice in Australia

Development of a standardised approach to observing hand hygiene compliance in Australia

Background: Evidence indicates that improved hand hygiene compliance can lead to reductions in healthcare associated infection. However, there are few papers that clearly document the observation method used to collect the hand hygiene compliance data. This article describes the Hand Hygiene Australia 5 Moments for Hand Hygiene observation method in detail.Methods: The Australian Commission for Safety and Quality in Health Care funded Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI) to improve hand hygiene compliance (HHC) and establish a national validated system of HHC auditing. Based on the World Health Organisation (WHO) World Alliance for Patient Safety campaign \u27Clean Care is Safer Care\u27, HHA adapted the WHO hand hygiene compliance data collection form to suit Australian healthcare facilities.Results: Hand Hygiene Australia developed a standardised approach to direct observation of HHC of healthcare workers by developing a uniform suite of tools and a data management system for accurate data collection and report generation.Conclusion: Implementation of the HHA 5 Moments HHC audit method has facilitated standardised, reliable and meaningful collection of hand hygiene compliance data that is driving HHC improvement across many different healthcare settings around Australia

Characteristics of national and statewide health care–associated infection surveillance programs: a qualitative study

Background: There are many well-established national health care&ndash;associated infection surveillance programs(HAISPs). Although validation studies have described data quality, there is little research describingimportant characteristics of large HAISPs. The aim of this study was to broaden our understanding andidentify key characteristics of large HAISPs.Methods: Semi-structured interviews were conducted with purposively selected leaders from nationaland state-based HAISPs. Interview data were analyzed following an interpretive description process.Results: Seven semi-structured interviews were conducted over a 6-month period during 2014-2015.Analysis of the data generated 5 distinct characteristics of large HAISPs: (1) triggers: surveillance wasinitiated by government or a cooperative of like-minded people, (2) purpose: a clear purpose is neededand determines other surveillance mechanisms, (3) data measures: consistency is more important thanaccuracy, (4) processes: a balance exists between the volume of data collected and resources, and (5) implementationand maintenance: a central coordinating body is crucial for uniformity and support.Conclusions: National HAISPs are complex and affect a broad range of stakeholders. Although the overallgoal of health care&ndash;associated infection surveillance is to reduce the incidence of health care&ndash;associated infection, there are many crucial factors to be considered in attaining this goal. The findingsfrom this study will assist the development of new HAISPs and could be used as an adjunct to evaluateexisting programs

Determining research priorities for clinician-initiated trials in infectious diseases

To determine research priorities of infectious diseases physicians for clinician-initiated randomised controlled trials (RCTs).Online survey of infectious diseases physicians in Australia and New Zealand.Research priorities for, and perceived barriers to, clinician-initiated RCTs.122/550 infectious diseases physicians (22%) responded to the survey. The five highest ranked proposals for clinician-initiated RCTs were in the areas of prosthetic joint infections, septic arthritis and osteomyelitis of native joints, Staphylococcus aureus bloodstream infections, diabetic foot infections and the treatment of serious multiresistant, gram-negative bacterial infections. Lack of funding was the most important perceived barrier to participation in clinician-initiated RCTs.The research focus of infectious diseases physicians - optimal treatment of commonly encountered serious infections - highlights a lack of well conducted RCTs in this area

Community-onset Escherichia coli infection resistant to expanded- spectrum cephalosporins in low-prevalence countries

Background By global standards the prevalence of community onset expanded-spectrum cephalosporin resistant Escherichia coli (ESC-R-EC) remains low in Australia and New Zealand. Of concern, our countries are in a unique position with high extramural resistance pressure from close population and trade links to Asia-Pacific neighbours with high ESC-R-EC rates. We aim to characterize the risks and dynamics of community onset ESC-R-EC in our low-prevalence region.Methods A case-control methodology was used. Patients with ESC-R-EC or susceptible E. coli isolated from blood or urine were recruited at six geographically dispersed tertiary hospitals in Australia and New Zealand. Epidemiological data was prospectively collected and bacteria were retained for analysis.Results In total, 182 patients (91 cases and 91 controls) were recruited. Multivariate logistic regression identified risk factors for ESC-R amongst E. coli including birth on the Indian subcontinent (OR=11.13, 2.17-56.98, p=0.003), urinary tract infection in the past year (per infection OR=1.430, 1.13-1.82, p=0.003), travel to South East Asia, China, Indian subcontinent, Africa and the Middle East (OR=3.089, 1.29-7.38, p=0.011), prior exposure to trimethoprim+/-sulfamethoxazole &amp;/or an expanded-spectrum cephalosporin (OR=3.665, 1.30-10.35, p=0.014) and healthcare exposure in the previous six months (OR=3.16, 1.54-6.46, p=0.02).Amongst our ESC-R-EC the blaCTX-M ESBLs was dominant (83% of ESC-R-EC), and the worldwide pandemic clone ST-131 was frequent (45% of ESC-R-EC).Conclusion In our low prevalence setting, ESC-R amongst community onset E. coli may be associated with both &lsquo;export&rsquo; from healthcare facilities into the community and direct &lsquo;import&rsquo; into the community from high-prevalence regions.<br /

Accuracy of Pulse Oximetry Screening for Critical Congenital Heart Defects after Home Birth and Early Postnatal Discharge

Objective: To assess the accuracy of pulse oximetry screening for critical congenital heart defects (CCHDs) in a setting with home births and early discharge after hospital deliveries, by using an adapted protocol fitting the work patterns of community midwives. Study design: Pre- and postductal oxygen saturations (SpO2) were measured ≥1 hour after birth and on day 2 or 3. Screenings were positive if the SpO2 measurement was 3%. Positive screenings were referred for pediatric assessment. Primary outcomes were sensitivity, specificity, and false-positive rate of pulse oximetry screening for CCHD. Secondary outcome was detection of noncardiac illnesses. Results: The prenatal detection rate of CCHDs was 73%. After we excluded these cases and symptomatic CCHDs presenting immediately after birth, 23 959 newborns were screened. Pulse oximetry screening sensitivity in the remaining cohort was 50.0% (95% CI 23.7-76.3) and specificity was 99.1% (95% CI 99.0-99.2). Pulse oximetry screening was false positive for CCHDs in 221 infants, of whom 61% (134) had noncardiac illnesses, including infections (31) and respiratory pathology (88). Pulse oximetry screening did not detect left-heart obstructive CCHDs. Including cases with prenatally detected CCHDs increased the sensitivity to 70.2% (95% CI 56.0-81.4). Conclusion: Pulse oximetry screening adapted for perinatal care in home births and early postdelivery hospital discharge assisted the diagnosis of CCHDs before signs of cardiovascular collapse. High prenatal detection led to a moderate sensitivity of pulse oximetry screening. The screening also detected noncardiac illnesses in 0.6% of all infants, including infections and respiratory morbidity, which led to early recognition and referral for treatment