Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study.

Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P \u3c .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P \u3c .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs

Differences in work environment for staff as an explanation for variation in central line bundle compliance in intensive care units.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. PURPOSE: The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). METHODOLOGY/APPROACH: A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. FINDINGS: Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. PRACTICE IMPLICATIONS: Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality

Smartphone Applications to Support Tuberculosis Prevention and Treatment: Review and Evaluation

Background: Tuberculosis (TB) remains a major global health problem and is the leading killer due to a single infectious disease. Mobile health (mHealth)–based tools such as smartphone apps have been suggested as tools to support TB control efforts (eg, identification, contact tracing, case management including patient support). Objective: The purpose of this review was to identify and assess the functionalities of mobile apps focused on prevention and treatment of TB. Methods: We searched 3 online mobile app stores. Apps were included if they were focused on TB and were in English, Spanish, or Portuguese. For each included app, 11 functionalities were assessed (eg, inform, instruct, record), and searches were conducted to identify peer-review publications of rigorous testing of the available apps. Results: A total of 1332 potentially relevant apps were identified, with 24 meeting our inclusion criteria. All of the apps were free to download, but 7 required login and password and were developed for specific clinics, regional sites, or research studies. Targeted users were mainly clinicians (n=17); few (n=4) apps were patient focused. Most apps (n=17) had 4 or fewer functions out of 11 (range 1-6). The most common functionalities were inform and record (n=15). Although a number of apps were identified with various functionalities to support TB efforts, some had issues such as incorrect spelling and grammar, inconsistent responses to data entry, problems with crashing, or links to features that had no data. Of more concern, some apps provided potentially harmful information to patients, such as links to natural remedies for TB and natural healers. One-third of the apps (8/24) had not been updated for more than a year and may no longer be supported. Peer-reviewed publications were identified for only two of the included apps. In the gray literature (not found in the app stores), three TB-related apps were identified as in progress, being launched, or tested. Conclusions: Apps identified for TB prevention and treatment had minimal functionality, primarily targeted frontline health care workers, and focused on TB information (eg, general information, guidelines, and news) or data collection (eg, replace paper-based notification or tracking). Few apps were developed for use by patients and none were developed to support TB patient involvement and management in their care (eg, follow-up alerts/reminders, side effects monitoring) or improve interaction with their health care providers, limiting the potential of these apps to facilitate patient-centered care. Our evaluation shows that more refined work is needed to be done in the area of apps to support patients with active TB. Involving TB patients in treatment in the design of these apps is recommended

Measurement of Organizational Culture and Climate in Healthcare

Although there is increasing interest in the relationship between organizational constructs and health services outcomes, information on the reliability and validity of the instruments measuring these constructs is sparse. Twelve instruments were identified that may have applicability in measuring organizational constructs in the healthcare setting. The authors describe and characterize these instruments and discuss the implications for nurse administrators

Advanced cognitive impairment among older nursing home residents

BACKGROUND: Though work has been done studying nursing home (NH) residents with either advanced Alzheimer\u27s disease (AD) or Alzheimer\u27s disease related dementia (ADRD), none have distinguished between them; even though their clinical features affecting survival are different. In this study, we compared mortality risk factors and survival between NH residents with advanced AD and those with advanced ADRD. METHODS: This is a retrospective observational study, in which we examined a sample of 34,493 U.S. NH residents aged 65 and over in the Minimum Data Set (2011-2013). Incident assessment of advanced disease was defined as the first MDS assessment with severe cognitive impairment (Cognitive Functional Score equals to 4) and diagnoses of AD or ADRD. Demographics, functional limitations, and comorbidities were evaluated as mortality risk factors using Cox models. Survival was characterized with Kaplan-Maier functions. RESULTS: Of those with advanced cognitive impairment, 35 % had AD and 65 % ADRD. At the incident assessment of advanced disease, those with AD had better health compared to those with ADRD. Mortality risk factors were similar between groups (shortness of breath, difficulties eating, substantial weight-loss, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and pneumonia; all p \u3c 0.01). However, stroke and difficulty with transfer (for women) were significant mortality risk factors only for those with advanced AD. Urinary tract infection, and hypertension (for women) only were mortality risk factors for those with advanced ADRD. Median survival was significantly shorter for the advanced ADRD group (194 days) compared to the advanced AD group (300 days). CONCLUSIONS: There were distinct mortality and survival patterns of NH residents with advanced AD and ADRD. This may help with care planning decisions regarding therapeutic and palliative care

Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature

Background Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care–associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs. Methods The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015. Results Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs. Conclusion Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area

Survey of financial burden of families in the U.S. with children using home mechanical ventilation.

Aim: To describe and quantify the out-of-pocket expenses, employment loss, and other financial impact related to caring for a child using home mechanical ventilation (HMV). METHOD: We conducted a cross-sectional survey of U.S. families with children who used HMV. Eligible participants were invited to complete a questionnaire addressing household and child characteristics, out-of-pocket expenses, employment loss/reduction, and financial stress. Participants were recruited with the help of three national patient registries. RESULTS: Two hundred twenty-six participants from 32 states (152 with children who used invasive ventilation and 74 with children who used noninvasive ventilation) completed the questionnaire. Participants' median reported yearly household income was $90 000 (IQR 70 000-150 000). The median amount paid in out-of-pocket expenses in the previous 3 months to care for their child using HMV totaled$3899 (IQR $2900-4550). Reported levels of financial stress decreased as income increased; 37-60% of participants, depending on income quintile, reported moderate financial stress with "some" of that stress due to their out-of-pocket expenses. A substantial majority reported one or more household members stopped or reduced work and took unpaid weeks off of work to care for their child. CONCLUSION: The financial impact of caring for a child using HMV is considerable for some families. Providers need to understand these financial burdens and should inform families of them to help families anticipate and plan for them

The Impact of State Mandated Healthcare-Associated Infection Reporting on Infection Prevention and Control Departments in Acute Care Hospitals: Results from a National Survey

Background: In addition to federally mandated reporting, most US states have adopted legislation requiring hospitals to submit healthcare-associated infection (HAI) data. Evidence that state HAI laws have increased patient safety and reduced HAI rates is inconsistent, however, and resources needed to comply are considerable. We evaluated the impact of state HAI laws on infection prevention and control departments (IPCD). Methods: Web-based survey of a national sample of hospital IPCD was conducted in Fall 2011; all non-VA hospitals enrolled in the National Healthcare Safety Network were eligible to participate. States with HAI laws effective prior to Fall 2011 were identified using systematic legal review. Variations in IPCD resources and characteristics in states with and without laws were compared using χ2or Wilcoxon-Mann-Whitney tests. Multinomial logistic regression was used to identify increases or decreases, vs no change, in resources and characteristics. Results: 1,038 IPCD provided complete data (30% response rate); 756 (73%) were located in states with laws. When asked how mandatory reporting affected their IPCD, more respondents in states with laws reported differences in resources (42% vs 33%, p \u3c 0.01), time for routine activities other than for mandatory reporting (79% vs 71%, p \u3c 0.01), influence in hospital decision making (55% vs 48%, p \u3c 0.05), and visibility of their department (75% vs 65%, p \u3c 0.001); they also spent more hours per week fulfilling mandatory reporting requirements (17 vs 13, p \u3c 0.0001). Based on regression analysis, respondents in states with laws were more likely to report increased resources (p = 0.02) and influence (p = 0.04) and decreased time for routine activities (p \u3c 0.01). Perception of visibility in the hospital was mixed with reports of both increased (p \u3c 0.001) and decreased (p = 0.01) visibility vs the same. Conclusion: Respondents in states with laws reported a significantly higher burden to their IPCD, beyond what was required by federally mandated HAI reporting alone. However, they also reported receiving increased resources to offset demands on time for routine activities and fulfilling reporting requirements. Further research is needed to investigate resources necessary to comply with state HAI laws, and to evaluate their unintended consequences

State law mandates for reporting of healthcare-associated Clostridium difficile infections in hospitals.

US state and territorial laws were reviewed to identify Clostridium difficile infection reporting mandates. Twenty states require reporting either under state law or by incorporating federal Centers for Medicare & Medicaid Services\u27 reporting requirements. Although state law mandates are more common, the incorporation of federal reporting requirements has been increasing

Patient Safety Climate: Variation in Perceptions by Infection Preventionists and Quality Directors

Background. Healthcare-associated infections (HAIs) are an important patient safety issue, and safety climate is an important organizational factor. This study explores perceptions of infection preventionists (IPs) and quality directors (QDs) regarding two safety microclimates, Senior Management Engagement (SME) and Leadership on Patient Safety (LOPS), across California hospitals. Methods. This was an analysis of two cross-sectional surveys. We conducted Wilcoxon signed-rank test, univariate analyses, and a multivariate ordinary least square regression. Results. There were 322 eligible hospitals; 149 hospitals (46.3%) responded to both surveys. The IP response rate was 59%, and the QD response rate was 79.5%. We found IPs perceived SME more positively than did QDs (21.4 vs. 20.4, P < 0.01). No setting characteristics predicted variation in perceptions. Presence of an independent budget predicted more positive perceptions of microclimates across personnel types (P < 0.01). Conclusions. Differences in perceptions continue to exist between essential leaders in acute health care settings which could have critical effects on outcomes such as HAIs. Having an independent budget for the infection prevention and control department may enhance the overall safety climate and in turn patient care