Dataset Information

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals.

ABSTRACT:

Importance

Visitor contact precautions (VCPs) are commonly used to reduce the transmission of Clostridioides difficile at health care institutions. Implementing VCPs requires considerable personnel and personal protective equipment resources. However, it is unknown whether VCPs are associated with reduced hospital-onset C difficile infection (HO-CDI) rates.

Objective

To estimate the association between VCPs and HO-CDI rates using simulation modeling.

Design, setting, and participants

This simulation study, conducted between July 27, 2020, and August 11, 2020, used an established agent-based simulation model of C difficile transmission in a 200-bed acute care adult hospital to estimate the association between VCPs and HO-CDI while varying assumptions about factors such as patient susceptibility, behavior, and C difficile transmission. The model simulated hospital activity for 1 year among a homogeneous, simulated adult population.

Interventions

No VCP use vs ideal use of VCPs under different hospital configurations.

Main outcomes and measures

The rate of HO-CDI per 10?000 patient-days according to the Centers for Disease Control and Prevention's definition of HO-CDI.

Results

With use of the simulation model, the baseline rate of HO-CDI was 7.94 10?000 patient-days (95% CI, 7.91-7.98 per 10?000 patient-days) with no VCP use compared with 7.97 per 10?000 patient-days (95% CI, 7.93-8.01 per 10?000 patient-days) with ideal VCP use. Visitor contact precautions were not associated with a reduction of more than 1% in HO-CDI rates in any of the tested scenarios and hospital settings. Independently increasing the hand-hygiene compliance of the average health care worker and environmental cleaning compliance by no more than 2% each was associated with greater HO-CDI reduction compared with all other scenarios, including VCPs.

Conclusions and relevance

In this simulation study, the association between VCPs and HO-CDI was minimal, but improvements in health care worker hand hygiene and environmental cleaning were associated with greater reductions in estimated HO-CDI. Hospitals may achieve a higher rate of reduction for HO-CDI by focusing on making small improvements in compliance with interventions other than VCP.

SUBMITTER: Scaria E

PROVIDER: S-EPMC7910816 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals.

Scaria Elizabeth E Barker Anna K AK Alagoz Oguzhan O Safdar Nasia N

JAMA network open 20210201 2

<h4>Importance</h4>Visitor contact precautions (VCPs) are commonly used to reduce the transmission of Clostridioides difficile at health care institutions. Implementing VCPs requires considerable personnel and personal protective equipment resources. However, it is unknown whether VCPs are associated with reduced hospital-onset C difficile infection (HO-CDI) rates.<h4>Objective</h4>To estimate the association between VCPs and HO-CDI rates using simulation modeling.<h4>Design, setting, and partic ...[more]

PMID: 33635330

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Project description:ImportanceRegulatory agencies and professional organizations recommend antibiotic stewardship programs (ASPs) in US hospitals. The optimal approach to establish robust, sustainable ASPs across diverse hospitals is unknown.ObjectiveTo assess whether the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use is associated with reductions in antibiotic use across US hospitals.Design, setting, and participantsA pragmatic quality improvement program was conducted and evaluated over a 1-year period in US hospitals. A total of 437 hospitals were enrolled. The study was conducted from December 1, 2017, to November 30, 2018. Data analysis was performed from March 1 to October 31, 2019.InterventionsThe Safety Program assisted hospitals with establishing ASPs and worked with frontline clinicians to improve their antibiotic decision-making. All clinical staff (eg, clinicians, pharmacists, and nurses) were encouraged to participate. Seventeen webinars occurred over 12 months, accompanied by additional durable educational content. Topics focused on establishing ASPs, the science of safety, improving teamwork and communication, and best practices for the diagnosis and management of infectious processes.Main outcomes and measuresThe primary outcome was overall antibiotic use (days of antibiotic therapy [DOT] per 1000 patient days [PD]) comparing the beginning (January-February 2018) and end (November-December 2018) of the Safety Program. Data analysis occurred using linear mixed models with random hospital unit effects. Antibiotic use from 614 hospitals in the Premier Healthcare Database from the same period was analyzed to evaluate contemporary US antibiotic trends. Quarterly hospital-onset Clostridioides difficile laboratory-identified events per 10 000 PD were a secondary outcome.ResultsOf the 437 hospitals enrolled, 402 (92%) remained in the program until its completion, including 28 (7%) academic medical centers, 122 (30%) midlevel teaching hospitals, 167 (42%) community hospitals, and 85 (21%) critical access hospitals. Adherence to key components of ASPs (ie, interventions before and after prescription of antibiotics, availability of local antibiotic guidelines, ASP leads with dedicated salary support, and quarterly reporting of antibiotic use) improved from 8% to 74% over the 1-year period (P < .01). Antibiotic use decreased by 30.3 DOT per 1000 PD (95% CI, -52.6 to -8.0 DOT; P = .008). Similar changes in antibiotic use were not observed in the Premier Healthcare Database. The incidence rate of hospital-onset C difficile laboratory-identified events decreased by 19.5% (95% CI, -33.5% to -2.4%; P = .03).Conclusions and relevanceThe Agency for Healthcare Research and Quality Safety Program appeared to enable diverse hospitals to establish ASPs and teach frontline clinicians to self-steward their antibiotic use. Safety Program content is publicly available.

Project description:ObjectiveLack of judicious testing can result in the incorrect diagnosis of Clostridioides difficile infection (CDI), unnecessary CDI treatment, increased costs and falsely augmented hospital-acquired infection (HAI) rates. We evaluated facility-wide interventions used at the VA San Diego Healthcare System (VASDHS) to reduce healthcare-onset, healthcare-facility-associated CDI (HO-HCFA CDI), including the use of diagnostic stewardship with test ordering criteria.DesignWe conducted a retrospective study to assess the effectiveness of measures implemented to reduce the rate of HO-HCFA CDI at the VASDHS from fiscal year (FY)2015 to FY2018.InterventionsMeasures executed in a stepwise fashion included a hand hygiene initiative, prompt isolation of CDI patients, enhanced terminal room cleaning, reduction of fluoroquinolone and proton-pump inhibitor use, laboratory rejection of solid stool samples, and lastly diagnostic stewardship with C. difficile toxin B gene nucleic acid amplification testing (NAAT) criteria instituted in FY2018.ResultsFrom FY2015 to FY2018, 127 cases of HO-HCFA CDI were identified. All rate-reducing initiatives resulted in decreased HO-HCFA cases (from 44 to 13; P ≤ .05). However, the number of HO-HCFA cases (34 to 13; P ≤ .05), potential false-positive testing associated with colonization and laxative use (from 11 to 4), hospital days (from 596 to 332), CDI-related hospitalization costs (from $2,780,681 to $1,534,190) and treatment cost (from $7,158 vs $1,476) decreased substantially following the introduction of diagnostic stewardship with test criteria from FY2017 to FY2018.ConclusionsInitiatives to decrease risk for CDI and diagnostic stewardship of C. difficile stool NAAT significantly reduced HO-HCFA CDI rates, detection of potential false-positives associated with laxative use, and lowered healthcare costs. Diagnostic stewardship itself had the most dramatic impact on outcomes observed and served as an effective tool in reducing HO-HCFA CDI rates.

Project description:ImportanceClostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile.ObjectiveTo compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles.Design, setting, and participantsThis economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature.InterventionsDaily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers.Main outcomes and measuresCost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY).ResultsIn this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively.Conclusions and relevanceThe findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.

Project description:ImportanceThe effectiveness and importance of contact precautions for endemic pathogens has long been debated, and their use has broad implications for infection control of other pathogens.ObjectiveTo estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals.Design, setting, and participantsThis retrospective cohort study used mathematical models applied to data from a population-based sample of adults hospitalized in 108 VA acute care hospitals for at least 24 hours from January 1, 2008, to December 31, 2017. Data were analyzed from May 2, 2019, to December 11, 2020.ExposuresA positive MRSA test result, presumed to indicate contact precautions use according to the VA MRSA Prevention Initiative.Main outcomes and measuresThe main outcome was the association between contact precautions and MRSA transmission, defined as the relative transmissibility attributed to contact precautions. A contact precaution effect estimate (<1 indicates a reduction in transmission associated with contact precautions) was estimated for each hospital and then pooled over time and across hospitals using meta-regression.ResultsIn this cohort study of 108 VA hospitals, more than 2 million unique individuals had over 5.6 million admissions, of which 14.1% were presumed to have contact precautions with more than 8.4 million MRSA surveillance tests. Pooled estimates found associations between contact precautions and transmission to be stable from 2008 to 2017, with estimated transmission reductions ranging from 43% (95% credible interval [CrI], 38%-48%) to 51% (95% CrI, 46%-55%). Over the entire 10-year study period, contact precautions reduced transmission 47% (95% CrI, 45%-49%), and the intrafacility autocorrelation coefficient estimate was 0.99, suggesting consistent estimates over time within facilities. Larger facilities and those with higher admission screening compliance observed additional reductions in transmission associated with contact precautions (relative rate, 0.84; 95% CI, 0.74-0.96 and 0.74; 95% CI, 0.58-0.96, respectively) compared with smaller facilities and those with lower admission screening compliance. Facilities in the southern US had a smaller transmission reduction attributable to contact precautions (relative rate, 1.14; 95% CI, 1.01-1.28) compared with facilities in other regions in the US.Conclusions and relevanceIn this cohort study of adults in VA hospitals, transmissibility of MRSA was found to be reduced by approximately 50% among patients with contact precautions. These results provide an explanation for decreasing acquisition rates in VA hospitals since the MRSA Prevention Initiative.

Dataset Information

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals.

Importance

Objective

Design, setting, and participants

Interventions

Main outcomes and measures

Results

Conclusions and relevance

Publications

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals.

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