RESUMEN
OBJECTIVE To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection. SETTING AND PARTICIPANTS Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status. MEASUREMENTS Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012. RESULTS There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%-92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%-100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation. CONCLUSIONS Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.
Asunto(s)
Instituciones de Atención Ambulatoria/estadística & datos numéricos , Adhesión a Directriz/estadística & datos numéricos , Higiene de las Manos/estadística & datos numéricos , Control de Infecciones/métodos , Diálisis Renal/estadística & datos numéricos , Instituciones de Atención Ambulatoria/normas , Antiinfecciosos Locales/uso terapéutico , Clorhexidina/uso terapéutico , Higiene de las Manos/normas , Humanos , Control de Infecciones/normas , Control de Infecciones/estadística & datos numéricos , Fallo Renal Crónico/terapia , Guías de Práctica Clínica como Asunto , Evaluación de Procesos, Atención de Salud , Mejoramiento de la Calidad , Diálisis Renal/normasRESUMEN
OBJECTIVE: To examine the relationship between community factors and hospital readmission rates. DATA SOURCES/STUDY SETTING: We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets. STUDY DESIGN: We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties. CONCLUSIONS: Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.
Asunto(s)
Casas de Salud/normas , Readmisión del Paciente/estadística & datos numéricos , Apoyo Social , Anciano , Centers for Medicare and Medicaid Services, U.S. , Capacidad de Camas en Hospitales , Hospitales/clasificación , Humanos , Modelos Lineales , Análisis Multivariante , Infarto del Miocardio/terapia , Neumonía/terapia , Factores Socioeconómicos , Estados UnidosRESUMEN
BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.
Asunto(s)
Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/prevención & control , Infección Hospitalaria/prevención & control , Unidades de Cuidados Intensivos , Adulto , Cateterismo Venoso Central/efectos adversos , Infección Hospitalaria/epidemiología , Humanos , Incidencia , Control de Infecciones/métodos , Evaluación de Programas y Proyectos de Salud , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Transformational change in health care calls on hospital boards of trustees to engage in quality ata level that has never been asked before. Yet little research has been conducted regarding the role of hospital governance in quality. METHODS: Interviews were conducted with chief executive officers (CEOs) and board chairpersons from aconvenient sample of 30 hospitals, representing 14 states across the United States. The interviews were 30 to 45 minutes in length and included approximately 30 questions that were open-ended and ratings based. RESULTS: The level of knowledge of landmark Institute of Medicine (IOM) quality reports among CEOs and board chairs was remarkably low. Conversely, board chairs and CEOs were well attuned to public reporting of quality information. There were significant differences between the CEOs' perception of the level of knowledge of their board chairs and the board chairs' self-perception. There was a mild association between board engagement in quality and hospital performance asdefined by their rates in their composite measure of heart failure, heart attack, and pneumonia. DISCUSSION: The engagement of hospital boards inquality can be enhanced by (1) increasing education on quality to increase the board's quality literacy; (2) improving the framing of an agenda for quality; (3) more quality planning, focus, and incentives for leadership and governance for quality improvement; and (4) greater focus on the patients. Implementing these steps can improve a hospital's overall performance.