Association of ertapenem and antipseudomonal carbapenem usage and carbapenem resistance in Pseudomonas aeruginosa among 12 hospitals in Queensland, Australia.

OBJECTIVES: The objective of this study was to determine the association between ertapenem and antipseudomonal carbapenem use and carbapenem resistance in Pseudomonas aeruginosa in 12 hospitals in Queensland, Australia. METHODS: Data on usage of ertapenem and other antipseudomonal carbapenems, measured in defined daily doses per 1000 occupied bed-days, were collated using statewide pharmacy dispensing and distribution software from January 2007 until June 2011. The prevalence of unique carbapenem-resistant P. aeruginosa isolates derived from statewide laboratory information systems was collected for the same time period. Mixed-effects models were used to determine any relationship between ertapenem and antipseudomonal carbapenem usage and carbapenem resistance among P. aeruginosa isolates in the 12 hospitals analysed. RESULTS: No relationship between ertapenem usage and P. aeruginosa carbapenem resistance was observed. The introduction of ertapenem did not replace antipseudomonal carbapenem prescribing to any significant extent. However, an association between greater usage of antipseudomonal carbapenems and greater P. aeruginosa carbapenem resistance was demonstrated. CONCLUSIONS: It is likely that the only mechanism by which ertapenem can improve P. aeruginosa resistance patterns is by being used as a substitute for, rather than in addition to, antipseudomonal carbapenems.

Surveillance of healthcare-acquired infections in Queensland, Australia: data and lessons from the first 5 years.

OBJECTIVE: To present healthcare-acquired infection surveillance data for 2001-2005 in Queensland, Australia. DESIGN: Observational prospective cohort study. SETTING: Twenty-three public hospitals in Queensland. METHODS: We used computer-assisted surveillance to identify episodes of surgical site infection (SSI) in surgical patients. The risk-adjusted incidence of SSI was calculated by means of a risk-adjustment score modified from that of the US National Nosocomial Infections Surveillance System, and the incidence of inpatient bloodstream infection (BSI) was adjusted for risk on the basis of hospital level (level 1, tertiary referral center; level 2, large general hospital; level 3, small general hospital). Funnel and Bayesian shrinkage plots were used for between-hospital comparisons. PATIENTS: A total of 49,804 surgical patients and 4,663 patients who experienced healthcare-associated BSI. RESULTS: The overall cumulative incidence of in-hospital SSI ranged from 0.28% (95% confidence interval [CI], 0%-1.54%) for radical mastectomies to 6.15% (95% CI, 3.22%-10.50%) for femoropopliteal bypass procedures. The incidence of inpatient BSI was 0.80, 0.28, and 0.22 episodes per 1,000 occupied bed-days in level 1, 2, and 3 hospitals, respectively. Staphylococcus aureus was the most commonly isolated microorganism for SSI and BSI. Funnel and shrinkage plots showed at least 1 hospital with a signal indicating a possible higher-than-expected rate of S. aureus-associated BSI. CONCLUSIONS: Comparisons between hospitals should be viewed with caution because of imperfect risk adjustment. It is our view that the data should be used to improve healthcare-acquired infection control practices using evidence-based systems rather than to judge institutions.

Techniques to monitor for endophthalmitis and other cataract surgery complications.

OBJECTIVE: To report complication incidence to identify outliers more reliably, to provide feedback on performance, and to generate more timely alerts. DESIGN: Data from a retrospective entire-population study was used as an example for the charting methods. PARTICIPANTS: The Western Australian (WA) Data Linkage System identified all cataract or lens-related procedures undertaken in WA and those operations complicated with endophthalmitis over 20 years from 1980. METHODS: Use of risk-adjusted charts to assess complication incidence between hospitals. We compare these with ones that demonstrate individual hospital performance. The latter also adjust for risk and enable reporting at the time of complication rather than after a data collection period. MAIN OUTCOME MEASURE: Excessive complication risk (postoperative endophthalmitis). RESULTS: Confidence limits allow comparison of hospitals performing different numbers of operations; the 95% Poisson prediction interval was exceeded by 4 possible-outlier hospitals. Case-mix risk adjustment better narrowed them to probable outliers (now only 2 hospitals). However, 2 high-volume nonoutlier hospitals had a short duration of significantly higher risk of endophthalmitis with cumulative sum analysis. Their endophthalmitis numbers were not excessive, and they were not identified as outliers by the other methods. CONCLUSION: Simple ranking (or league) tables are not useful enough; someone is always first and last. Chance and circumstance will push all towards the middle with time. Risk-adjusted observed versus expected charting better identifies outliers than a funnel plot. Better still, the use of cumulative sum analysis can help surgeons distinguish between failures due to random processes and those that are associated with problems that require investigation to search for potentially correctable causes.

Factors associated with health care-acquired urinary tract infection.

BACKGROUND: Health care-acquired urinary tract infection is common, and the risk factors should be understood by those who manage hospitalized patients and researchers interested in interventions and programs designed to reduce rates. METHODS: We used multivariable logistic regression to identify factors that demonstrated a statistical association with infection. RESULTS: The incidence rate for infection was 1.66%, and risks increased for patients with prolonged length of stay (odd ratio [OR], 5.28; 95% confidence interval [CI]: 2.46-11.34), urinary catheter (OR, 5.16; 95% CI: 2.84-9.36), unresolved spinal injury (OR, 4.07; 95% CI: 1.04-15.92), transfer to/from another hospital (OR, 2.9; 95% CI: 1.39-6.04), some assistance for daily living prior to admission (OR, 2.58; 95% CI: 1.51-4.41), underlying neurologic disease (OR, 2.59; 95% CI: 1.49-4.49), previous stroke (OR, 1.94; 95% CI: 1.03-3.67), and fracture or dislocation on admission (OR, 3.34; 95% CI: 1.75-6.38). Male sex was protective (OR, 0.44; 95% CI: 0.26-0.77). CONCLUSION: Our data describe a general hospital population and therefore have relevance to many hospital-based health care professionals. The statistical model is a good fit to the data and has good predictive power. We identify high-risk groups and confirm the need for good decision making for managing the risks of health care-acquired urinary tract infection. This requires information on the effectiveness of risk-reducing strategies and the changes to economic costs and health benefits that result and the synthesis of these data in appropriately designed economic models.

Reflections on the Bundaberg Hospital failure.

Present-day public hospitals are often lacking in humanity, costing more and doing less, and run by executive staff with minimal clinical knowledge.

A PCR method for the identification of methicillin-resistant Staphylococcus aureus (MRSA) from screening swabs.

AIM: The aim of this study was to assess the discriminatory power and potential turn around time (TAT) of a PCR-based method for the detection of methicillin-resistant Staphylococcus aureus (MRSA) from screening swabs. METHODS: Screening swabs were examined using the current laboratory protocol of direct culture on mannitol salt agar supplemented with oxacillin (MSAO-direct). The PCR method involved pre-incubation in broth for 4 hours followed by a multiplex PCR with primers directed to mecA and nuc genes of MRSA. The reference standard was determined by pre-incubation in broth for 4 hours followed by culture on MSAO (MSAO-broth). RESULTS: A total of 256 swabs was analysed. The rates of detection of MRSA using MSAO-direct, MSAO-broth and PCR were 10.2, 13.3 and 10.2%, respectively. For PCR, the sensitivity, specificity, positive predictive value and negative predictive values were 66.7% (95%CI 51.9-83.3%), 98.6% (95%CI 97.1-100%), 84.6% (95%CI 76.2-100%) and 95.2% (95%CI 92.4-98.0%), respectively, and these results were almost identical to those obtained from MSAO-direct. The agreement between MSAO-direct and PCR was 61.5% (95%CI 42.8-80.2%) for positive results, 95.6% (95%CI 93.0-98.2%) for negative results and overall was 92.2% (95%CI 88.9-95.5%). CONCLUSIONS: (1) The discriminatory power of PCR and MSAO-direct is similar but the level of agreement, especially for true positive results, is low. (2) The potential TAT for the PCR method provides a marked advantage over conventional methods. (3) Further modifications to the PCR method such as increased broth incubation time, use of selective broth and adaptation to real-time PCR may lead to improvement in sensitivity and TAT.

Cumulative sum control charts for assessing performance in arterial surgery.

BACKGROUND: The Melbourne Vascular Surgical Association (Melbourne, Australia) undertakes surveillance of mortality following aortic aneurysm surgery, patency at discharge following infrainguinal bypass and stroke and death following carotid endarterectomy. Quality improvement protocol employing the Deming cycle requires that the system for performing surgery first be analysed and optimized. Then process and outcome data are collected and these data require careful analysis. There must be a mechanism so that the causes of unsatisfactory outcomes can be determined and a good feedback mechanism must exist so that good performance is acknowledged and unsatisfactory performance corrected. A simple method for analysing these data that detects changes in average outcome rates is available using cumulative sum statistical control charts. METHODS: Data have been analysed both retrospectively from 1999 to 2001, and prospectively during 2002 using cumulative sum control methods. A pathway to deal with control chart signals has been developed. RESULTS: The standard of arterial surgery in Victoria, Australia, is high. In one case a safe and satisfactory outcome was achieved by following the pathway developed by the audit committee. CONCLUSION: Cumulative sum control charts are a simple and effective tool for the identification of variations in performance standards in arterial surgery. The establishment of a pathway to manage problem performance is a vital part of audit activity.

Monitoring the evolutionary process of quality: risk-adjusted charting to track outcomes in intensive care.

OBJECTIVE: To present graphical procedures for prospectively monitoring outcomes in the intensive care unit. DESIGN: Observational study: risk-adjusted control chart analysis of a case series. SETTING: Tertiary referral adult intensive care unit: Princess Alexandra Hospital, Brisbane, Australia. PATIENTS: A total of 3398 intensive care unit admissions from January 1, 1995, to January 1, 1998. CONCLUSIONS: Risk-adjusted process control charting procedures for continuous monitoring of intensive care unit outcomes are proposed as quality management tools. A modified Shewhart p chart and cumulative sum process control chart, using the Acute Physiology and Chronic Health Evaluation III model mortality prediction for risk adjustment, are presented. The risk-adjusted p chart summarizes performance at arbitrary intervals and plots observed against predicted mortality rate to detect large changes in risk-adjusted mortality. The risk-adjusted cumulative sum procedure is a likelihood-based scoring method that adjusts for estimated risk of death, accumulating evidence from outcomes of all previous patients. It formally tests the hypothesis of a change in the odds of death. In this application, we detected a decrease from above to predicted risk-adjusted mortality. This was temporally related to increased senior staffing levels and enhanced ongoing multidisciplinary review of practice, quality improvement, and educational activities. Formulas and analyses are provided as appendices.