Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

BACKGROUND: Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff. DESIGN: Evaluation of a mixed qualitative and quantitative methodology ("trilogic evaluation model"). SETTING: Six hospitals that joined the campaign before June 2006. PARTICIPANTS: Three strata of staff (executive leadership, midlevel, and frontline) at each hospital. RESULTS. Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability. CONCLUSIONS: The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC).

This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings or other events resulting in mass casualties. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to blood, body fluids, or tissue from other injured persons and thus be at risk for bloodborne infections. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma and emergency response medical communities participating in CDC's Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) project. The recommendations contained in this report represent the consensus of U.S. federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.

Postexposure interventions to prevent infection with HBV, HCV, or HIV, and tetanus in people wounded during bombings and other mass casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention and Disaster Medicine and Public Health Preparedness.

People wounded during bombings or other events resulting in mass casualties or in conjunction with the resulting emergency response may be exposed to blood, body fluids, or tissue from other injured people and thus be at risk for bloodborne infections such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or tetanus. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma, and emergency response medical communities participating in the Centers for Disease Control and Prevention's Terrorism Injuries: Information, Dissemination and Exchange project. There recommendations contained in this report represent the consensus of US federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.

Antiretroviral drug resistance in human immunodeficiency virus-infected source patients for occupational exposures to healthcare workers.

OBJECTIVE: To assess the prevalence of HIV antiretroviral resistance among source patients for occupational HIV exposures. DESIGN: Blood and data (eg, stage of HIV, previous antiretroviral drug therapy, and HIV RNA viral load) were collected from HIV-infected patients who were source patients for occupational exposures. SETTING: Seven tertiary-care medical centers in five U.S. cities (San Diego, California; Miami, Florida; Boston, Massachusetts; Albany, New York; and New York, New York [three sites]) during 1998 to 1999. PARTICIPANTS: Sixty-four HIV-infected patients who were source patients for occupational exposures. RESULTS: Virus from 50 patients was sequenced; virus from 14 patients with an undetectable (ie, < 400 RNA copies/mL) viral load could not be sequenced. Overall, 19 (38%) of the 50 patients had primary genotypic mutations associated with resistance to reverse transcriptase or protease inhibitors. Eighteen of the 19 viruses with primary mutations and 13 wild type viruses were phenotyped by recombinant assays; 19 had phenotypic resistance to at least one antiretroviral agent. Of the 50 source patients studied, 26 had taken antiretroviral agents in the 3 months before the occupational exposure incident. Sixteen (62%) of the 26 drug-treated patients had virus that was phenotypically resistant to at least one drug. Four (17%) of 23 untreated patients had phenotypically resistant virus. No episodes of HIV transmission were observed among the exposed HCWs. CONCLUSIONS: There was a high prevalence of drug-resistant HIV among source patients for occupational HIV exposures. Healthcare providers should use the drug treatment information of source patients when making decisions about post-exposure prophylaxis.

New guidelines for occupational exposure to blood-borne viruses.

The US Public Health Service recently updated its guidelines for managing health care workers exposed to blood or other body fluids that might contain blood-borne viruses. The update addresses, among other things, timely administration of hepatitis B immune globulin and hepatitis B vaccine, appropriate testing for hepatitis C exposure, and new information on prophylaxis after exposure to human immunodeficiency virus (HIV).

Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker.

BACKGROUND: We report a case of simultaneous HIV and hepatitis C virus (HCV) transmission from a nursing home patient to a health care worker (HCW) whose HIV and HCV infections were diagnosed during routine blood donor screening. METHODS: Detailed information about the HCW, possible occupational and nonoccupational blood and body fluid exposures, and possible source patient was collected. Blood samples were drawn from the HCW and patient, and HIV and HCV laboratory testing was performed at the Centers for Disease Control and Prevention. RESULTS: The HCW, who worked as a nursing home aide, had no nonoccupational risk factors for HIV or HCV infection but provided care for 1 HIV-infected patient with dementia and urinary and fecal incontinence. The HCW had numerous exposures to the patient's emesis, feces, and urine to unprotected chapped and abraded hands. HCW and patient blood samples were positive for anti-HCV by enzyme immunoassay and recombinant immunoblot assay testing. The HCW's and patient's HCV were genotyped as 1a, and their HIV-1 was genotyped as subtype B. HIV and HCV ribonucleic acid (RNA) sequence analysis showed that the HCW's and patient's viruses were very closely related. CONCLUSIONS: HIV and HCV transmission from the patient to the HCW appears to have occurred through nonintact skin exposure. Bloodborne pathogen transmission may have been prevented in this situation by consistent, unfailing use of barrier precautions.

A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study, 1993-1995.

OBJECTIVE: To examine a comprehensive approach for preventing percutaneous injuries associated with phlebotomy procedures. DESIGN AND SETTING: From 1993 through 1995, personnel at 10 university-affiliated hospitals enhanced surveillance and assessed underreporting of percutaneous injuries; selected, implemented, and evaluated the efficacy of phlebotomy devices with safety features (ie, engineered sharps injury prevention devices [ESIPDs]); and assessed healthcare worker satisfaction with ESIPDs. Investigators also evaluated the preventability of a subset of percutaneous injuries and conducted an audit of sharps disposal containers to quantify activation rates for devices with safety features. RESULTS: The three selected phlebotomy devices with safety features reduced percutaneous injury rates compared with conventional devices. Activation rates varied according to ease of use, healthcare worker preference for ESIPDs, perceived "patient adverse events," and device-specific training. CONCLUSIONS: Device-specific features and healthcare worker training and involvement in the selection of ESIPDs affect the activation rates for ESIPDs and therefore their efficacy. The implementation of ESIPDs is a useful measure in a comprehensive program to reduce percutaneous injuries associated with phlebotomy procedures.

Transmission of drug-resistant HIV after an occupational exposure despite postexposure prophylaxis with a combination drug regimen.

We documented a case of occupational human immunodeficiency virus (HIV) despite postexposure prophylaxis (PEP) with a combination drug regimen after percutaneous injury with a needle from a sharps disposal container in the hospital room of an HIV-infected patient. This failure of PEP with a combination drug regimen may have been related to antiretroviral drug resistance, other factors, or both. This case highlights the importance of preventing injury to prevent occupational transmission of HIV.

Comparative analysis of two commercial phenotypic assays for drug susceptibility testing of human immunodeficiency virus type 1.

Human immunodeficiency virus type 1 (HIV-1) isolates from 50 plasma specimens were analyzed for phenotypic susceptibility to licensed reverse transcriptase inhibitors and protease inhibitors by the Antivirogram and PhenoSense HIV assays. Twenty of these specimens were from recently seroconverted drug-naïve persons, and 30 were from patients who were the sources of occupational exposures to HIV-1; 16 of the specimens in the latter group were from drug-experienced patients. The phenotypic results of the Antivirogram and PhenoSense HIV assays were categorized as sensitive or reduced susceptibility on the basis of the cutoff values established by the manufacturers of each assay. Data for 12 to 15 drugs were available by both assays for 38 specimens and represented a total of 529 pairs of results. The two data sets had a 91.5% concordance by phenotypic category. The discordant results (n = 45) were distributed randomly among 26 specimens and included 28 results (62.2%) which were within a twofold difference of the assay cutoff values. None of the discordant results were associated with primary resistance mutations that predicted high-level (>20-fold) resistance. Discordant results were distributed equally among specimens from drug-experienced and drug-naïve individuals and were slightly higher for protease inhibitors than for nonnucleoside reverse transcriptase inhibitors or nucleoside reverse transcriptase inhibitors. The findings of the present study demonstrate that the results of the Antivirogram and PhenoSense HIV assays correlate well, despite the use of different testing strategies.

Use of HIV postexposure prophylaxis by dental health care personnel: an overview and updated recommendations.

BACKGROUND: The authors conducted a study on the use of postexposure prophylaxis, or PEP, for exposure to human immunodeficiency virus, or HIV, among dental health care personnel, or DHCP, enrolled in a surveillance system established by the Centers for Disease Control and Prevention, or CDC. They also discuss updated U.S. Public Health Service, or USPHS, recommendations for managing occupational exposures to HIV, as well as considerations for dentistry. METHODS: The authors analyzed occupational exposures reported by DHCP to the CDC to describe characteristics of the exposure (for example, type and severity), the source patient's HIV status and use of PEP. RESULTS: From June 1995 through August 2001, DHCP reported 208 exposures--199 percutaneous injuries, six mucous membrane exposures and three skin exposures--to the CDC. One-third of these percutaneous injuries were caused by small-bore hollow syringe needles, and most (66 percent) were moderate in depth. Nearly half the devices involved (46 percent) were visibly bloody at the time of injury. Per the criteria described in USPHS guidelines, one-half of the injuries were categorized as "less severe." Twenty-four (13 percent) known source patients were HIV-positive; 14 had symptomatic HIV infection or a high viral load. In this study, three in four DHCP exposed to an HIV-positive source warranted a three-drug PEP regimen. Twenty-nine (24 percent) DHCP exposed to a source patient who subsequently was found to be HIV-negative took PEP; six took PEP for five to 29 days. No exposures resulted in HIV infection. CONCLUSIONS: Findings of this study are consistent with earlier reports indicating that the risk of HIV transmission in dental settings is low. Strategies such as rapid HIV testing of source patients and follow-up counseling may reduce unnecessary use of PEP. CLINICAL IMPLICATIONS: Dental practices should develop comprehensive, written programs for preventing and managing occupational exposures to blood.