Improving leadership skills of infection prevention and control teams by psychological empowerment: study protocol for a cluster randomised controlled trial (IP-POWER).

INTRODUCTION: Infection prevention and control (IPC) teams are routinely confronted with intense emotions in their daily work, as they are involved in many change processes with front-line medical staff, for example, when promoting compliance with basic IPC measures. In addition, they are confronted with challenges due to their role as intermediaries. Based on former research, this study aims to empower IPC teams to promote clinicians' compliance through interventions focusing on the IPC teams' leadership skills. METHODS AND ANALYSIS: The IP-POWER study (Infection Prevention with head and heart: Psychological empowerment of IPC teams), a multicentre, two-arm, non-blinded, cluster-randomised controlled trial with a parallel waiting control group, is planned to be conducted in Germany as of February to November 2024. A group of 10 voluntary hospitals is going to participate in a multistage intervention programme, including 2 days of intense psychological training; 5 hospitals will be randomly assigned to the waiting control group. After the workshops, there will be a 12-week follow-up period during which the contents learnt within the workshops can be applied and internalised into IPC practice. The proposed outcomes (both self-assessed and other-assessed leadership competencies of IPC team members and their task profiles, perceived workload, motivation to act in order to implement IP measures and goal attainment) are going to be collected with an online questionnaire, followed by an analysis with IBM SPSS (Statistics 29 (or later)) using descriptive analyses and multiple linear regressions. Additionally, as external data sources, hand hygiene compliance rates from the study hospitals' monitoring systems will be analysed using χ² tests. ETHICS AND DISSEMINATION: This study was reviewed and approved by the ethics committee of the University of Leipzig (184/23-ek; vote from 4 July 2023). Findings will be disseminated via peer-review publications, and national and international conference presentations. TRIAL REGISTRATION NUMBER: DRKS00031879.

Incidence, risk factors and healthcare costs of central line-associated nosocomial bloodstream infections in hematologic and oncologic patients.

Non-implanted central vascular catheters (CVC) are frequently required for therapy in hospitalized patients with hematological malignancies or solid tumors. However, CVCs may represent a source for bloodstream infections (central line-associated bloodstream infections, CLABSI) and, thus, may increase morbidity and mortality of these patients. A retrospective cohort study over 3 years was performed. Risk factors were determined and evaluated by a multivariable logistic regression analysis. Healthcare costs of CLABSI were analyzed in a matched case-control study. In total 610 patients got included with a CLABSI incidence of 10.6 cases per 1,000 CVC days. The use of more than one CVC per case, CVC insertion for conditioning for stem cell transplantation, acute myeloid leukemia, leukocytopenia (≤ 1000/µL), carbapenem therapy and pulmonary diseases were independent risk factors for CLABSI. Hospital costs directly attributed to the onset of CLABSI were 8,810 € per case. CLABSI had a significant impact on the overall healthcare costs. Knowledge about risk factors and infection control measures for CLABSI prevention is crucial for best clinical practice.

Incidence and risk factors of surgical site infection after total knee arthroplasty: Results of a retrospective cohort study.

Knee arthroplasty is commonly performed in the case of advanced osteoarthritis, and deep joint infections represent a severe complication following surgery. A 4-year retrospective cohort study was conducted to determine the incidence and risk factors for such surgical site infections. Of the 2439 patients included in the study, 84 of them (3.4%) developed infections. Postoperative bleeding, Ahlbäck's disease, obesity, smoking, and male gender were independent risk factors that should be considered when caring for those patients.

Economic burden of nosocomial infections caused by vancomycin-resistant enterococci.

Background: Nosocomial infections due to vancomycin-resistant enterococci (VRE) have become a major problem during the last years. The purpose of this study was to investigate the economic burden of nosocomial VRE infections in a European university hospital. Methods: A retrospective matched case-control study was performed including patients who acquired nosocomial infection with either VRE or vancomycin-susceptible enterococci (VSE) within a time period of 3 years. 42 cases with VRE infections and 42 controls with VSE infections were matched for age, gender, admission and discharge within the same year, time at risk for infection, Charlson comorbidity index (±1), stay on intensive care units and non-intensive care units as well as for the type of infection, using criteria of the Centers for Disease Control and Prevention. Results: The median overall costs per case were significantly higher than for controls (EUR 57,675 vs. EUR 38,344; p = 0.030). Costs were similar between cases and controls before onset of infection (EUR 17,893 vs. EUR 16,600; p = 0.386), but higher after onset of infection (EUR 37,971 vs. EUR 23,025; p = 0.049). The median attributable costs per case for vancomycin-resistance were EUR 13,157 (p = 0.036). The most significant differences in costs between cases and controls turned out to be for pharmaceuticals (EUR 6030 vs. EUR 2801; p = 0.008) followed by nursing staff (EUR 8956 vs. EUR 4621; p = 0.032), medical products (EUR 3312 vs. EUR 1838; p = 0.020), and for assistant medical technicians (EUR 3766 vs. EUR 2474; p = 0.023). Furthermore, multivariate analysis revealed that costs were driven independently by vancomycin-resistance (1.4 fold; p = 0.034). Conclusions: This analysis suggested that nosocomial VRE infections significantly increases hospital costs compared with VSE infections. Therefore, hospital personal should implement control measures to prevent VRE transmission.

EFFECT of daily antiseptic body wash with octenidine on nosocomial primary bacteraemia and nosocomial multidrug-resistant organisms in intensive care units: design of a multicentre, cluster-randomised, double-blind, cross-over study.

INTRODUCTION: Nosocomial infections are serious complications that increase morbidity, mortality and costs and could potentially be avoidable. Antiseptic body wash is an approach to reduce dermal micro-organisms as potential pathogens on the skin. Large-scale trials with chlorhexidine as the antiseptic agent suggest a reduction of nosocomial infection rates. Octenidine is a promising alternative agent which could be more effective against Gram-negative organisms. We hypothesise that daily antiseptic body wash with octenidine reduces the risk of intensive care unit (ICU)-acquired primary bacteraemia and ICU-acquired multidrug-resistant organisms (MDRO) in a standard care setting. METHODS AND ANALYSIS: EFFECT is a controlled, cluster-randomised, double-blind study. The experimental intervention consists in using octenidine-impregnated wash mitts for the daily routine washing procedure of the patients. This will be compared with using placebo wash mitts. Replacing existing washing methods is the only interference into clinical routine.Participating ICUs are randomised in an AB/BA cross-over design. There are two 15-month periods, each consisting of a 3-month wash-out period followed by a 12-month intervention and observation period. Randomisation determines only the sequence in which octenidine-impregnated or placebo wash mitts are used. ICUs are left unaware of what mitts packages they are using.The two coprimary endpoints are ICU-acquired primary bacteraemia and ICU-acquired MDRO. Endpoints are defined based on individual ward-movement history and microbiological test results taken from the hospital information systems without need for extra documentation. Data on clinical symptoms of infection are not collected. EFFECT aims at recruiting about 45 ICUs with about 225 000 patient-days per year. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of the University of Leipzig (number 340/16-ek) in November 2016. Findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: DRKS-ID: DRKS00011282.

Promoting Hand Hygiene Compliance: PSYGIENE­a Cluster-Randomized Controlled Trial of Tailored Interventions

BACKGROUND: The German "Clean Hands Campaign" (an adaptation of the WHO "Clean Care is Safer Care" programme) to promote hand hygiene among hospital personnel at Hannover Medical School (MHH, Medizinische Hochschule Hannover), known as Aktion Saubere Hände (ASH), met with initial success. By 2013, however, compliance rates with hygienic hand disinfection in the hospital's ten intensive care units (ICUs) and two hematopoietic stem cell transplantation units (HSCTUs) had relapsed to their initial levels (physicians: 48%; nurses: 56%). The cluster- randomized controlled trial PSYGIENE was conducted to investigate whether interventions tai - lored in ways suggested by research in behavioral psychology might bring about more sustainable improvements than the ASH. METHODS: The "Health Action Process Approach" (HAPA) compliance model specifies key psychological determinants of compliance. These determinants were assessed among health care workers in the ICUs and HSCTUs of the MHH by questionnaire (response rates: physicians: 71%; nurses: 63%) and by interviews of the responsible ward physicians and head nurses (100%). In 2013, 29 tailored behavior change techniques were implemented in educational training sessions and feedback discussions in the six wards that constituted the intervention arm of the trial, while ASH training sessions were provided in the control arm. The compliance rates for 2014 and 2015 (the primary outcomes of the trial) were determined by nonparticipating observation of hygienic hand disinfection, in accordance with the World Health Organization's gold standard. RESULTS: The two groups did not differ in their baseline compliance rates in 2013 (intervention: 54%, control: 55%, p = 0.581). The tailored interventions led to increased compliance in each of the two follow-up years (2014: 64%, p<0.001; 2015: 70%, p = 0.001), while the compliance in the control arm increased to 68% in 2014 (p<0.001) but fell back to 64% in 2015 (p = 0.007). The compliance increases from 2013-2015 and the compliance rate in 2015 were higher in the intervention arm (p<0.005). This was mainly attributable to the nurses' behavior, as the corresponding parameters for physicians did not differ significantly between the two study arms in stratified analysis. CONCLUSION: Tailored interventions based on behavioral psychology principles led to more sustainable increases in compliance with hand hygiene guidelines than ASH training sessions did. This was true among nurses, and thus also for hospital ward personnel as a whole (i.e., nurses and physicians combined). Further studies are needed to identify more target group-specific interventions that may improve compliance among physicians.

Hand hygiene compliance in transplant and other special patient groups: an observational study.

BACKGROUND: This study evaluates hand hygiene behavior of health care workers in a German university hospital stratified for treatment of special patient groups (eg, transplant patients). METHODS: From 2008 to 2010, comprehensive education and training of all health care workers was implemented to improve hand hygiene compliance. Consumption rates of alcohol-based hand rub and gloves were collected and evaluated. RESULTS: Of the 5,647 opportunities of hand disinfection evaluated, 1,607 occurred during care for transplant patients. To our knowledge, this is the largest survey of hand hygiene compliance in special patient groups on intensive care units in a university hospital in Germany. Health care workers on surgical intensive care units showed lower hand hygiene compliance compared with health care workers on other types of intensive care units. Compliance toward hand hygiene was significantly higher on hemato-oncologic and pediatric wards. In general, hand disinfection was performed significantly more frequently after an intervention than before (P < .05, 95% confidence interval: 1.24-1.84). Overall, there was no significant difference in hand hygiene compliance when caring for transplant patients or other patients (odds ratio, 1.16; 95% confidence interval: 0.95-1.42). Nurse's and physician's hand hygiene compliance improved because of education. CONCLUSION: Hand hygiene compliance is not increased in the care for transplant patients (despite their predisposition for nosocomial infections) compared with other patients. Additional studies will be necessary to further investigate these findings.

Surgical site infections--economic consequences for the health care system.

PURPOSES: Unfortunately, surgical site infections (SSIs) are a quite common complication and represent one of the major causes of postoperative morbidity and mortality, and may furthermore lead to enormous additional costs for hospitals and health care systems. METHODS: In order to determine the estimated costs due to SSIs, a MEDLINE search was performed to identify articles that provide data on economic aspects of SSIs and compared to findings from a matched case-control study on costs of SSIs after coronary bypass grafting (CABG) in a German tertiary care university hospital. RESULTS: A total of 14 studies on costs were found. The additional costs of SSI vary between $3,859 (mean) and $40,559 (median). Median costs of a single CABG case in the recently published study were $49,449 (€36,261) vs. $18,218 (€13,356) in controls lacking infection (p < 0.0001). The median reimbursement from health care insurance companies was $36,962 (€27,107) leading to a financial loss of $12,482 (€9,154) each. CONCLUSION: Costs of SSIs may almost triple the individual overall health care costs and those additional charges may not be sufficiently covered. Appropriate measures to reduce SSI rates must be taken to improve the patient's safety. This should also diminish costs for health care systems which benefits the entire community.

Economic aspects of deep sternal wound infections.

OBJECTIVES: Surgical-site infections are a very expensive complication in cardiac surgery. Thus, the total costs for coronary artery bypass grafting (CABG) surgery may substantially increase when a deep sternal wound infection (DSWI) occurs. This may be due to an extended length of stay (LOS), the need for additional surgical procedures, vacuum-assisted wound dressing and antibiotic therapy. This study compares the LOS in the hospital and on an intensive care unit (ICU) as well as the total costs for patients undergoing CABG depending upon the occurrence of a subsequent DSWI. METHODS: A case-control study was performed. Total costs of DSWI cases were analysed and compared to patients undergoing CABG without DSWI. Inclusion criterion for cases was the development of a DSWI according to the CDC criteria during hospital stay after CABG. Two control patients without any signs or symptoms of an infection during hospital stay were matched to each case by (1) type of surgery according to their diagnosis-related group (DRG), (2) age +/-5 years, (3) gender and (4) duration of preoperative hospital stay +/-2 days, but at least as long as the time at risk of cases before infection. RESULTS: Between January 2006 and March 2008, 17 CABG patients with DSWI (cases) and 34 matched controls were included. The median overall costs of a CABG case were 36,261 Euro compared with 13,356 Euro per control patient without infection (p<0.0001). The median overall LOS was 34.4 days versus 16.5 days, respectively (p=0.0006). The median LOS on ICU was 6.3 days versus 5.3 days (no significant difference). CONCLUSION: DSWI represents an important economic factor for the hospital as they may almost triple the costs for patients undergoing CABG. Thus, appropriate infection control measures for the prevention of DSWI should be enforced.