Background

Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI.

Objective

Determine whether there is an association between the nurse work environment and hospital-onset CDI.

Methods

Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average.

Results

In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile.

Conclusions

Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

The assessment of MDRO infection and colonization should include the identification of known carriers, the detection of hospital-specific and healthcare-associated acquisition, an estimation of the burden of serious infection, an understanding of the reservoir affecting the transmission of MDROs, and an evaluation of the effect of intervention. Several strategies can be used to obtain data that aid in this assessment. We have defined and categorized the recommended metrics for each of these aspects of measuring MDRO infection and colonization, for use by healthcare facilities. © 2008 by The Society for Healthcare Epidemiology of America. All rights reserved.

To determine frequency of methicillin-resistant Staphylococcus aureus infections caused by strains typically associated with community-acquired infections (USA300) among persons with healthcare-related risk factors (HRFs), we evaluated surveillance data. Of patients with HRFs, 18%-28% had a "community-associated" strain, primarily USA300; of patients without HRFs, 26% had a "healthcare-associated" strain, typically USA100.

Background

Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records.

Objective

To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics.

Research design

Retrospective.

Subjects

Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities.

Measures

We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration.

Results

Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%-98%, κ=0.5-0.82), antibiotic choice (agreement=89%-100%, κ=0.70-0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r=0.97, P<0.001; antipseudomonal r=0.95, P<0.001) and therapy duration (r=0.77, P<0.001) but lower facility-level consistency for days to clinical stability (r=0.52, P=0.006) or excessive duration of therapy (r=0.55, P=0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity.

Conclusions

Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.