Weekly emails to hospital C-suite halt superbug outbreak
Efforts to reduce and stop the spread of infections caused by a highly resistant organism, carbapenem-resistant Acinetobacter baumannii, at a large Florida hospital proved ineffective until executives there added another weapon — weekly emails from the medical director of infection control to hospital leadership, according to a study published in the May issue of the American Journal of Infection Control, the publication of the Association for Professionals in Infection Control and Epidemiology.
When the hospital added the step of sending comprehensive weekly reports to physician, hospital nursing, medical, and administrative leadership, the rate of A. baumannii transmission decreased by 63 percent, according to the research team from the University of Miami Miller School of Medicine. Prior to this, endemic rates of A. baumannii had been present at the institution for nearly two decades.
"These regular highly visible communications allowed us to create a sense of accountability for new cases that unified both the leadership and providers toward the common goal of decreasing new acquisitions of carbapenem-resistant A. baumannii," state the study authors.
"These weekly emails not only packaged information on the number and locations of new acquisitions of A. baumannii, but also described and explained the results of environmental initiatives, hand culture results, and identification of shared objects among patients," add the authors. "Additionally, these communications advised the hospital and each ICU's leaders about the infection control data and provided action plans based on the findings."
The bundle of infection prevention measures included 1) patient screening tests upon admission to the ICU and weekly thereafter; 2) isolation and separation of patients testing positive for A. baumannii; 3) weekly sampling of surfaces in the hospital environment to assess thoroughness of cleaning; 4) hand hygiene interventions, including random cultures of healthcare workers' hands, the results of which were included in the weekly reports; 5) observing shared objects that moved from patient-to-patient; and 6) monthly multidisciplinary meetings to discuss all issues related to implementing the bundle.
The authors conclude, "This is the first study to examine the effect of mass electronic dissemination of results from a bundle of interventions. Weekly electronic communications were associated with a striking decrease in the rate of new acquisitions of A. baumannii at our institution probably because of a combination of education, communication, feedback, and peer pressure."
Acinetobacter baumannii is a type of gram-negative bacteria that is resistant to most antibiotics and has become one of the most worrisome and frequent organisms causing healthcare-associated infections in U.S. health care facilities.
Infections from A. baumannii occur mainly in intensive care units and affect primarily very ill, wounded, or immunocompromised patients. The germ can remain on wet or dry surfaces for longer than most other organisms, making it harder to eradicate. Multidrug-resistant Acinetobacter is classified as a serious threat by the Centers for Disease Control and Prevention.
Overuse of blood transfusions increases infection risk
Blood transfusions are one of the most common procedures patients receive in the hospital but the more red blood cells they receive, the greater their risk of infection, according to a study led by the University of Michigan Heath System and VA Ann Arbor Healthcare System.
Researchers analyzed 21 randomized controlled trials for the study that appears in today's Journal of the American Medical Association.
Elderly patients undergoing hip or knee surgeries were most susceptible, with a 30 percent lower risk of infection when fewer transfusions were used. Overall, for every 38 hospitalized patients considered for a red blood cell transfusion, one patient would be spared a serious infection if fewer transfusions were used.
Transfusions are often used for anemia or during surgery to make up for blood loss. The authors evaluated all health care-associated infections that were reported after receiving donor blood in the randomized trials. These included serious infections such as pneumonia, bloodstream infections and wound infections.
"The fewer the red blood cell transfusions, the less likely hospitalized patients were to develop infections, " says lead author Jeffrey M. Rohde, M.D., assistant professor of internal medicine in the division of general medicine at the U-M Medical School. "This is most likely due to the patient's immune system reacting to donor blood (known as transfusion-associated immunomodulation or TRIM). Transfusions may benefit patients with severe anemia or blood loss; however, for patients with higher red blood cell levels, the risks may outweigh the benefits."
Risks of additional hospital infections were particularly high for patients who already had sepsis. Patients with sepsis were twice as likely to develop additional infections when they received more transfusions.
Approximately 14 million red blood cell units were used in the United States in 2011, most often in the hospital. Lower hemoglobin thresholds are recommended by recent guidelines, but only 27 percent of hospitals that responded to the National Blood Collection and Utilization Survey reported using them after surgery. Only 31 percent of hospitals reported having a blood management program that aims to optimize the care of patients who might need a transfusion.
A nationwide effort called the "Choosing Wisely" campaign recommends that patients planning for surgery or a hospital admission discuss transfusions and other common medical procedures with their physician ahead of time.
Study Finds Physical Signs of Depression Common Among ICUSurvivors
Depression affects more than one out of three survivors of critical illness, according to a Vanderbilt study released in The Lancet Respiratory Medicine, and the majority of patients experience their symptoms physically rather than mentally.
It is one of the largest studies to investigate the mental health and functional outcomes of critical care survivors, according to lead author James Jackson, assistant professor of medicine, and it highlights a significant public health issue, with roughly 5 million patients admitted to intensive care units in the United States each year.
Weakness, appetite change and fatigue — all signs of somatic, or physical, depression — were present in two-thirds of the patients, as opposed to cognitive symptoms such as sadness, guilt or pessimism.
"We need to pay more attention to preventing and treating the physical rather than psychological symptoms of depression in ICU survivors," Jackson said. "The physical symptoms of depression are often resistant to standard treatment with antidepressant drugs, so we need to determine how best to enhance recovery with a new focus on physical and occupational rehabilitation."
The BRAIN-ICU study observed 821 critically ill patients ages 18-90 with respiratory failure or severe sepsis (blood poisoning) admitted to medical or surgical ICUs at Vanderbilt University Hospital and Saint Thomas Hospital.
Vanderbilt researchers assessed survivors for depression, PTSD, functional disability and impact on quality of life at three-month and one-year intervals, reporting that 149 of the 407 patients (37 percent) assessed at three months had at least mild depression, while only 7 percent of patients experienced symptoms of PTSD.
"Depression symptoms were significantly more common than symptoms of PTSD," Jackson said. "And they occurred to a large degree across the entire age range. People tend to have a vision of a frail, older patient who goes to the ICU and is at risk for adverse mental health and, in particular, functional outcomes. But what people don't anticipate is someone in their 20s, 30s or 40s could go to the ICU and leave with functional disability, depression or PTSD. These problems are not really a function of old age."
One-third of the survivors who developed depression still had depressive symptoms at their one-year assessment, a statistic that Jackson said could, in part, be due to high expectations they set for rehabilitation.
"They have some arbitrary timeline set and they reach that date and they're still not better and, in some cases, not a lot better at all," he said. "Then what can happen is that depression can really worsen because they set this expectation that was really unrealistic and they feel like they have missed the goal.
"So that's a big challenge, recalibrating expectations. This is especially hard for the many high-achieving, type A, patients that we might see who leave the ICU and want to get back to work right away, want to compete in the triathlon right away. They tend to have the hardest time," he said.
Jackson said study authors gained additional perspective on their patients by doing at-home assessments following discharge.
"Home visits were the really interesting part of this," Jackson said. "What it enabled us to do was to see patients in their real-life surroundings in actual circumstances in which they were sometimes a little more willing, I think, to disclose their problems. When you see someone in a hospital, the situation is a little more sterile. When you get to know them in their homes, we felt like you really get to know them and that was often the context where they told us about their depression.
"One thing we learned was that if people don't have significant social support, they are profoundly limited in their ability to access care or improve in key areas," he added.
Vanderbilt is now following ICU patients after discharge through the Vanderbilt ICU Recovery Center, which opened in late 2012, Jackson said.