Browsing by Author "Barnett, Adrian G."
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Item An Environmental Cleaning Bundle and Health-Care-Associated Infections in Hospitals (REACH): A Multicentre, Randomised Trial(2019-04-01) Graves, Nicholas; Gericke, Christian A.; Farrington, Alison; Page, Katie; Gardner, Anne; Riley, Thomas V.; Paterson, David L.; Halton, Kate; Barnett, Adrian G.; White, Nicole; Hall, Lisa; Mitchell, Brett G.Background The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals.
Methods The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505.
Findings Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41–0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60–1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88–1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83–2·34, p
Interpretation The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice.
Funding National Health and Medical Research Council (Australia).
Item Cost-Effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare Associated Infections(2020-06-15) Graves, Nicholas; Gericke, Christian A.; Page, Katie; Gardner, Anne; Riley, Thomas V.; Paterson, David L.; Halton, Kate; Farrington, Alison; Mitchell, Brett G.; Hall, Lisa; Barnett, Adrian G.; White, NicoleBackground
Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016–2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs.
Methods
A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices.
Results
Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices.
Conclusions
A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.
Item Length of Stay and Mortality Associated with Healthcare-Associated Urinary Tract Infections: A Multi-State Model(2016-05-01) Barnett, Adrian G.; Sear, Jacqueline; Anderson, Malcolm; Ferguson, John K.; Mitchell, Brett G.Background: The emergence of antimicrobial resistance is of particular concern with respect to urinary tract infections, since the majority of causative agents are Gram negative bacteria. Healthcare-associated urinary tract infections (HAUTIs) are frequently associated with instrumentation of the urinary tract, specifically within dwelling catheters.
Aim: To evaluate the current incidence, mortality, and length of hospital stay associated with HAUTIs.
Methods: A non-concurrent cohort study design was used, conducted between January 1st, 2010 and June 30th, 2014. All patients admitted to one of the eight participating Australian hospitals and who were hospitalized for more than two days were included. The primary outcome measures were the incidence, mortality, and excess length of stay associated with HAUTIs.
Findings: From 162,503 patient admissions, 1.73% [95% confidence interval (CI): 1.67 e1.80] of admitted patients acquired a HAUTI. Using a multi-state model, the expected extra length of stay due to HAUTI was four days (95% CI: 3.1e5.0 days). Using a Cox regression model, infection significantly reduced the rate of discharge (hazard ratio: 0.78; 95% CI: 0.73e0.83). Women were less likely to die (0.71; 0.66e0.75), whereas older patients were more likely to die (1.40; 1.38e1.43). Death was rarer in a tertiary referral hospital compared to other hospitals, after adjusting for age and sex (0.74; 0.69e0.78).
Conclusion: This study is the first to explore the burden of HAUTIs in hospitals using appropriate statistical methods in a developed country. Our study indicates that the incidence of HAUTI, in addition to its associated extra length of stay in hospital, presents a burden to the hospital system. With increasing incidence of UTI due to antimicrobial-resistant organisms, surveillance and interventions to reduce the incidence of HAUTI are required.
Item Length of Stay and Mortality Associated with Healthcare-Associated Urinary Tract Infections: A Multistate Model(2016-04-01) Barnett, Adrian G.; Sear, Jacqueline; Anderson, Malcolm; Ferguson, John K.; Mitchell, Brett G.Background: To evaluate the current incidence, mortality and length of stay associated with healthcare associated urinary tract infections (HAUTIs). Material/methods: A non-concurrent cohort study design is used, conducted between 1 January 2010 and 30 June 2014. All patients admitted to one of the eight participating Australian hospitals and who were hospitalised more than two days were included. The primary outcomes measures were the incidence, mortality and excess length of stay associated with healthcare associated urinary tract infections. Results: From 162,503 patient admissions, 1.73% (95% CI 1.67–1.80) of admitted patients acquired a HAUTI. Using a multi-state model, the expected extra length of stay due to HAUTI was 4 days, 95% CI 3.1–5.0 days. Using a Cox regression model, infection significantly reduced the rate of discharge (HR 0.78, 95%CI, 0.73-0.83. Women were less likely to die (HR 0.71, 95%CI 0.66-0.75), whereas older patients were more likely to die (HR 1.40, 95%CI 1.38-1.43). Death was rarer in a tertiary referral hospital compared to other hospitals, after adjusting for age and sex (HR 0.74, 95%CI, 0.69-0.78). Conclusions: This study is the first study to explore the burden of HAUTIs in hospitals using appropriate statistical methods in a developed country. Our study indicates that the incidence of HAUTI in addition to its associated extra length of stay in hospital, present a burden to the hospital system. With increasing incidence of UTI due to antimicrobial resistant organisms, surveillance and interventions to reduce the incidence of HAUTI are required.
Item Researching Effective Approaches to Cleaning in Hospitals: Protocol of the REACH Study, A Multi-Site Stepped-Wedge Randomised Trial(2016-03-24) Graves, Nicholas; Paterson, David L.; Gericke, Christian A.; Riley, Thomas V.; Dancer, Stephanie; Bailey, Emily; Havers, Sally; Gardner, Anne; Page, Katie; Allen, Michelle; Halton, Kate; Barnett, Adrian G.; Mitchell, Brett G.; Farrington, Alison; Hall, LisaBackground: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.
Methods/design: The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle. The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital
Discussion: Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.
Item The High Costs of Getting Ethical and Site-Specific Approvals for Multi-Centre Research(2016-12-07) Graves, Nicholas; Mitchell, Brett G.; Gardner, Anne; Page, Katie; Hall, Lisa; Farrington, Alison; Shield, Carla; Campbell, Megan J.; Barnett, Adrian G.Background
Multi-centre studies generally cost more than single-centre studies because of larger sample sizes and the need for multiple ethical approvals. Multi-centre studies include clinical trials, clinical quality registries, observational studies and implementation studies. We examined the costs of two large Australian multi-centre studies in obtaining ethical and site-specific approvals.
Methods
We collected data on staff time spent on approvals and expressed the overall cost as a percent of the total budget.
Results
The total costs of gaining approval were 38 % of the budget for a study of 50 centres (mean cost AUD $6960 per site) and 2 % for a study of 11 centres (mean cost AUD $2300 per site). Seventy-five and 90 % of time was spent on repeated tasks, respectively, and many time-consuming tasks, such as reformatting documents, did nothing to improve the study design or participant safety.
Conclusions
Improvements have been made to the ethical approval application system, but more gains could be made without increasing risks of harm to research participants. We propose that ethical review bodies and individual sites publish statistics on how long they take to process approvals which could then be nationally benchmarked.
Item The Impact of Urinary Tract Infections in an Australian Setting: A Multi-State Model(2016-04-01) Barnett, Adrian G.; Sear, Jacqueline; Anderson, Malcolm; Ferguson, John K.; Mitchell, Brett G.The emergence of antimicrobial resistance is of particular concern with respect to urinary tract infections, since the majority of causative agents are Gram negative bacteria. Healthcare-associated urinary tract infections (HAUTIs) are frequently associated with instrumentation of the urinary tract, specifically within dwelling catheters.
Item The Prolongation of Length of Stay Because of Clostridium Difficile Infection(2014-02-01) Graves, Nicholas; Hiller, Janet; Barnett, Adrian G.; Gardner, Anne; Mitchell, Brett G.Background
Clostridium difficile infection (CDI) possibly extends hospital length of stay (LOS); however, the current evidence does not account for the time-dependent bias, ie, when infection is incorrectly analyzed as a baseline covariate. The aim of this study was to determine whether CDI increases LOS after managing this bias.
Methods
We examined the estimated extra LOS because of CDI using a multistate model. Data from all persons hospitalized >48 hours over 4 years in a tertiary hospital in Australia were analyzed. Persons with health care-associated CDIs were identified. Cox proportional hazards models were applied together with multistate modeling.
Results
One hundred fifty-eight of 58,942 admissions examined had CDI. The mean extra LOS because of infection was 0.9 days (95% confidence interval: −1.8 to 3.6 days, P = .51) when a multistate model was applied. The hazard of discharge was lower in persons who had CDI (adjusted hazard ratio, 0.42; P < .001) when a Cox proportional hazard model was applied.
Conclusion
This study is the first to use multistate models to determine the extra LOS because of CDI. Results suggest CDI does not significantly contribute to hospital LOS, contradicting findings published elsewhere. Conversely, when methods prone to result in time-dependent bias were applied to the data, the hazard of discharge significantly increased. These findings contribute to discussion on methods used to evaluate LOS and health care-associated infections.
Item Variation in Hospital Cleaning Practice and Process in Australian Hospitals: A Structured Mapping Exercise(2017-12-01) Graves, Nicholas; Paterson, David L.; Gericke, Christian A.; Riley, Thomas V.; Dancer, Stephanie; Page, Katie; Halton, Kate; Barnett, Adrian G.; Hall, Lisa; Gardner, Anne; Allen, Michelle; Farrington, Alison; Mitchell, Brett G.Background: The purpose of this paper is to highlight the range of cleaning practices and processes in 11 Australian hospitals and to discuss the challenges this variation poses to the implementation of clinical trials or changes to hospital cleaning practices.
Methods: A cross-sectional study design was used to determine cleaning practices and processes in hospitals participating in the ‘Researching Effective Approaches to Cleaning in Hospitals’ (REACH) study. A standardised template and approach was used to collect information. Data collection activities included structured on-site discussions, a review of hospital practices and a document review of policy and procedural documents related to cleaning.
Results: Variations in the auditing process used to evaluate environmental cleanliness, cleaning practices, product use, training and communication pathways available to cleaning staff were identified. There was also variation in workforce structure and responsibilities for cleaning.
Conclusion: This paper is the first to describe the differences in cleaning practices between Australian hospitals. The variations identified present a number of challenges for the conduct of research and have important implications for both monitoring of and standards for cleanliness. These challenges include implementing a practice change or cleaning study where hospitals have different processes, practices and structures.