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Biomedical subjects

R W Haley

Publications and source records attributed to R W Haley.

At least 19 recordsLinked to original sources
PubMed1992

The necessity and efficiency of wound surveillance after discharge.

A surgical wound surveillance program followed up 16,453 consecutive patients from 1983 through 1988. Patients were followed up for 30 days after operation, and 516 (35%) of the surgical wound infections first became manifest after discharge. In-hospital surveillance alone would have estimated the surgical wound infection rate to be 5.8% when the true rate was 8.9%. Infections that occurred after discharge were more likely in clean operations, in shorter operations, in obese patients, and in nonalcoholic patients. The probability that infections would begin after discharge was inversely associated with the duration of postoperative stay in the hospital. Postdischarge follow-up of patients who previously have undergone surgery is necessary to avoid underestimated of the infection rates and biases related to known risk factors. The most efficient time to survey patients appears to be at 21 days after the operation, at which time 90% of surgical wound infections have occurred.

Alcoholism↗
PubMed1991

Measuring the costs of nosocomial infections: methods for estimating economic burden on the hospital.

To compete more effectively for resources, it is increasingly important for infection control practitioners to estimate the costs of nosocomial infections and the amount of money their infection control programs save the hospital. Studies on costs should estimate both extra length of stay and extra costs attributable to infectious complications. Cost estimates should either adjust charges by a cost to charge ratio, which is relatively easy, or estimate hospital costs directly by detailed cost-accounting, which is comparatively more difficult. If there is insufficient time to measure costs concurrently in every infected patient, comparative studies can be done by comparing infected and uninfected patients matched on characteristics that control for the preexisting differences between them. Diagnosis-related groups and the number of diagnoses appear to be useful matching variables because they are strongly associated with both nosocomial infection and length of stay. The final results should be expressed as either potential or actual savings to the hospital, depending on whether significant reductions in nosocomial infection rates have been achieved.

Cost Savings↗
PubMed1991

Nosocomial infections in surgical patients: developing valid measures of intrinsic patient risk.

For surgeons or hospitals to compare their rates of wound infection meaningfully, the analysis must first control for the mix of intrinsic infection risk of their patients. Research over the past century has led to the development of several intrinsic risk indexes that can be used to stratify the wound infection rates so that valid comparisons can be made within risk strata. For an intrinsic risk index to be useful for comparing rates, it must control for all of the important intrinsic risk constructs; merely being statistically associated with infection rates does not ensure that a risk index will be useful. Understanding how a risk index can be both parsimonious and comprehensive requires consideration of the competing principles of multicollinearity and orthogonality. Various techniques of multivariate analysis are used to develop multivariate risk indexes, but the success of the process depends on having all of the important orthogonal risk constructs represented in the pool of predictor variables available for the analysis, either directly by variables in the pool or by demonstrated multicollinearity. Despite recent advances in risk measurement, many important questions remain.

Cross Infection↗
PubMed1989

Tuberculosis epidemic among hospital personnel.

Six employees of the emergency department at Parkland Memorial Hospital developed active tuberculosis in 1983-1984. Five of the cases occurred four to 12 months after exposure to the index case, a patient with severe cavitary tuberculosis seen in the emergency department in April 1983. One resident physician developed cavitary disease after exposure to this patient. An additional employee case may have resulted from transmission from one of the initial employee cases. One immunocompromised patient may have acquired tuberculosis as a result of exposure to the index case. In addition, the tuberculin skin tests of at least 47 employees exposed to the index case converted from negative to positive. Of 112 previously tuberculin-negative emergency department employees who were tested in October 1983, 16 developed positive skin tests, including the 5 employees with active disease. Fifteen of these new positives had worked on April 7, 1983, while the index case was in the emergency department (X2 = 20.6, P less than 0.001). Factors related to the genesis of the epidemic included the disease characteristics in the index case and the recirculation of air in the emergency department. This investigation indicates that city-county hospital emergency department employees should be screened at least twice a year for evidence of tuberculosis and that the employee health services of such hospitals should regard the surveillance of tuberculosis infection among personnel at a high-priority level.

Aged↗
PubMed1987

The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system. An empirical determination from a nationally representative sample.

To clarify the financial incentives for hospitals to prevent nosocomial infections, we analyzed 9423 nosocomial infections identified in 169 526 admissions selected randomly from the adult admissions to a random sample of US hospitals. By classifying each admission into a baseline diagnosis related group (DRG) (after first excluding all diagnoses of nosocomial infection) and a final DRG (after including these diagnoses), we found that only 5% to 18% of nosocomial infections would have caused the admission to be reclassified to a higher-paying DRG, depending on the extent to which physicians recorded nosocomial infection diagnoses in patients' medical records. The extra payment from the reclassification, averaged over all nosocomial infections, would have been no more than $93 per infection (in 1985 reimbursement rates), constituting only 5% of the hospitals' costs for treating these infections. Thus, at least 95% of the cost savings obtained from preventing nosocomial infections represents financial gains to the hospital.

Adult↗
PubMed1987

Fever in hospitalized patients. With special reference to the medical service.

Fever (oral temperature of 38 degrees C or more on two or more consecutive days) during the hospital stay of 4,065 patients admitted to Grady Memorial Hospital during an 11-week period was studied. At least one episode of fever occurred in 1,194 patients (29 percent). Rates of fever were highest on medical and surgical services. Review of 341 episodes of fever in 302 patients on the medical service identified a single potential cause in 56 percent. Multiple factors were present in 26 percent, and no potential causes were found in 18 percent. Of 390 factors identified, 44 percent were community-acquired infections, 9 percent were nosocomial infections, 20 percent possibly involved infection, and 26 percent were noninfectious processes. Fever is a frequent finding in hospitalized patients. Both infectious and noninfectious processes play important roles. Determining the cause of fever is complicated by the multiplicity of possible causes.

Cross Infection↗
PubMed1987

Factors which influence the risk of wound infection in trauma patients.

Surgical wound infections following traumatic injury remain a source of morbidity and mortality. A simple system for estimating the risk of infectious complications was evaluated in 949 trauma patients requiring operative therapy. The majority of cases were caused by penetrating trauma (784). Truncal, neck, and extremity procedures were included. The overall wound infection rate was 7%. Infection rates were related to amount of bacterial contamination and mechanism of injury. Age, type of antibiotics, and delay time from injury to operation were not risk factors for any injury type. Wound classification, shock, blood loss, number of organs injured, and operative time were significant risk factors, but had different effects on infection rate related to injury type. Multivariate analysis revealed no significant infectious risk factors for stabwounds. Significant factors were wound class (p = 0.02) and shock (p = 0.001) for gunshot wounds, wound class (p = 0.03) and number of organs injured (p = 0.01) for blunt trauma, and blood loss (p = 0.01) for shotgun wounds. This classification system can be used to review outcome and compare trauma patient populations for infectious morbidity in a more uniform fashion.

Adult↗
PubMed1985

Update from the SENIC project. Hospital infection control: recent progress and opportunities under prospective payment.

From a survey of all U.S. hospitals in 1976 and of a random sample in 1983, we found that the intensity of infection surveillance and control activities greatly increased, and the percentage of hospitals with an infection control nurse per 250 beds increased from 22% to 57%. The percentage with a physician trained in infection control remained low (15%), and there was a drop in the percentages of hospitals doing surgical wound infection surveillance (from 90% down to 79%) and reporting surgeon-specific rates to surgeons (from 19% down to 13%). There was an increase in the percentage of hospitals with programs shown to be effective in preventing urinary tract infections, bacteremias, and pneumonias, but not surgical wound infections. The percentage of nosocomial infections being prevented nationwide appears to have increased from 6% to only 9%, whereas 32% could be prevented if all hospitals adopted the most effective programs.

Cross Infection↗
PubMed1985

How frequent are outbreaks of nosocomial infection in community hospitals?

A statistical algorithm was used to identify potentially important clusters among nosocomial infections reported each month by 7 community hospitals. Epidemiologic review and on-site investigations distinguished outbreaks of clinical disease from factitious clusters. In 1 year, 8 outbreaks were confirmed. They involved 82 patients--approximately 2% of patients with nosocomial infections and 0.09% of all discharges. One true outbreak occurred for every 12,000 discharges--at least 1 outbreak per year for the average community hospital. Five (63%) outbreaks were recognized independently by the hospitals' infection control personnel. Four (50%) resolved spontaneously; the hospitals' own control measures were necessary in 2; and 2 resolved only after an outside investigation. Organized surveillance appears necessary to detect some outbreaks, and control measures are needed to stop many. Since, however, outbreaks account for such a small proportion of nosocomial infections, infection control programs should be sufficiently staffed and managed so that most of the effort is directed toward the surveillance and control of endemic infection problems, but with adequate resources remaining to respond to outbreaks when they occur.

Cross Infection↗
PubMed1985

The nationwide nosocomial infection rate. A new need for vital statistics.

From a random sample of patients and hospitals and extrapolation ratios derived from the best available sources of data, the authors estimate that the nationwide nosocomial infection rate among the 6,449 acute-care US hospitals in 1975-1976 was 5.7 nosocomial infections per 100 admissions and that over 2 million nosocomial infections occurred in a 12-month period in these hospitals. Nosocomial urinary tract infections constituted 42% of the infections, surgical wound infections 24%, nosocomial pneumonia 10%, nosocomial bacteremia 5%, and nosocomial infections at all other sites 19%. If adjustments are made for the accuracy of the diagnostic method, the increasing nationwide secular trend, and the number of nosocomial infections in nursing homes, however, as many as 4 million nosocomial infections per year may now be occurring. This greatly exceeds previous estimates and calls for timely and accurate vital statistics on the problem.

Adult↗
PubMed1985

Increased recognition of infectious diseases in US hospitals through increased use of diagnostic tests, 1970-1976.

To assess the influence of physicians' diagnostic practices on the recognition of nosocomial infections, the authors analyzed data collected on 339,044 patients selected randomly from admissions in 1970 and 1975-1976 to 338 randomly selected hospitals representative of all acute-care US hospitals. Eight rates representing the frequency of cultures or chest x-rays among patients with or without signs of infection were calculated. These varied widely among hospitals, were highest in teaching hospitals and in the Northeast, but increased more among small hospitals and in the South and West. Rates of performing urine cultures and reporting colony counts were highly correlated with observed rates of nosocomial urinary tract infection. Analogous measures were moderately correlated with observed bacteremia rates and pneumonia rates but were only weakly associated with surgical wound infection rates. These data indicate that the nationwide increase in the use of these diagnostic tests increased the recognition of infectious diseases in US hospitals.

Cost Control↗
PubMed1985

The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.

In a representative sample of US general hospitals, the authors found that the establishment of intensive infection surveillance and control programs was strongly associated with reductions in rates of nosocomial urinary tract infection, surgical wound infection, pneumonia, and bacteremia between 1970 and 1975-1976, after controlling for other characteristics of the hospitals and their patients. Essential components of effective programs included conducting organized surveillance and control activities and having a trained, effectual infection control physician, an infection control nurse per 250 beds, and a system for reporting infection rates to practicing surgeons. Programs with these components reduced their hospitals' infection rates by 32%. Since relatively few hospitals had very effective programs, however, only 6% of the nation's approximately 2 million nosocomial infections were being prevented in the mid-1970s, leaving another 26% to be prevented by universal adoption of these programs. Among hospitals without effective programs, the overall infection rate increased by 18% from 1970 to 1976.

Adult↗
PubMed1985

Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination.

To predict the likelihood that a patient will develop a surgical wound infection from several risk factors, the authors used information collected on 58,498 patients undergoing operations in 1970 to develop a simple multivariate risk index. Analyzing 10 risk factors with stepwise multiple logistic regression techniques, they developed a model combining information on four of the risk factors to predict a patient's probability of getting a surgical wound infection. Then, with information collected on another sample of 59,352 surgical patients admitted in 1975-1976, the validity of this index as a predictor of surgical wound infection risk was verified. With the simplified index, a subgroup, consisting of half the surgical patients, can be identified in whom 90% of the surgical wound infections will develop. By the inclusion of factors measuring the risk due to the patient's susceptibility as well as that due to the level of wound contamination, the simplified index predicts surgical wound infection risk about twice as well as the traditional classification of wound contamination (Goodman-Kruskal G = 0.67 vs. 0.36, p less than 0.0001). Use of this new index might substantially increase the efficiency of routine surgical wound infection surveillance and control.

Abdomen↗
PubMed1985

A new approach to the isolation of hospitalized patients with infectious diseases: alternative systems.

A new guideline developed by the Centers for Disease Control suggests that hospitals adopt one of two alternative isolation systems: the category system or the disease-specific system. The older category system has been modified to reflect current knowledge; for example, the category of protective isolation has been deleted, new categories for contact precautions and tuberculosis precautions have been added, the specific precautions indicated in the other categories have been substantially modified, and many infections have been assigned to new categories. The disease-specific system, a newly developed approach, lists the specific isolation precautions indicated for each infectious disease. Whereas the revised category system offers greater simplicity in practice, the disease-specific system minimizes unnecessary precautions. Both systems allow patient-care personnel more decision-making authority in determining which precautions to apply.

Centers for Disease Control and Prevention, U.S.↗