The rate of influenza vaccination among healthcare workers (HCWs) is low, despite a good rationale and strong recommendations for vaccination from many health organizations.

To increase influenza vaccination rates by instituting the first mandatory influenza vaccination program for HCWs.

A 5-year study (from 2005 to 2010) at Virginia Mason Medical Center, a tertiary care, multispecialty medical center in Seattle, Washington, with approximately 5,000 employees.

All HCWs of the medical center were required to receive influenza vaccination. HCWs who were granted an accommodation for medical or religious reasons were required to wear a mask at work during influenza season. The main outcome measure was rate of influenza vaccination among HCWs.

In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.

A mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years.

To use social network analysis to design more effective strategies for vaccinating healthcare workers against influenza.

An agent-based simulation.

A simulation based on a 700-bed hospital.

We first observed human contacts (defined as approach within approximately 0.9 m) performed by 15 categories of healthcare workers (eg, floor nurses, intensive care unit nurses, staff physicians, phlebotomists, and respiratory therapists). We then constructed a series of contact graphs to represent the social network of the hospital and used these graphs to run agent-based simulations to model the spread of influenza. A targeted vaccination strategy that preferentially vaccinated more “connected” healthcare workers was compared with other vaccination strategies during simulations with various base vaccination rates, vaccine effectiveness, probability of transmission, duration of infection, and patient length of stay.

We recorded 6,654 contacts by 148 workers during 606 hours of observations from January through December 2006. Unit clerks, X-ray technicians, residents and fellows, transporters, and physical and occupational therapists had the most contacts. When repeated contacts with the same individual were excluded, transporters, unit clerks, X-ray technicians, physical and occupational therapists, and social workers had the most contacts. Preferentially vaccinating healthcare workers in more connected job categories yielded a substantially lower attack rate and fewer infections than a random vaccination strategy for all simulation parameters.

Social network models can be used to derive more effective vaccination policies, which are crucial during vaccine shortages or in facilities with low vaccination rates. Local vaccination priorities can be determined in any healthcare facility with only a modest investment in collection of observational data on different types of healthcare workers. Our findings and methods (ie, social network analysis and computational simulation) have implications for the design of effective interventions to control a broad range of healthcare-associated infections.

Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.

We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.

We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.

Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

Standard precautions are advocated for reducing the number of injuries caused by needles and sharp medical devices (“sharps injuries”), but the effectiveness of gloves in preventing such injuries has not been established. We evaluated factors associated with gloving practices and identified associations between gloving practices and sharps-injury risk.

Usual-frequency case-crossover study.

Thirteen medical centers in the United States and Canada.

Six hundred thirty-six healthcare workers who presented to employee health clinics after sharps injury.

Structured telephone questionnaires were administered to assess usual behaviors and circumstances at the time of injury.

Of 636 injured healthcare workers, 195 were scrubbed in an operating room or procedure suite when injured, and 441 were injured elsewhere. Nonscrubbed individuals were more commonly gloved when treating patients who were perceived to have a high risk of human immunodeficiency virus, hepatitis B virus, or hepatitis C virus infection than when treating other patients (adjusted odds ratio [aOR], 2.53 [95% confidence interval {CI}, 1.30-4.91]). Nurses (aOR, 0.11 [95% CI, 0.04-0.32]) and other employees (aOR, 0.24 [95% CI, 0.07-0.77]) were less commonly gloved at injury than were physicians and physician trainees. Gloves reduced injury risk in case-crossover analyses (incidence rate ratio [IRR], 0.33 [95% CI, 0.22-0.50]). In scrubbed individuals, involvement in an orthopedic procedure was associated with double gloving at injury (aOR, 13.7 [95% CI, 4.55-41.3]); this gloving practice was associated with decreased injury risk (IRR, 0.20 [95% CI, 0.10-0.42]).

Although the use of gloves reduces the risk of sharps injuries in health care, use among healthcare workers is inconsistent and may be influenced by risk perception and healthcare culture. Glove use should be emphasized as a key element of multimodal sharps-injury reduction programs.

To present the evaluation of a large-scale quantitative respirator-fit testing program.

Concurrent questionnaire survey of fit testers and test subjects.

Ambulatory care, home nursing care, and acute care hospitals across South Australia.

Quantitative facial-fit testing was performed with TSI PortaCount instruments for healthcare workers (HCWs) who wore 5 different models of a disposable P2 (N95-equivalent) respirator. The questionnaire included questions about the HCWs age, sex, race, occupational category, main area of work, smoking status, facial characteristics, prior training and experience in use of respiratory masks, and number of attempts to obtain a respirator fit.

A total of 6,160 HCWs were successfully fitted during the period from January through July 2007. Of the 4,472 HCWs who responded to the questionnaire and were successfully fitted, 3,707 (82.9%) were successfully fitted with the first tested respirator, 551 (12.3%) required testing with a second model, and 214 (4.8%) required 3 or more tests. We noted an increased pass rate on the first attempt over time. Asians (excluding those from South and Central Asia) had the highest failure rate (16.3% [45 of 276 Asian HCWs were unsuccessfully fitted]), and whites had the lowest (9.8% [426 of 4,338 white HCWs]). Race was highly correlated with facial shape. Among occupational groups, doctors had the highest failure rate (13.4% [81 of 604 doctors]), but they also had the highest proportion of Asians. Prior education and/or training in respirator use were not associated with a higher pass rate.

Certain facial characteristics were associated with higher or lower pass rates with regard to fit testing, and fit testers were able to select a suitable respirator on the basis of a visual assessment in the majority of cases. For the fit tester, training and experience were important factors; however, for the HCW being fitted, prior experience in respirator use was not an important factor.

Nosocomial infections are still a major cause of morbidity and mortality among neonates admitted to neonatal intensive care units (NICUs).

To describe the epidemiology of nosocomial infections in NICUs and to assess the risk of nosocomial infection related to the therapeutic procedures performed and to the clinical characteristics of the neonates at birth and at admission to the NICU, taking into account the time between the exposure and the onset of infection.

A multicenter, prospective cohort study.

A total of 1,692 neonates admitted to 6 NICUs in Italy were observed and monitored for the development of nosocomial infection during their hospital stay.

Data were collected on the clinical characteristics of the neonates admitted to the NICUs, their therapeutic interventions and treatments, their infections, and their mortality rate. The cumulative probability of having at least 1 infection and the cumulative probability of having at least 1 infection or dying were estimated. The hazard ratio (HR) for the first infection and the HR for the first infection or death were also estimated.

A total of 255 episodes of nosocomial infection were diagnosed in 217 neonates, yielding an incidence density of 6.9 episodes per 1,000 patient-days. The risk factors related to nosocomial infection in very-low-birth-weight neonates were receipt of continuous positive airway pressure (HR, 3.8 [95% confidence interval {CI}, 1.7-8.1]), a Clinical Risk Index for Babies score of 4 or greater (HR, 2.2 [95% CI, 1.4-3.4]), and a gestational age of less than 28 weeks (HR, 2.1 [95% CI, 1.2-3.8]). Among heavier neonates, the risk factors for nosocomial infection were receipt of parenteral nutrition (HR, 8.1 [95% CI, 3.2-20.5]) and presence of malformations (HR, 2.3 [95% CI, 1.5-3.5]).

Patterns of risk factors for nosocomial infection differ between very-low-birth-weight neonates and heavier neonates. Therapeutic procedures appear to be strong determinants of nosocomial infection in both groups of neonates, after controlling for clinical characteristics.

To assess the representativeness of the data in the Krankenhaus Infektions Surveillance System (KISS), which is a nosocomial infections surveillance system for intensive care units (ICUs) in Germany.

Prospective and retrospective surveillance study.

Medical-surgical ICUs in Germany.

A sample of medical-surgical ICUs from all over Germany, stratified according to hospital size, was randomly selected. Surveillance personnel from the hospitals were trained in surveillance of nosocomial infections, and they subsequently conducted a 2-month surveillance in their ICUs. Data were compared with KISS data for medical-surgical ICUs.

During the period from 2004 through 2005, a total of 50 medical-surgical ICUs agreed to participate in our study: 21,832 patient-days were surveyed, and 262 cases of nosocomial infection were registered, 176 of which were cases of device-associated nosocomial infection (100 cases of lower respiratory tract infection, 47 cases of urinary tract infection, and 29 cases of bloodstream infection). The overall incidence density of all types of nosocomial infections was estimated to be 10.65 cases per 1,000 patient-days. Device utilization rates in the study ICUs and in the KISS medical-surgical ICUs were similar. The pooled mean device-associated infection rates were higher in the study ICUs than in the KISS medical-surgical ICUs (10.2 vs 5.1 cases of pneumonia; 2.0 vs 1.2 cases of bloodstream infection; and 2.7 vs 1.2 cases of urinary tract infection), but the pooled mean device-associated infection rates in the study ICUs were comparable to those of the KISS ICUs during their first year of participation in KISS. The incidence density for nosocomial infections in the study ICUs varied according hospital size, with ICUs in larger hospitals having a higher incidence density than those in smaller hospitals.

KISS ICUs started with nosocomial infection rates comparable to those found in our study ICUs. Over the years of participation, however, a decrease in nosocomial infections is seen. Thus, rates of nosocomial infection from KISS should be used as benchmarks, but estimations for Germany that are based on KISS data may underestimate the real burden of nosocomial infections.

To explore epidemiological patterns of the incidence of Clostridium difficile infection (CDI) and hospital characteristics associated with increased incidence during nonepidemic and epidemic years.

Retrospective and prospective ecological study.

Eighty-three acute care hospitals participating in CDI surveillance in the province of Quebec, Canada.

A Serfling-type regression model applied to data obtained from an administrative database (1998-2006) and prospective Quebec CDI surveillance (2004-2006) was used to calculate expected CDI baseline incidence and to detect incidence exceeding the defined epidemic threshold at the provincial and hospital level. Multivariable Poisson regression was used to determine hospital characteristics associated with increased incidence during nonepidemic (1998-2001) and epidemic (2003-2005) periods.

During the study period (1998-2006), 4,525,847 discharges, including 45,508 with a CDI in any diagnosis field, were reported by 83 hospitals. During 1998-2001, the average Quebec incidence of CDI was 10,304 cases in 1,775,822 discharges (5.8 cases per 1,000 discharges) and presented a pattern of seasonality, with similar patterns at the hospital level for some hospitals. The Quebec epidemic started in October-November 2002 and peaked in March 2004 at 845 cases in 40,852 discharges (20.7 cases per 1,000 discharges). In multivariable analysis, higher incidence was associated with location in Montreal and surrounding regions, greater hospital size, larger proportion of hospitalized elderly patients, longer length of stay, and greater proportion of comorbidities in patients, whereas teaching profile was associated with decreased incidence during both nonepidemic and epidemic periods. The effect of geographical location on incidence was greater during the epidemic.

Baseline incidence from nonepidemic years and hospital characteristics associated with CDI incidence should be taken into account when estimating the efficacy of interventions.