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Journal ArticleDOI

A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price?

01 May 2004-Infection Control and Hospital Epidemiology (Infect Control Hosp Epidemiol)-Vol. 25, Iss: 5, pp 418-424

TL;DR: Infection control policies (eg, gown use) initially increase the cost of health services delivery, however, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment.

AbstractObjective:To determine the net benefit and costs associated with gown use in preventing transmission of van-comycin-resistant Enterococcus (VRE).Design:A cost-benefit analysis measuring the net benefit of gowns was performed. Benefits, defined as averted costs from reduced VRE colonization and infection, were estimated using a matched cohort study. Data sources included a step-down cost allocation system, hospital informatics, and microbiology databases.Setting:The medical intensive care unit (MICU) at Barnes-Jewish Hospital, St. Louis, Missouri.Patients:Patients admitted to the MICU for more than 24 hours from July 1, 1997, to December 31, 1999.Interventions:Alternating periods when all healthcare workers and visitors were required to wear gowns and gloves versus gloves alone on entry to the rooms of patients colonized or infected with VRE.Results:On base-case analysis, 58 VRE cases were averted with gown use during 18 months. The annual net benefit of the gown policy was 1,897. The analysis was most sensitive to the level of VRE transmission.Conclusions:Infection control policies (eg, gown use) initially increase the cost of health services delivery. However, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment. The cost savings to the hospital plus the benefits to patients and their families of avoiding nosocomial infections make effective infection control policies a good investment.

Topics: Infection control (51%)

Summary (2 min read)

Study Population

  • During the 12 months between these two periods, gowns were not required.
  • The institutional review board committees of Saint Louis University and Washington University approved this study.
  • During the entire study period, all patients were actively screened for VRE by collection of stool for cultures or rectal swabs on admission, every 7 days, and at discharge from the MICU.
  • Two patients without VRE were randomly selected, using the same matching criteria, for each patient with VRE bacteremia.

Costs

  • Overall costs for the VRE surveillance and infection control program were estimated using the hospital’s step- down cost allocation system, which recorded line-item cost data per resource consumed and total cost per hospital admission.
  • The cost for each isolation cart included all initial supplies.
  • Observational time trials were used to estimate the time required for healthcare workers to retrieve, don, doff, and properly dispose of gowns.
  • 18 To estimate the cost associated with excess workload per VRE patient contact, the average time was multiplied by the average registered nurse salary (excluding fringe benefits).
  • Microbiology costs for each patient were obtained from line-item reports from the hospital’s microbiology database.

Decision Analysis

  • The costs, benefits, and net benefit for the enhanced infection control and VRE surveillance programs are listed in Table 3.
  • The incremental cost per case of VRE colonization averted was $1,897.

Sensitivity Analysis

  • Several parameters were changed to determine the impact of their four main assumptions on the net benefit of gowns.
  • The results were most sensitive to the probability of acquiring enteric VRE.
  • Specifically, gowns are more likely to impact transmission when there are high rates of VRE colonization compared with when there are low rates.

Statistical Analysis

  • Univariate statistics were obtained using SPSS software (version 10.0; SPSS, Inc., Chicago, IL).
  • Differences in characteristics between patients with and patients without VRE were identified using t tests for continuous covariates and chi-square tests for categorical covariates.
  • A Decision Tree Add-In for Microsoft Excel was used for the decision analysis (TreePlan, version 1.62; Microsoft Corp., Redmond, WA).

Matched Cohort

  • Based on the matching criteria, patients with and patients without VRE were closely matched.
  • The mean APACHE II scores were similar between patients colonized with VRE and their matched controls and between patients with VRE bacteremia and their matched controls (22.0 vs 21.8 and 26.5 vs 26.3, respectively), as were the mean ages (62.3 vs 62.2 years and 65.4 vs 64.0 years, respectively).
  • An event pathway showing vancomycin-resistant enterococci (VRE) colonization and infection rates from July 1, 1997, to December 31, 1999, for patients in the medical intensive care unit.

Primary Outcomes

  • The length of MICU stay, length of hospital stay, MICU costs, and hospital costs attributable to VRE were less for patients colonized with VRE than for patients with VRE bacteremia (Table 2).
  • Five patients in the latter group died while hospitalized.

DISCUSSION

  • The results of this cost–benefit analysis provide evidence that gown use adds costs to the delivery of health services in a MICU setting, but the benefits from averting enteric VRE transmission outweigh those costs.
  • The increased cost associated with gown use needs to be considered relative to the attributable length of stay, mortality, and costs associated with VRE acquisition.
  • There are several limitations to this study.
  • The limitation that biases the study toward finding gowns to be cost-saving relates to the fact that the infection control protocols for this study were already in place at this insti- tution prior to the start of the study.
  • The authors would have been potentially able to determine the number of secondary cases of VRE generated from a primary case of VRE and more accurately quantify the number of VRE cases averted.

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A Cost–Benefit Analysis of Gown Use in Controlling Vancomycin‐Resistant Enterococcus
Transmission: Is It Worth the Price?• 
Author(s): Laura A. Puzniak , PhD, Kathleen N. Gillespie , PhD, Terry Leet , PhD, Marin Kollef
, MD, Linda M. Mundy , MD
Reviewed work(s):
Source:
Infection Control and Hospital Epidemiology,
Vol. 25, No. 5 (May 2004), pp. 418-424
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of
America
Stable URL: http://www.jstor.org/stable/10.1086/502416 .
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418 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY May 2004
A C
OST–BENEFIT ANALYSIS OF GOWN USE IN
C
ONTROLLING VANCOMYCIN-RESISTANT
E
NTEROCOCCUS
TRANSMISSION: IS IT WORTH THE PRICE?
Laura A. Puzniak, PhD; Kathleen N. Gillespie, PhD; Terry Leet, PhD; Marin Kollef, MD; Linda M. Mundy, MD
Enterococci are the third most common pathogen
associated with nosocomial infections, accounting for 12%
of intensive care unit infections.
1
The increasing preva-
lence of enterococcal infections is problematic due to lim-
ited treatment and eradication strategies. Furthermore,
the public health threat from vancomycin-resistant ente-
rococci (VRE) is more imminent given the recent detec-
tion of vancomycin-resistant Staphylococcus aureus
(VRSA).
2-4
The presence of vanA in a clinical isolate of
VRSA from a host colonized with VRE suggests exchange
of genetic material between these gram-positive
pathogens.
2
Hospital Infection Control Practices Advisory
Committee guidelines for controlling VRE include screen-
ing high-risk populations, using vancomycin appropriately,
educating medical staff, and implementing infection con-
trol procedures.
5
Recommended infection control prac-
tices include the use of gloves and gowns with patients col-
onized or infected with drug-resistant pathogens.
5
Despite
encouraging results for the efficacy of gown use, there is
ongoing debate over the cost versus benefit of requiring
gown use to prevent VRE transmission.
6-15
Few studies have assessed the costs and benefits
associated with gown use.
11-13
One study reported an
annual cost increase of $11,303 for gowns and gloves after
a VRE epidemic began.
12
The authors concluded that pre-
venting a case of VRE bacteremia was worth the addition-
al cost for implementing isolation precautions. In contrast,
a study in a bone marrow transplant unit reported that dis-
continuing the use of gowns and shoe covers created a
$70,000 savings for the unit with no increase in infection
rates.
11
Our prior work showed that requiring healthcare
workers and visitors to wear gowns when entering the
rooms of patients in a medical intensive care unit (MICU)
reduced the patients’ risk of VRE acquisition during peri-
ods of high VRE colonization pressure.
13
The purpose of
this study was to determine the costs and benefits of this
enhanced infection control program aimed at reducing
VRE transmission.
Drs. Puzniak, Leet, and Mundy are from the Department of Community Health and Dr. Gillespie is from the Department of Health
Management and Policy, Saint Louis University School of Public Health, St. Louis, Missouri. Drs. Kollef and Mundy are from the Department of
Medicine, Washington University School of Medicine, St. Louis, Missouri.
Address reprint requests to Linda M. Mundy, MD, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St.
Louis, MO 63110.
The authors thank the 65 members of the medical intensive care unit, the Barnes–Jewish Hospital medicine residents, and the Washington
University faculty who participated in the care of these patients; Donna Prentice and Jennie Mayfield for managing the VRE surveillance program;
Joan Hoppe-Bauer for providing microbiology data; and Dr. Brooke Shadel for her insightful comments during manuscript review.
OBJECTIVE: To determine the net benefit and costs
associated with gown use in preventing transmission of van-
comycin-resistant Enterococcus (VRE).
DESIGN: A cost–benefit analysis measuring the net ben-
efit of gowns was performed. Benefits, defined as averted costs
from reduced VRE colonization and infection, were estimated
using a matched cohort study. Data sources included a step-down
cost allocation system, hospital informatics, and microbiology
databases.
SETTING: The medical intensive care unit (MICU) at
Barnes–Jewish Hospital, St. Louis, Missouri.
PATIENTS: Patients admitted to the MICU for more than
24 hours from July 1, 1997, to December 31, 1999.
INTERVENTIONS: Alternating periods when all health-
care workers and visitors were required to wear gowns and
gloves versus gloves alone on entry to the rooms of patients col-
onized or infected with VRE.
RESULTS: On base-case analysis, 58 VRE cases were
averted with gown use during 18 months. The annual net benefit
of the gown policy was $419,346 and the cost per case averted of
VRE was $1,897. The analysis was most sensitive to the level of
VRE transmission.
CONCLUSIONS: Infection control policies (eg, gown
use) initially increase the cost of health services delivery.
However, such policies can be cost saving by averting nosocomi-
al infections and the associated costs of treatment. The cost sav-
ings to the hospital plus the benefits to patients and their families
of avoiding nosocomial infections make effective infection con-
trol policies a good investment (Infect Control Hosp Epidemiol
2004;25:418-424).
ABSTRACT

Vol. 25 No. 5 COST–BENEFIT ANALYSIS OF GOWNS 419
METHODS
Study Population
All patients staying more than 24 hours in a 19-bed
MICU at Barnes–Jewish Hospital from July 1, 1997, to
December 31, 1999, were eligible. All healthcare workers
and visitors were required to wear gowns and gloves on
entry into the rooms of patients colonized or infected with
VRE from July, 1, 1997, to June 30, 1998, and from July 1,
1999, to December 31, 1999. During the 12 months
between these two periods, gowns were not required. The
institutional review board committees of Saint Louis
University and Washington University approved this
study.
During the entire study period, all patients were
actively screened for VRE by collection of stool for cul-
tures or rectal swabs on admission, every 7 days, and at
discharge from the MICU. Per hospital protocol, stool
specimens sent for the detection of Clostridium difficile
toxin were also screened for VRE. For each patient with
VRE, a sign requiring contact precautions and an isolation
cart containing a dedicated stethoscope, a glass ther-
mometer, and gloves were placed at the entrance to the
patient’s room. Contact precautions were continued
unless a patient had two subsequent consecutive stool
surveillance specimens that tested negative. Gowns that
were fluid resistant and laundered after each use were
added to the isolation cart during the designated gown
periods.
A matched cohort study design was used to deter-
mine the attributable cost of VRE. Patients without VRE
from the same MICU population were matched to patients
with VRE by diagnosis-related group (DRG) code, Acute
Physiology and Chronic Health Evaluation (APACHE) II
16
severity of illness score (± 2 points), and age (± 5 years).
17
One patient without VRE was randomly selected for each
patient colonized with VRE when there were multiple
patients without VRE with the same matching criteria.
Two patients without VRE were randomly selected, using
the same matching criteria, for each patient with VRE bac-
teremia. Two matched controls were used to increase sta-
tistical power due to the small number of patients with
VRE bacteremia. Four patients colonized with VRE and
two patients with VRE bacteremia were excluded from the
study population because there was not a match of a
patient without VRE.
Clinical endpoints were obtained from the hospital’s
informatics system. These included MICU and hospital
lengths of stay, presence of nosocomial bacteremia due to
oxacillin-resistant S. aureus (ORSA) or Pseudomonas
aeruginosa, and presence of colitis or diarrhea associated
with C. difficile toxin. The three nosocomial pathogens
were used to determine whether the frequency of co-
infections was similar between patients with and patients
without VRE.
Costs
Overall costs for the VRE surveillance and infection
control program were estimated using the hospital’s step-
down cost allocation system, which recorded line-item
cost data per resource consumed and total cost per hospi-
tal admission. MICU costs were estimated from these
data by dividing the patient’s total hospitalization cost by
total days of hospitalization and then multiplying the quo-
tient by the patient’s total MICU-days. This data system
also provided hospital reimbursement data, type of insur-
ance, case mix index, and DRG. Medicare patients from
the study population were used to determine the average
non-reimbursed hospitalization cost by VRE status.
The cost for each isolation cart included all initial
supplies. In addition to the costs for gowns, the costs
resulting from staff time to comply with gown use were
estimated. Observational time trials were used to estimate
the time required for healthcare workers to retrieve, don,
doff, and properly dispose of gowns. On three separate
occasions, two unobtrusive observers measured the
amount of time required by 128 healthcare workers to
comply with the gown policy. Our observations showed
that the average worker needed 60 seconds (range, 35 to
95 seconds) to don and doff gowns, which was similar to
the amount of time needed for the same activities in anoth-
er study.
18
To estimate the cost associated with excess
workload per VRE patient contact, the average time was
multiplied by the average registered nurse salary (exclud-
ing fringe benefits). Because a range of healthcare work-
ers entered a patient’s room, the average registered
nurse’s salary was used to approximate this cost.
Microbiology costs for each patient were obtained
from line-item reports from the hospital’s microbiology
database. Microbiology costs were inclusive of all related
testing costs (ie, materials, technician time, nursing time
for culture procurement, and overhead). Individualized
costs associated with contact precautions and surveil-
lance are listed in Table 1. All costs were reported in U.S.
dollars.
Decision Analysis
An event pathway of the study was constructed
showing VRE colonization and infection rates during this
30-month study period (Figure).
13
Costs were allocated to
each arm based on actual resources consumed per
patient. Each patient with VRE, regardless of study peri-
od, was charged the costs for a cart, gloves, and hand
hygiene. During the gown period, patients with VRE were
charged additional costs for gowns and nursing time to
comply with the gown policy.
Benefits were measured as the number of VRE
cases and the MICU costs averted. The number of VRE
cases averted was estimated by multiplying the difference
in the VRE rates between the study periods by the num-
ber of patients in the gown period. The number of VRE
cases averted per 1,000 MICU-days was calculated by tak-
ing the number of cases averted and dividing it by the
total number of MICU patient-days in the gown period and
multiplying by 1,000. Averted attributable cost for the
gown period and net benefit of the gown policy
19
were
computed as shown in equations 1 and 2, respectively.

420 INFECTION
CONTROL AND H
OSPITAL
EPIDEMIOLOGY
May 2004
(1) averted attributable cost
gown
= (attributable cost
of VRE colonization annualized number of VRE colo-
nized cases averted) + (weighted mean attributable cost
of both diagnostic criteria of VRE bacteremia annual-
ized number of VRE bacteremic cases averted)
(2) net benefit = averted attributable cost
gown
-
(annualized isolation/surveillance cost
gown
- isolation/sur-
veillance cost
no-gown
)
The latter term in equation 2 measured the incre-
mental costs of the gown policy. Costs and benefits in the
gown period were annualized because the gown period
was 6 months longer than the no-gown period.
Sensitivity Analysis
A sensitivity analysis was performed varying sever-
al parameters related to the assumptions regarding the
number of gowns used, time required to don and doff
gowns, VRE transmission rates for this analysis, and cost
of materials. Our baseline estimate for the number of
gowns used was 100 gowns per patient per day. We used
the previously reported value of 60 contacts per day
18
for
the lower limit and an equivalent difference, 140 contacts
per day, for the upper limit. The average number of VRE
cultures performed during the study was 2 per patient per
MICU stay. To adjust for variation in surveillance mecha-
nisms,
20-23
we used 2 cultures as the baseline measure and
varied this measure between 1 and 4 cultures per MICU
stay. Because there were differences in cost between pos-
itive and negative cultures, we used the same proportion
of positive cultures as the original analyses when the para-
meter was changed to 4 cultures per patient. Because the
costs of isolation materials and laboratory testing can dif-
fer between hospitals and can increase due to inflation, we
altered the costs for these items by 20% in both directions.
As shown in the figure, the risks of both acquiring VRE
and developing bacteremia were lower in the gown peri-
od; therefore, we altered the probability of acquiring VRE
in the gown period from 40% to 100% of the probability of
acquiring VRE in the no-gown period to determine the net
benefit at varying levels of VRE transmission.
Statistical Analysis
Univariate statistics were obtained using SPSS soft-
ware (version 10.0; SPSS, Inc., Chicago, IL). Differences
in characteristics between patients with and patients with-
out VRE were identified using t tests for continuous
covariates and chi-square tests for categorical covariates.
A Decision Tree Add-In for Microsoft Excel was used for
the decision analysis (TreePlan, version 1.62; Microsoft
Corp., Redmond, WA).
RESULTS
Matched Cohort
Based on the matching criteria, patients with and
patients without VRE were closely matched. The mean
APACHE II scores were similar between patients colo-
nized with VRE and their matched controls and between
patients with VRE bacteremia and their matched controls
(22.0 vs 21.8 and 26.5 vs 26.3, respectively), as were the
mean ages (62.3 vs 62.2 years and 65.4 vs 64.0 years,
respectively). In addition, there were no significant differ-
ences in the frequency of co-infections between patients
TABLE 1
INDIVIDUALIZED
COSTS ASSOCIATED WITH CONTACT PRECAUTIONS
AND VANCOMYCIN-RESISTANT ENTEROCOCCI SURVEILLANCE IN THE
M
EDICAL INTENSIVE CARE UNIT
Cost
Variable Cost per Day
Gown $0.75 each $75.00
Gloves $0.07/pair $7.00
Hand hygiene $0.10/use $10.00
Nursing time to don and doff gowns $27.00/hour $45.00
Isolation cart set up (cost of initial $18.00 One-time
cart set up—bag of gowns, cost
stethoscope, thermometer, and
box of gloves)
VRE-negative test $12.13 Varies
VRE-positive test $24.29 Varies
VRE = vancomycin-resistant enterococci.
89
VRE colonization from admission culture
94 95%
VRE + on admission
8%
5
VRE infection from admission culture
5%
1164
Admission gown period
62%
1011
No acquisition
94%
1070
VRE - admission 55
VRE acquired colonization
92%
59 93%
VRE acquisition
6%
4
1872 VRE acquired infection
Enter
1 7%
79
VRE colonization from admission culture
88 90%
VRE + on admission
12%
9
VRE infection from admission culture
10%
708
Admission no gown period
38%
552
No acquisition
89%
620
VRE - admission 62
VRE acquired colonization
88%
68 91%
VRE acquisition
11%
6
VRE acquired infection
9%
FIGURE. An event pathway showing vancomycin-resistant enterococci
(VRE) colonization and infection rates from July 1, 1997, to December 31,
1999, for patients in the medical intensive care unit.

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TL;DR: There is no evidence that using antiseptics or disinfectants selects for antibiotic-resistant organisms in nature or that such mutants survive in nature.
Abstract: The issue of whether low-level tolerance to germicides selects for antibiotic-resistant strains is unsettled but might depend on the mechanism by which tolerance is attained. For example, changes in the permeability barrier or efflux mechanisms might affect susceptibility to both antibiotics and germicides, but specific changes to a target site might not. Some researchers have suggested that use of disinfectants or antiseptics (e.g., triclosan) could facilitate development of antibiotic-resistant microorganisms 334, 335, . Although evidence in laboratory studies indicates low-level resistance to triclosan, the concentrations of triclosan in these studies were low (generally <1 μg/mL) and dissimilar from the higher levels used in antimicrobial products (2,000–20,000 μg/mL) 364, . Thus, researchers can create laboratory-derived mutants that demonstrate reduced susceptibility to antiseptics or disinfectants. In some experiments, such bacteria have demonstrated reduced susceptibility to certain antibiotics . There is no evidence that using antiseptics or disinfectants selects for antibiotic-resistant organisms in nature or that such mutants survive in nature. ). In addition, the action of antibiotics and the action of disinfectants differ fundamentally. Antibiotics are selectively toxic and generally have a single target site in bacteria, thereby inhibiting a specific biosynthetic process. Germicides generally are considered nonspecific antimicrobials because of a multiplicity of toxic-effect mechanisms or target sites and are broader spectrum in the types of microorganisms against which they are effective 344, .

813 citations



Journal ArticleDOI
TL;DR: The attributable mortality from nosocomial bloodstream infection is high in critically ill patients and is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden.
Abstract: OBJECTIVE To determine the excess length of stay, extra costs, and mortality attributable to nosocomial bloodstream infection in critically ill patients. DESIGN Pairwise-matched (1:1) case-control study. SETTING Surgical intensive care unit (SICU) in a tertiary health care institution. PATIENTS All patients admitted in the SICU between July 1, 1988, and June 30, 1990, were eligible. Cases were defined as patients with nosocomial bloodstream infection; controls were selected according to matching variables in a stepwise fashion. METHODS Matching variables were primary diagnosis for admission, age, sex, length of stay before the day of infection in cases, and total number of discharge diagnoses. Matching was successful for 89% of the cohort; 86 matched case-control pairs were studied. MAIN OUTCOME MEASURES Crude and attributable mortality, excess length of hospital and SICU stay, and overall costs. RESULTS Nosocomial bloodstream infection complicated 2.67 per 100 admissions to the SICU during the study period. The crude mortality rates from cases and controls were 50% and 15%, respectively (P < .01); thus, the estimated attributable mortality rate was 35% (95% confidence interval, 25% to 45%). The median length of hospital stay significantly differed between cases and controls (40 vs 26 days, respectively; P < .01). When only matched pairs who survived bloodstream infection were considered (n = 41), cases stayed in the hospital a median of 54 days vs 30 days for controls (P < .01), and cases stayed in the SICU a median of 15 days vs 7 days for controls (P < .01). Thus, extra hospital and SICU length of stay attributable to bloodstream infection was 24 and 8 days, respectively. Extra costs attributable to the infection averaged $40,000 per survivor. CONCLUSIONS The attributable mortality from nosocomial bloodstream infection is high in critically ill patients. The infection is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden.

797 citations


Journal Article
TL;DR: Routine surveillance of VAPs is mandatory, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor filtered air.
Abstract: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.

405 citations


Cites background from "A cost-benefit analysis of gown use..."

  • ...133 Infection control practices to prevent nosocomial spread of respiratory viral infections include: (1) a high level of immunization of patients and staff against influenza; (2) prevention of patient contact with persons (friends, family, and health-care staff) who have active respiratory symptoms; (3) use of rapid diagnostic tests to quickly identify symptomatic patients with potentially transmissible viral pathogens, to facilitate early implementation of isolation precautions; (4) cohorting patients with confirmed infection when single rooms are not available; and (5) placement of patients with suspected community-acquired respiratory viral infections in droplet isolation precautions....

    [...]

  • ...1): (1) by aspiration of microbeladen secretions, either from the oropharynx directly or, secondarily, by reflux from the stomach into the oropharynx, then into the lower respiratory tract;37–39 (2) by direct extension of a contiguous infection, such as a pleuralspace infection;40 (3) through inhalation of contaminated air or medical aerosols;41 or (4) by hematogenous carriage of microorganisms to the lung from remote sites of local infection, such as vascular or urinary catheter-related bloodstream infection....

    [...]


References
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Journal ArticleDOI
TL;DR: The form and validation results of APACHE II, a severity of disease classification system that uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status, are presented.
Abstract: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

13,727 citations


Journal ArticleDOI
TL;DR: This letter is in response to your two Citizen Petitions, requesting that the Food and Drug Administration (FDA or the Agency) require a cancer warning on cosmetic talc products.
Abstract: This letter is in response to your two Citizen Petitions dated November 17, 1994 and May 13, 2008, requesting that the Food and Drug Administration (FDA or the Agency) require a cancer warning on cosmetic talc products. Your 1994 Petition requests that all cosmetic talc bear labels with a warning such as \"Talcum powder causes cancer in laboratory animals. Frequent talc application in the female genital area increases the risk of ovarian cancer.\" Additionally, your 2008 Petition requests that cosmetic talcum powder products bear labels with a prominent warning such as: \"Frequent talc application in the female genital area is responsible for major risks of ovarian cancer.\" Further, both of your Petitions specifically request, pursuant to 21 CFR 1 0.30(h)(2), a hearing for you to present scientific evidence in support of this petition.

8,390 citations


Posted Content
Abstract: The purpose of economic evaluation is to inform decisions intended to improve healthcare. The new edition of Methods for the Economic Evaluation of Health Care Programmes equips the reader with the necessary tools and understanding required to undertake evaluations by providing an outline of key principles and a 'tool kit' based on the authors' own experiences of undertaking economic evaluations. Building on the strength of the previous edition, the accessible writing style ensures the text is key reading for the non-expert reader, as no prior knowledge of economics is required. The book employs a critical appraisal framework, which is useful both to researchers conducting studies and to decision-makers assessing them. Practical examples are provided throughout to aid learning and understanding. The book discusses the analytical and policy challenges that face health systems in seeking to allocate resources efficiently and fairly. New chapters include 'Principles of economic evaluation' and 'Making decisions in healthcare' which introduces the reader to core issues and questions about resource allocation, and provides an understanding of the fundamental principles which guide decision making. A key part of evidence-based decision making is the analysis of all the relevant evidence to make informed decisions and policy. The new chapter 'Identifying, synthesising and analysing evidence' highlights the importance of systematic review, and how and why these methods are used. As methods of analysis continue to develop, the chapter on 'Characterising, reporting and interpreting uncertainty' introduces the reader to recent methods of analysis and why characterizing uncertainty matters for health care decisions. The fourth edition of Methods for the Economic Evaluation of Health Care Programmes has been thoroughly revised and updated, making it essential reading for anyone commissioning, undertaking, or using economic evaluations in health care, including health service professionals, health economists, and health care decision makers.

8,313 citations


Journal ArticleDOI
TL;DR: Using archival material supplemented by interviews with community physicians, Jane Lewis shows how 'public health' and 'preventive medicine' have been supplanted as the central concern of medicine by curative and acute specialties.
Abstract: Public health in the Victorian era had two major concerns: housing conditions and sanitation. These two elements were seen as crucial in improving the health status of the population. This Victorian notion of public health was, therefore, centred upon the prevention rather than cure ofdisease. The early years ofthis century saw a narrowing of this Victorian vision with an increased emphasis on personal hygiene and individual action in the prevention of disease. Thus there was a shift in the focus of disease prevention from society as a whole to its individual members. This influenced the role of public health doctors whose administrative responsibilities were increasing as they assumed responsibility for municipal hospitals. These administrative and preventive roles brought public health doctors into conflict with family doctors about the scope and objectives of public health. The establishment of the National Health Service, which left public health doctors in charge ofa range of community services, only served to heighten the conflicts within the medical profession about the role of public health within a socialised medical system. The emergence of the social work profession created a further area of conflict. Although the 1974 reorganisation of the NHS created the specialty of community medicine, thereby providing public health doctors with a career structure similar to that of other specialties within medicine, the role of the new specialty was emasculated. The fledgling specialty was given the responsibility for planning and coordinating health care delivery within local areas. However, few resources were provided and little opportunity has arisen for the new community physicians to implement their plans. The provision of a medicalised career structure has done little to overcome the negative image of community medicine within the rest of the medical profession. This book presents an historical view of the development of one branch of the medical profession. Using archival material supplemented by interviews with community physicians, Jane Lewis shows how 'public health' and 'preventive medicine' have been supplanted as the central concern of medicine by curative and acute specialties. The much vaunted current policies of prevention and community care have not served to rescue community medicine from languishing in obscurity. This book provides an interesting account of the development of the medical 355

6,243 citations


Journal ArticleDOI
TL;DR: The form and validation results of APACHE II, a severity of disease classification system, are presented, showing an increasing score was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals.
Abstract: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

4,603 citations


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