Infection Prevention Practices in Japan, Thailand, and the United States: Results From National Surveys Free

Abstract

Background.

Numerous evidence-based practices for preventing device-associated infections are available, yet the extent to which these practices are regularly used in acute care hospitals across different countries has not been compared, to our knowledge.

Methods.

Data from hospital surveys conducted in Japan, the United States, and Thailand in 2012, 2013, and 2014, respectively, were evaluated to determine the use of recommended practices to prevent central line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). The outcomes were the percentage of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 [never use] to 5 [always use]) of each practice across countries and identified hospital characteristics associated with the use of selected practices in each country.

Results.

Survey response rates were 71% in Japan and the United States and 87% in Thailand. A majority of hospitals in Japan (76.6%), Thailand (63.2%), and the United States (97.8%) used maximum barrier precautions for preventing CLABSI and semirecumbent positioning to prevent VAP (66.2% for Japan, 86.7% for Thailand, and 98.7% for the United States). Nearly all hospitals (>90%) in Thailand and the United States reported monitoring CLABSI, VAP, and CAUTI rates, whereas in Japan only CLABSI rates were monitored by a majority of hospitals. Regular use of CAUTI prevention practices was variable across the 3 countries, with only a few practices adopted by >50% of hospitals.

Conclusions.

A majority of hospitals in Japan, Thailand, and the United States have adopted certain practices to prevent CLABSI and VAP. Opportunities for targeting prevention activities and reducing device-associated infection risk in hospitals exist across all 3 countries.

Preventing healthcare-associated infection (HAI) is an important challenge worldwide. The significance of HAI prevention is demonstrated by global initiatives, such as the World Health Organization’s patient safety Clean Care is Safer Care program [1] and the International Nosocomial Infection Control Consortium in America, Africa, and Europe [2, 3]. Likewise, there are many localized infection prevention efforts underway, including regional infection prevention collaboratives in Japan [4], a patient safety campaign in Thailand [5], and the Department of Health and Human Services National Action Plan to Prevent HAI in the United States [6, 7].

Although HAI prevention initiatives vary worldwide, most focus on a core set of recommended prevention practices. For example, use of maximum sterile barrier precautions during central line insertion is a generally established recommendation for preventing central line–associated bloodstream infection (CLABSI), based on guidelines published by the Centers for Disease Control and Prevention and expert guidance from numerous professional organizations [3, 8–14]. Similarly, there are commonly recommended practices for preventing ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infection (CAUTI) [3, 8, 10, 13]. Despite these recommendations, the extent to which certain practices are used by acute care hospitals across different countries has not been compared. Therefore, using data collected during comparable timeframes and with similar questions, we evaluated the use of key practices for preventing CLABSI, VAP, and CAUTI in Japan, Thailand, and the United States. Comparing practice adoption across countries provides unique information about the similarities and differences in practice use as well as potential opportunities for targeting prevention activities.

METHODS

Study Design and Data Collection

Data were collected as part of ongoing projects focusing on infection prevention practices in acute care hospitals, with a similar survey instrument and methodology used in all 3 countries [4, 15–18]. For the United States, in May 2013, a 58-question survey inquiring about the use of practices to prevent CLABSI, VAP, and CAUTI was mailed to infection preventionists at a national random sample of nonfederal US hospitals. The survey sample consisted of 571 US hospitals, of a group of 600 originally identified in 2005. Additional details about the sample and the survey process are published elsewhere [16].

In Japan, between 1 April 2012 and 31 January 2013, a survey was mailed to the lead infection preventionist at 971 hospitals that had ≥1 nurse certified by the Japanese Nursing Association in infection prevention [4]. In Thailand, from 1 January 2014 to 30 November 2014, hospitals that had an intensive care unit (ICU) and ≥250 beds (n = 245) were surveyed through an interview with the lead infection control professional, following a previously established process [15, 18]. Institutional review board approval was provided by the University of Michigan, the VA Ann Arbor Healthcare System, the Faculty of Medicine, Thammasat University, and St Luke’s International Hospital.

Survey Instrument

The survey instrument, as first used in 2005, was designed to assess the use of practices to prevent device-associated infections, specifically CLABSI, VAP, and CAUTI [17, 19]. The survey was translated into Thai by an experienced hospital epidemiologist and into Japanese by a panel of bilingual infection prevention professionals. In addition to questions about the use of specific infection prevention practices, the instrument also elicited information about general hospital characteristics and the infection control program at each responding hospital.

Study Measures

The main outcome was a binary variable (0 or 1) indicating regular use of evidence-based recommendations to prevent CLABSI, VAP, and CAUTI, as described in published guidelines [3, 8–14]. Respondents were asked to rate the frequency of practice use on a scale from 1 (never use) to 5 (always use). Regular use was defined as a rating of 4 (almost always) or 5 (always). Information collected about the hospital included numbers of acute care and ICU beds, affiliation with a medical school, presence of a hospital epidemiologist, involvement in an HAI-related collaborative, and the number of full-time equivalent infection preventionists. Respondents were also asked to rate the perceived importance to hospital leadership of preventing CLABSI, VAP, and urinary tract infection (UTI) (minimally, moderately, very, or extremely important) and level of agreement with the statement “Leadership is driving us to be a safety-centered institution” (from 1 [strongly agree] to 5 [strongly disagree]).

Statistical Analysis

The survey data were analyzed by comparing regular use of each practice for preventing CLABSI, VAP, or CAUTI across the 3 countries. We determined the percentage of hospitals reporting regular use along with the 95% confidence interval (CI), estimated using the Agresti-Coull method for binomial parameters [20, 21]. Percentages across countries were compared using a Pearson χ² test. One practice from each infection category was then selected for further examination. The criteria for practice selection, established a priori, focused on practices for which there was at least a sufficient level of use as well as potential opportunity for improvement, operationalized as practices used by >10% and <80% of hospitals across the 3 countries. This resulted in the selection of avoidance of the femoral site for central line insertion to prevent CLABSI, use of subglottic secretion drainage to prevent VAP, and use of reminders or stop orders to prevent CAUTI. Although nurse-initiated discontinuation also met the general selection criteria, we focused on reminders or stop orders, given the strong evidence base to support this practice [22]. We used logistic regression to identify hospital characteristics associated with the use of each selected practice within each country. All reported P values were 2 tailed, and all analyses were conducted using Stata software, version 14.0 (StataCorp).

RESULTS

Survey response rates were 71% in Japan (685 of 971) and the United States (403 of 571) and 87% in Thailand (212 of 245). Overall, hospitals in Thailand had more acute care and ICU beds than hospitals in the United States or Japan (Table 1). More than 50% of hospitals in Thailand reported an affiliation with a medical school, compared with 10.4% in Japan and 29.8% in the United States (P < .001). A significantly higher percentage of hospitals in Japan and the United States reported being involved in a collaborative to reduce HAI (49.5% for Thailand vs 82.7% for the United States vs 92.2% for Japan; P < .001) and higher levels of infection preventionist staffing relative to hospitals in Thailand. Most hospitals in Thailand (92.8%) agreed that “leadership is driving us to be a safety-centered institution,” compared with 49.3% of hospitals in Japan and 85.5% in the United States. Similarly, whereas the majority (>80%) of hospitals in Thailand reported that preventing CLABSI, VAP, and UTI were very or extremely important to hospital leadership, the percentages were notably lower for hospitals in Japan (with the highest percentage, only 51.6%, related to CLABSI prevention).

Practices to Prevent CLABSI

A majority of hospitals reported use of maximum barrier precautions, 76.6% in Japan, 63.2% in Thailand, and 97.8% in the United States (Figure 1A). Use of other CLABSI prevention practices was more variable, especially among hospitals in Japan and Thailand. In Japan, 3.3% of hospitals used an antimicrobial dressing and 18.7% chlorhexidine for insertion site antisepsis, 67.3% monitored CLABSI rates, and >75% used maximum barrier precautions. In Thailand, less than half of hospitals (48.5%) reported use of an antimicrobial dressing, but >90% monitored CLABSI rates, and 73.5% used chlorhexidine for insertion site antisepsis.

Avoidance of the femoral site for central line insertion was practiced by 29.7% of hospitals in Japan, 58.0% in Thailand and 70.6% in the United States. In Japan use of this practice was associated with the number of acute care beds (odds ratio [OR], 1.13; 95% CI, 1.02–1.25) and a stronger drive by leadership to be safety centered (1.60; 1.06–2.42) (Table 2). In Thailand, avoidance of the femoral site was associated with hospitals involved in a collaborative (OR, 2.23; 95% CI, 1.20–4.13) and those where leadership was driving the institution to be safety centered (4.64; 1.17–18.3). None of the hospital characteristics assessed was associated with avoidance of the femoral site in the US hospital sample.

Practices to Prevent VAP

There was a high degree of adoption across all 3 countries of the use of semirecumbent positioning (Figure 1B). A majority of hospitals in Thailand and the United States also reported using an antimicrobial mouth rinse and monitoring VAP rates, whereas these practices were much less prevalent among hospitals in Japan. Selective digestive tract decontamination had the lowest level of use, used by only about a quarter of hospitals in Thailand and the United States and 3.6% in Japan. There was, however, a modest level of adoption for subglottic secretion drainage, ranging from 19.2% of hospitals in Japan to 35.3% in Thailand to 56.1% in the United States.

Among hospitals in Japan, the odds of using subglottic secretion drainage increased with the number of acute care beds (OR, 1.13; 95% CI, 1.01–1.27) (Table 2), whereas in Thailand having a hospital epidemiologist doubled the odds of using this practice (2.01; 1.08–3.73) (Table 2). For hospitals in the United States, the odds of using subglottic secretion drainage decreased in relation to the number of infection preventionists per 100 acute care beds (OR, 0.59; 95% CI, .38–.90) and was higher if hospital leadership perceived preventing VAP as very or extremely important (2.05; 1.18–3.53).

Practices to Prevent CAUTI

Monitoring of UTI rates was reported by nearly all hospitals in Thailand and the United States, compared with about one-third of those in Japan (Figure 1C). Use of bladder ultrasound was reported by 57.1% of US hospitals but significantly fewer hospitals in Japan and Thailand (11.3% and 4.7%, respectively). Nurse-initiated discontinuation was slightly more prevalent among hospitals in Thailand (41.5%) than among those in Japan (34.0%) or the United States (38.5%); silver alloy catheters were more frequently used by hospitals in Japan (44.1%) than in Thailand (8.9%) or the United States (33.0%).

Use of reminders and urinary catheter stop orders was reported by 21.7% of hospitals in Japan, 28.3% in Thailand, and 54.0% in the United States. No specific hospital characteristics were associated with use of this practice among hospitals in Japan. In Thailand, having a hospital epidemiologist was significantly associated with use of reminders or stop orders to prevent CAUTI (OR, 3.18; 95% CI, 1.67–6.07), whereas in the United States the odds of use was higher among hospitals involved in an HAI collaborative (2.25; 1.20–4.21).

DISCUSSION

Using contemporaneous data, collected via a similar survey instrument, we found distinct patterns related to the use of key practices for preventing CLABSI, VAP, and CAUTI across Japan, Thailand, and the United States. The results show that a majority of hospitals in all 3 countries use maximum barrier precautions for preventing CLABSI and semirecumbent positioning for preventing VAP. Nearly all hospitals in Thailand and the United States also monitor CLABSI, VAP, and UTI rates, whereas in Japan only CLABSI rates are monitored by a majority of hospitals. Reported use of many of the practices, regardless of type of infection, seemed to be lower among hospitals in Japan, yet this is not universally true, and there are potential opportunities for targeting prevention activities in hospitals across all 3 countries.

More than half of hospitals in all 3 countries identified CLABSI prevention as very or extremely important to hospital leadership. This view was especially prevalent in the United States, with >90% of hospitals identifying CLABSI prevention as important. Indeed, nearly all American hospitals report monitoring CLABSI rates and using maximum barrier precautions and chlorhexidine site antisepsis during insertion, according to current recommendations [9, 23]. Although we cannot directly link reported practice use with infection rates, there has been a 50% decrease in CLABSI from 2008 to 2014 among US acute care hospitals [24]. However, although guidelines generally recommend avoiding the femoral vein for central venous access [11, 14], practice adoption ranges from approximately 30% of hospitals in Japan to 70% in the United States. In both Japan and Thailand, safety-centered leadership was associated with avoidance of the femoral site. This association was not found for the United States, and strategies to further encourage use may be needed.

Compared with CLABSI, fewer hospitals perceived preventing VAP as very or extremely important to hospital leadership, particularly in the United States and Japan. Nonetheless, adoption of semirecumbent positioning was quite high, ranging from 66% of hospitals in Japan to nearly all hospitals in the United States. A majority of hospitals in Thailand and the United States also reported using antimicrobial mouth rinse and monitoring VAP rates, but use of both practices was significantly less common in Japan. The use of endotracheal tubes with subglottic secretion drainage ports is also variable. Our findings show that in Japan, hospital size is associated with use of this technology, whereas in America perceived importance of VAP prevention to hospital leadership and in Thailand presence of a hospital epidemiologist increased the use of subglottic secretion drainage. The extent to which further adoption should be encouraged, however, remains unclear given uncertainty regarding the benefits of this approach relative to other practices, such as minimizing sedation and daily spontaneous awakening and breathing trials, which may have a positive effect on a broader set of clinical outcomes [25, 26].

More than 90% of hospitals in Thailand identified UTI prevention as very or extremely important to hospital leadership, compared with <50% of hospitals in Japan and the United States. However, aside from monitoring UTI rates, few CAUTI prevention practices are used by >50% of hospitals. Among hospitals in Japan and Thailand, the most commonly reported practices are use of silver alloy catheters (44%) and nurse-initiated discontinuation (41%), respectively. The apparently lower rate of adoption of CAUTI prevention practices relative to those for CLABSI and VAP could be due in part to national policies. For example, since joining the Global Patient Safety Challenge [1] in 2007, hospitals in Thailand have focused on specific initiatives such as hand hygiene [5, 18], and bundles for preventing CAUTI have not been implemented. Nonetheless, there was a 32% reduction in CAUTI rates in non-ICUs among American hospitals that participated in a national CAUTI prevention program [27], suggesting that, with focused attention, improvements can be made in addressing this common infection.

Our study has several limitations. First, although response rates for all surveys were quite high, the findings could still be affected by nonresponse bias. Second, even though data were collected using a similar survey instrument, differences in responses could result owing to translation issues or cross-cultural interpretation. Third, we do not have information about patient characteristics or hospital-specific infection rates, which, along with the substantial variation in hospital characteristics across the 3 countries, could influence practice use. However, based on comparable data reported by the International Nosocomial Infection Control Consortium, which includes hospitals in Southeast Asia and the Western Pacific as well as Latin America, Europe and the Eastern Mediterranean, and the US National Healthcare Safety Network, rates of CLABSI, VAP, and CAUTI all seem to be lower in US ICUs [2].

Limitations notwithstanding, our findings show that hospitals in Japan, Thailand, and the United States are using a number of recommended practices to prevent device-associated infections. However, although some practices, such as maximum barrier precautions and semirecumbent positioning, are used by a majority of hospitals in all 3 countries, there is considerable variation in the use of other practices both within and across countries. Factors that facilitate practice adoption may also vary across countries, although more work is needed to identify which hospital characteristics or external factors affect the use of key infection prevention practices and promote reductions in infection risk. Finally, these results suggest that the use of practices to prevent CAUTI tend to be relatively low and that opportunities for targeting prevention activities and reducing device-associated infection risk in hospitals exist across all 3 countries.

Notes

Disclaimer. The study sponsors had no role in the design or conduct of the study; the collection, management, analysis, and interpretation of the data; of the preparation, review, or approval of the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Financial support. This work was supported by the Blue Cross Blue Shield of Michigan Foundation (grant 1907.II), the US Department of Veterans Affairs (VA) Health Services Research Service and National Center for Patient Safety, VA Health Services Research and Development (Research Career Scientist award RCS 11-222 to S. L. K.), and the National Research University Project of the Thailand Office of Higher Education Commission (A. A.).

Supplement sponsorship. This article appears as part of the supplement “Infection Prevention in Asia Pacific,” sponsored by the Infectious Diseases Association of Thailand (IDAT) with additional author sponsorship.

Potential conflicts of interest. All authors: No potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

References

Author notes