American Journal of Infection Control 42 (2014) 888-93
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American Journal of Infection Control
American Journal of Infection Control
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Major article
Health careeassociated infection prevention in Japan: The role of safety culture Fumie Sakamoto BSN, MPH, CIC a, *, Tomoko Sakihama RN, CNS, MSN b, Sanjay Saint MD, MPH c, d, e, M. Todd Greene PhD, MPH c, d, David Ratz MS d, e, Yasuharu Tokuda MD, MPH f a
Center for Quality Improvement, St Luke’s International Medical Center, Tokyo, Japan Division of Infection Control and Prevention, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan d Department of Veterans Affairs/University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan e Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan f Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan b c
Key Words: Health careeassociated infection Infection prevention Safety culture Japanese hospitals Nosocomial
Background: Limited data exist on the use of infection prevention practices in Japan. We conducted a nationwide survey to examine the use of recommended infection prevention strategies and factors affecting their use in Japanese hospitals. Methods: Between April 1, 2012, and January 31, 2013, we surveyed 971 hospitals in Japan. The survey instrument assessed general hospital and infection prevention program characteristics and use of infection prevention practices, including practices specific to preventing catheter-associated urinary tract infection (CAUTI), central lineeassociated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Logistic regression models were used to examine multivariable associations between hospital characteristics and the use of the various prevention practices. Results: A total of 685 hospitals (71%) responded to the survey. Maintaining aseptic technique during catheter insertion and maintenance, avoiding routine central line changes, and using maximum sterile barrier precautions and semirecumbent positioning were the only practices regularly used by more than one-half of the hospitals to prevent CAUTI, CLABSI, and VAP, respectively. Higher safety-centeredness was associated with regular use of prevention practices across all infection types. Conclusions: Although certain practices were used commonly, the rate of regular use of many evidencebased prevention practices was low in Japanese hospitals. Our findings highlight the importance of fostering an organization-wide atmosphere that prioritizes patient safety. Such a commitment to patient safety should in turn promote the use of effective measures to reduce health careeassociated infections in Japan. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
* Address correspondence to Fumie Sakamoto, BSN, MPH, CIC, Center for Quality Improvement, St Luke’s International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, Japan 104-8560. E-mail address: [email protected] (F. Sakamoto). Funding was provided by St Luke’s Life Science Institute (grant number 2012-8), which had no role in study design; collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the manuscript for publication. FS had full access to all of the study data and had final responsibility for the decision to submit the manuscript for publication. Authorship statement: FS designed the study, performed the literature search, and contributed to data collection and interpretation and manuscript preparation. TS contributed to data collection and interpretation and manuscript preparation. SS contributed to study conception and design, data interpretation, and critical
revisions. MTG contributed to data management, analysis, and interpretation, manuscript preparation, and critical revisions. DR performed data management and analysis tasks and contributed to the preparation of the Methods and Results sections of the manuscript. YT contributed to data interpretation of manuscript preparation. Conflict of interest: SS has received numerous honoraria and speaking fees from academic medical centers, hospitals, group-purchasing organizations (eg, VHA, Premier), specialty societies, state-based hospital associations, and nonprofit foundations (eg, Michigan Health and Hospital Association, Institute for Healthcare Improvement) for lectures about CAUTI and implementation science. YT has received numerous honoraria and speaking fees from universities, hospitals, academic societies, and pharmaceutical companies for lectures and workshops on general medicine. None of the other authors has any conflicts of interest to disclose.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.05.018
F. Sakamoto et al. / American Journal of Infection Control 42 (2014) 888-93
Health careeassociated infection (HAI) is a major cause of patient morbidity and mortality. In high- and middle-income countries, HAI affects an estimated 5%-8% of patient populations.1 Major types of HAI include catheter-associated urinary tract infection (CAUTI), central lineeassociated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP).1 It has been reported that as much as 65%-70% of CAUTI and CLABSI and 55% of VAP could be prevented by practicing current evidence-based strategies.2 Starting in 2005, the World Health Organization started an initiative to campaign for patient safety through the 2005-2006 Global Patient Safety Challenge project “Clean Care is Safer Care.” The primary focus of that project was on the prevention of infections associated with health care through the implementation of low-cost, simple, and effective strategies, such as hand hygiene and evidence-based practices, to prevent HAI.3 Although the project started with a focus on hand hygiene, there is an appreciation of the need for attention to additional strategies specific to the prevention of different clinical infections (eg, CAUTI, CLABSI, VAP) to improve patient safety and quality of care in hospitals worldwide. Although Japan did not sign the pledge to support the “Clean Care is Safer Care” campaign until June 2010, guidelines and recommendations to prevent several types of HAI, published by several organizations and government agencies,4-10 have been widely implemented by health care providers in Japan. Despite this, however, data on the use of various strategies to prevent HAI are limited. To date, 2 surveys have been conducted with the goal of describing infection prevention practices in Japan. A survey study conducted in 2004 found a relatively low frequency of use of evidence-based practices, ranging from 20% for HAI surveillance to 39% for maximum sterile barrier precautions.11 That study also found that in more than one-half of the hospitals studied, infection prevention practitioners spent less than 20% of their working hours on infection prevention. A separate survey study targeted a representative sample of hospitals to study the association between CAUTI prevention practices and hospital size, and found that a higher proportion of larger hospitals practiced evidence-based CAUTI prevention measures compared with smaller hospitals.12,13 Although the foregoing surveys provided valuable information regarding infection control in Japan, we are unaware of any other studies that have investigated both the extent to which evidencebased practices are used to prevent multiple types of HAI and factors that predict their use in Japan. As such, we conducted a nationwide survey study to elucidate the use of a comprehensive set of currently recommended infection prevention strategies and to examine various structural and organizational factors affecting their use in hospitals across Japan.
METHODS Survey instrument Between April 1, 2012, and January 31, 2013, we surveyed 971 hospitals in Japan that had at least 1 nurse certified in infection prevention by the Japanese Nursing Association. The survey instrument, developed by Krein, Saint, and colleagues,14-16 was translated into Japanese by a panel of bilingual infection prevention professionals. The translated surveys were mailed to each hospital and addressed to the lead infection preventionist. The survey responses were anonymized. The instrument contained questions about general hospital characteristics, structure and staffing of the infection prevention program, use of general infection prevention practices such as hand hygiene, and use of specific practices related to the prevention and monitoring of CAUTI, CLABSI, and VAP.
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Responses about the frequency of use for each infection prevention practice were assigned a value between 1 (never) and 5 (always). A response of 4 (almost always) or 5 (always) was defined as regular use of the particular prevention practice. All prevention practices examined were dichotomized into binary dependent variables, with regular use coded as 1 and 0 otherwise. A safety score was defined as the summation of responses regarding agreement to 2 statements about safety: “Leadership is driving us to a safety-centered institution” and “I would feel safe being treated here as a patient.” These statements were selected for conceptual reasons stemming from previous work.14 Each of these survey items was scored from 1 (strongly agree) to 5 (strongly disagree), and before responses were combined they were reverse-scored, with a higher score indicating a more safety-centered culture. Statistical analysis Bivariate associations between hospital characteristics and regular use of infection prevention practices were assessed using unadjusted binary logistic regression models. Pearson correlation coefficients were obtained for all pairs of independent variables to avoid multicollinearity in our multivariate analyses. Logistic regression was used to examine multivariable associations between hospital characteristics and the use of the various prevention practices. Several practices were excluded owing to low frequency of use (ie, 95%). The number of acute care hospital beds, presence of infectious disease physicians, presence of hospitalists, safety score, and whether the lead infection preventionist is a registered nurse (RN) were included as independent variables in all models. RESULTS A total of 971 hospitals met the inclusion criteria, of which 685 (71%) responded to the survey. The hospitals included in this study were larger, with an average of 322 acute care beds, compared with a random sample of Japanese hospitals.17 Table 1 presents descriptive characteristics of the responding hospitals. Of the 685 responding hospitals, 41% had hospitalists, 20% had hospital epidemiologists, 18% had infectious disease physicians, and 62% had an RN as the lead infection preventionist. The vast majority (92%) reported participating in a collaborative focusing on HAI prevention. These collaboratives typically were smaller regional collaboratives consisting of only a few hospitals. Nurse staffing issues were reported by many responding hospitals. In addition, very few hospitals reported receiving adequate support from hospital leadership for infection prevention efforts. A total of 49% agreed (reported as “agree” or “strongly agree”) with the statement that “leadership is driving us to be a safety-centered institution,” and 31% agreed with the statement that “I would feel safe being treated here as a patient.” Responses to these 2 statements were positively correlated (r ¼ 0.54; P < .001). Combining the responses for these 2 statements to generate a safety score yielded a mean score of 6.3. Figure 1 shows the percentage of hospitals that reported regular use of the various infection prevention practices examined. For general infection prevention practices, the majority of hospitals had a daily oral care regimen (87%) and used alcohol-based hand rub (85%). Direct monitoring of hand hygiene compliance (29%) and active surveillance cultures for multidrug-resistant organisms (24%) were less frequent. For CAUTI, aseptic technique during
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Table 1 Hospital characteristics (n ¼ 685) Characteristic General Has hospitalists, n (%) Has a hospital epidemiologist, n (%) Has infectious disease physicians, n (%) Lead infection preventionist is an RN, n (%) Medical school affiliation, n (%) Member of a collaborative focusing on HAI prevention, n (%) Number of adult ICU beds, mean SD Number of acute care hospital beds, mean SD Number of full-time infection control professionals, mean SD Facility closed beds/units owing to nurse staffing problems, n (%) Nurse staffing is generally adequate to ensure patient safety, n (%) Very good/excellent infection control program support from leadership, n (%) Safety score (range 2-10),* mean SD CAUTI-specific Has a surveillance system for monitoring CAUTI rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%) CLABSI-specific Has a surveillance system for monitoring CLABSI rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%) VAP-specific Has a surveillance system for monitoring VAP rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%)
Value 281 (41) 134 (20) 125 (18) 426 (62) 71 (10) 627 (92) 13.4 36.3 321.9 244.4 3.2 4.0 180 (26) 108 (16) 21 (3) 6.3 1.6 240 (35) 268 (39)
458 (67) 355 (52)
215 (31) 297 (43)
SD, standard deviation. *Defined as the combination of the responses to 2 statements about safety: “Leadership is driving us to be a safety-centered institution” and “I would feel safe being treated here as a patient.”
urinary catheter insertion and maintenance was used by nearly all responding hospitals (92%). In contrast, fewer hospitals reported regular use of strategies to shorten the duration of catheter use, such as intermittent catheterization (35%), nurse-initiated catheter discontinuation (34%), and urinary catheter reminder or stop orders (20%). For CLABSI, avoiding routine central line changes (96%) and maximum sterile barrier precautions (76%) were the most common practices. Avoiding catheter insertion into the femoral site (29%) and using chlorhexidine gluconate for skin antisepsis (19%) were much less frequent. For VAP, 65% of hospitals reported regularly using semirecumbent positioning, but only 32% used sedation vacation and 19% used subglottic secretion drainage. The proportion of hospitals conducting surveillance for monitoring infection rates was 35% for CAUTI, 67% for CLABSI, and 31% for VAP. In addition, nearly one-half of the responding hospitals indicated that a moderate to large increase in the priority of infection prevention would be anticipated if nonpayment for device-associated HAI was introduced in Japan. Adjusted odds ratios (aORs) from the multivariable regression analysis are presented in Table 2. The hospital characteristic most commonly associated with the infection prevention practices examined was the safety score, statistically associated with the regular use of 15 different prevention practices across all infection types. All associations were positive, and the aORs varied from 1.1 (95% confidence interval [CI], 1.0-1.3) for direct monitoring of hand hygiene compliance to 1.4 (95% CI, 1.2-1.6) for use of a daily oral care regimen. The safety score was also significantly associated with whether or not a hospital monitored infection rates for all 3 types of HAI (data not shown). The number of acute care beds in the hospital was associated with regular use of 5 different general, CLABSI, and
VAP prevention practices, but with no practices for CAUTI. Having an RN as the lead infection preventionist was associated with 3 prevention practices, 2 for VAP and 1 for general infection prevention.
DISCUSSION In this large-scale, cross-sectional, national survey, less than one-half of responding Japanese hospitals reported regularly using many of the infection prevention practices investigated. Of note, we observed significant variability within each infection type in the regular use of prevention practices recommended in published guidelines or supported by recent systematic reviews.4-10,18 For example, although the majority of hospitals reported using alcoholbased hand rub on a daily basis, less than 30% conducted direct monitoring of hand hygiene compliance. Similarly, for CAUTI, whereas nearly all hospitals reported using aseptic technique during urinary catheter insertion and maintenance, measures to shorten the duration of catheter use were practiced much less frequently. There was also substantial variation in the regular use of the following CLABSI prevention practices: maintaining maximal barrier precautions, avoiding catheter insertion into the femoral site, and using chlorhexidine gluconate antisepsisdall key components of a recommended central line insertion bundle.19 Similar variability in the regular use of VAP prevention practices was observed, with semirecumbent positioning the sole VAP-specific prevention practice used regularly by more than one-half of the responding hospitals. It is also noteworthy that the proportion of hospitals conducting HAI surveillance, which is strongly recommended in major infection prevention guidelines,5-10 was relatively low and varied among the different infection types. Compared with findings from previous surveys conducted in the Unites States and Thailand,14-16,20 we identified several differences and similarities in device-related infection prevention practice use in hospitals across Japan. In all 3 countries, less than one-half of responding hospitals reported the regular use of all CAUTI prevention practices examined, with the exception of aseptic technique for urinary catheter insertion and maintenance. In contrast, there was a pronounced difference in the regular use of many CLABSI prevention practices between Japan and the United States. In particular, the regular use of chlorhexidine gluconate and avoidance of catheter insertion into the femoral site was much higher in the United States than in Japan. Regular use of VAP prevention practices was lowest in Japan compared with the United States and Thailand. The Japanese health care system is decentralized, and intensive care is poorly distributed, with only 1% of beds designated as intensive care unit (ICU) beds.21 A recent survey of health care professionals found that adherence to VAP prevention measures in Japan was low overall, but that compliance was greater in intensivist-led ICUs.22 Unlike the United States, which has a system of nonpayment for certain types of HAI,23 there are not strong financial incentives or penalties for Japanese hospitals to use evidence-based infection prevention practices if they incur any additional costs. One exception is that, as of September 2013, the Japanese health care reimbursement system requires hospitals that receive additional fees for enhanced infection prevention to hire at least 1 full-time infection prevention professional regardless of hospital size and to participate in regional infection prevention collaboratives. Consequently, the level of effort that a hospital chooses to dedicate to facilitate evidence-based infection prevention is dependent on the hospital’s resources and overall attitude toward patient safety. This view is supported by our findings suggesting that numerous infection prevention practices are used more frequently in hospitals
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Fig 1. Reported regular use of infection prevention practices. HCWs, health care workers; IP, infection prevention; MDROs, multidrug-resistant organisms; MRSA, methicillinresistant Staphylococcus aureus.
Table 2 Factors significantly associated with regular use of infection prevention practices Infection General
Practice
Variable
Alcohol-based hand rub Direct monitoring of hand hygiene compliance Active surveillance of cultures for colonization Decolonization of nose and skin in patients with MRSA before surgery Antimicrobial stewardship program Daily oral care regimen Provide education/training in infection prevention in professions other than nurses
CAUTI
Urinary catheter reminder or stop order Nurse-initiated urinary catheter discontinuation Portable bladder ultrasound scan Aseptic technique during insertion or maintenance
CLABSI
Maximal sterile barrier precautions Avoidance of femoral insertion site
VAP
Semirecumbent positioning Subglottic secretion drainage Sedation vacation
Safety score Safety score Number of acute care beds* Safety score Number of acute care beds* Safety score Safety score Safety score RN as lead infection preventionist Safety score Safety score Safety score Safety score Has hospitalists Number of acute care beds* Safety score Number of acute care beds* Safety score Number of acute care beds* Safety score Safety score RN as lead infection preventionist Safety score RN as lead infection preventionist
aOR (95% CI) 1.2 1.1 1.1 1.1 1.1 1.4 1.4 1.3 1.4 1.2 1.2 1.2 1.3 0.5 1.2 1.3 1.1 1.2 1.1 1.2 1.2 1.8 1.2 0.7
(1.1-1.4) (1.0-1.3) (1.0-1.2) (1.0-1.3) (1.0-1.2) (1.2-1.5) (1.2-1.6) (1.1-1.4) (1.0-2.1) (1.1-1.4) (1.1-1.4) (1.0-1.4) (1.1-1$5) (0.3-0.9) (1.1-1.3) (1.2-1.5) (1.1-1.2) (1.0-1.3) (1.0-1.2) (1.0-1.3) (1.0-1.3) (1.1-2.9) (1.1-1.3) (0.5-1.0)
aOR, adjusted odds ratio; MRSA, methicillin-resistant Staphylococcus aureus; RN, registered nurse. *aORs given for a 100-bed increase.
that have more beds and resources, a dedicated RN serving as the lead infection preventionist, and a greater culture of safety. Implementing many, if not all, of the infection prevention practices investigated and conducting HAI surveillance will require additional costs, multidisciplinary teamwork, and assertiveness and/or autonomy of nonphysician health care providers. For example, chlorhexidine gluconate is more expensive than alcohol or povidone-iodine, which has been conventionally used for skin
antisepsis in Japanese hospitals.24 Direct monitoring of hand hygiene compliance, intermittent catheterization, and HAI surveillance requires additional personnel training and working hours. Multidisciplinary teamwork is necessary to practice sedation vacations and avoiding catheter insertion into the femoral site. In addition, nonphysician health care providers, namely nurses, must be assertive and given autonomy to initiate urinary catheter discontinuation. Thus, in today’s health care system in Japan,
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adoption and sustained use of these infection prevention measures may rely heavily on hospital leadership’s willingness to prioritize the development of a sound patient safety culture. Highlighting the importance of leadership in preventing HAIs, Saint et al25 identified various leadership behaviors that may contribute to the successful implementation of HAI prevention strategies. Successful leaders commonly cultivate and communicate a culture of clinical excellence, focus on identifying and overcoming barriers and resistance to change, exhibit enthusiasm and inspirational motivation, and plan strategically while acting locally.25 In addition to having support from hospital leadership, identifying and appointing enthusiastic and motivated individuals who are willing to champion evidence-based infection prevention practices may aid the successful implementation of the technical and behavioral changes that may be required to improve infection prevention efforts.26 Effective championing, infection rate feedback and national comparisons, local comparisons of infection prevention practice compliance, and participation in collaborative efforts focused on reducing HAIs are important considerations to help overcome the active resistance that is frequently met when attempting to implement changes in clinical practice.27 Our study has several important limitations. First, we did not randomly select hospitals from the more than 8000 hospitals in Japan, of which almost 70% have fewer than 200 beds,17 but rather targeted hospitals with at least 1 professional trained in infection prevention. We chose this inclusion criterion because knowledge of both recent evidence-based infection prevention practices and their frequency of use were needed to respond to the survey questions. Second, because our response rate was below 100%, our results are subject to nonresponse bias. These 2 limitations may limit the generalizability of our study results. Third, the frequency of use of infection prevention practices relies solely on selfreported data from the lead infection preventionist at each responding hospital. The respondents might have overestimated or underestimated the true frequencies of use of certain infection prevention practices examined, although we have no reason to believe this has resulted in a systematic error. Fourth, we did not collect data on infection rates, and thus were unable to evaluate associations between the regular use of various infection prevention practices and patient outcomes. Finally, because we did not measure patient-level case mix, our results might have been biased by unknown confounders. Despite these limitations, however, this study is the first to provide a comprehensive description of current infection prevention practices and possible factors affecting their use in hospitals across Japan. We believe that our study provides valuable information and insights for policy makers, hospital administrators, clinicians, and infection prevention professionals who are responsible for HAI prevention in Japanese hospitals. Results from our national survey highlight several areas of HAI prevention that have room for improvement in Japanese hospitals. First, our findings suggest the need for strategies to strengthen hospital leadership to foster a safety culture to implement and sustain the use of evidence-based infection prevention practices. This finding regarding the importance of establishing and nurturing an effective culture of patient safety is similar to results observed in a similar survey conducted in Thailand.20 As such, hospital leadership’s commitment to a safety culture may be a universal driving force for improving infection prevention in health care settings internationally. Second, our results also suggest that substantial financial incentives and/or penalties also may be necessary to facilitate the adoption of resource-intensive preventive measures, given that nearly one-half of the respondents indicated that nonpayment for certain preventable HAIs likely would increase the priority of infection prevention efforts. Finally, appointing champions with
strong motivation, communication skills, and knowledge may play an important role in promoting evidence-based infection prevention practices. Some of the infection prevention practices that were reported less frequently (eg, nurse-initiated removal of unnecessary urinary catheters) require assertiveness and/or autonomy by nonphysician health care providers. The presence of enthusiastic champions likely would help facilitate the adoption of patient safety as a shared value across all professions and departments, thereby making it easier for all to voice concerns about infection prevention regardless of profession or position. HAI prevention is a relatively new practice in the history of Japanese health care.28 Although knowledge of the importance of infection prevention has increased in recent years, more emphasis has been placed on structural elements, (eg, staffing infection prevention professionals and forming regional collaboratives) than on ensuring the adoption of evidence-based infection prevention practices. Consequently, as our results show, there is currently wide variation among Japanese hospitals in the use of practices focused on preventing HAI. Our study emphasizes the strong need to foster an organization-wide atmosphere that prioritizes patient safety, which should in turn promote the adoption of effective measures to improve HAI prevention in Japan. Acknowledgment We thank Andy Hickner, MSI for assistance with manuscript preparation. References 1. World Health Organization. WHO report on the burden of endemic health caree associated infection worldwide. 2011. Available from http://apps.who.int/iris/ bitstream/10665/80135/1/9789241501507_eng.pdf . Accessed August 12, 2013. 2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101-14. 3. Pittet D, Allegranzi B, Storr J, Donaldson L. “Clean Care is Safer Care”: the global patient safety challenge 2005-2006. Int J Infect Dis 2006;10:419-24. 4. World Health Organization. WHO guidelines on hand hygiene in health care: a summary. Available from http://apps.who.int/medicinedocs/documents/ s16320e/s16320e.pdf . Accessed August 12, 2013. 5. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheterassociated urinary tract infections, 2009. Infect Control Hosp Epidemiol 2010; 31:319-26. 6. Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S41-50. 7. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39:S1-34. 8. Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent central lineeassociated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S22-30. 9. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing healthcareeassociated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53:1-36. 10. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S31-40. 11. Kobayashi H, Okubo T, Kizu J, Fujii A, Tomono K, Oie S, et al. Hospital infection control programs in Japan: current practices and activities in 466 teaching hospitals. Kankyo Kansen 2006;21:200-8. 12. Nishida M, Utsumi M, Makimoto K. Nationwide hospital survey on infection control system and urinary catheter care practice in Japan. Kankyo Kansen 2010;25:41-6. 13. Utsumi M, Fujita M, Makimoto K. Hospital size affects infection control system and urinary catheter care practice: a national postal survey, part 2. Kankyo Kansen 2011;26:350-7. 14. Krein SL, Hofer TP, Kowalski CP, Olmsted RN, Kauffman CA, Forman JH, et al. Use of central venous cathetererelated bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672-8.
F. Sakamoto et al. / American Journal of Infection Control 42 (2014) 888-93 15. Krein SL, Kowalski CP, Damschroder L, Forman J, Kaufman SR, Saint S. Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study. Infect Control Hosp Epidemiol 2008;29: 933-40. 16. Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46:243-50. 17. Japan Ministry of Health, Labor, and Welfare. Hospital statistics, 2011. Available from: http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/11/. Accessed August 12, 2013. 18. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and metaanalysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 2010;51:550-60. 19. Institute for Healthcare Improvement. Implement the IHI central line bundle. Available from: http://www.ihi.org/knowledge/Pages/Changes/Implementthe CentralLineBundle.aspx. Accessed September 5, 2013. 20. Apisarnthanarak A, Greene MT, Kennedy EH, Khawcharoenporn T, Krein S, Saint S. National survey of practices to prevent healthcare-associated infections in Thailand: the role of safety culture and collaboratives. Infect Control Hosp Epidemiol 2012;33:711-7.
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21. Sirio CA, Tajimi K, Taenaka N, Ujike Y, Okamoto K, Katsuya H. A cross-cultural comparison of critical care delivery: Japan and the United States. Chest 2002; 121:539-48. 22. Shime N, Morrow LE. Current practices for ventilator-associated pneumonia prevention in Japan: a survey study. Chest 2012;141:281-3. 23. Rosenthal MB. Nonpayment for performance? Medicare’s new reimbursement rule. N Engl J Med 2007;357:1573-5. 24. Japan Ministry of Health, Labor, and Welfare. Drug price list, 2013. Available from: http://www.mhlw.go.jp/topics/2012/03/tp120305-01.html. Accessed August 12, 2013. 25. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol 2010;31:901-7. 26. Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, Saint S, Krein SL. The role of the champion in infection prevention: results from a multisite qualitative study. Qual Saf Health Care 2009;18:434-40. 27. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. How active resisters and organizational constipators affect health careeacquired infection prevention efforts. Jt Comm J Qual Patient Saf 2009;35:239-46. 28. Kobayashi H. History and perspective of hospital infection control. Nippon Rinsho 2002;60:2067-71.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Health careeassociated infection prevention in Japan: The role of safety culture Fumie Sakamoto BSN, MPH, CIC a, *, Tomoko Sakihama RN, CNS, MSN b, Sanjay Saint MD, MPH c, d, e, M. Todd Greene PhD, MPH c, d, David Ratz MS d, e, Yasuharu Tokuda MD, MPH f a
Center for Quality Improvement, St Luke’s International Medical Center, Tokyo, Japan Division of Infection Control and Prevention, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan d Department of Veterans Affairs/University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan e Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan f Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan b c
Key Words: Health careeassociated infection Infection prevention Safety culture Japanese hospitals Nosocomial
Background: Limited data exist on the use of infection prevention practices in Japan. We conducted a nationwide survey to examine the use of recommended infection prevention strategies and factors affecting their use in Japanese hospitals. Methods: Between April 1, 2012, and January 31, 2013, we surveyed 971 hospitals in Japan. The survey instrument assessed general hospital and infection prevention program characteristics and use of infection prevention practices, including practices specific to preventing catheter-associated urinary tract infection (CAUTI), central lineeassociated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Logistic regression models were used to examine multivariable associations between hospital characteristics and the use of the various prevention practices. Results: A total of 685 hospitals (71%) responded to the survey. Maintaining aseptic technique during catheter insertion and maintenance, avoiding routine central line changes, and using maximum sterile barrier precautions and semirecumbent positioning were the only practices regularly used by more than one-half of the hospitals to prevent CAUTI, CLABSI, and VAP, respectively. Higher safety-centeredness was associated with regular use of prevention practices across all infection types. Conclusions: Although certain practices were used commonly, the rate of regular use of many evidencebased prevention practices was low in Japanese hospitals. Our findings highlight the importance of fostering an organization-wide atmosphere that prioritizes patient safety. Such a commitment to patient safety should in turn promote the use of effective measures to reduce health careeassociated infections in Japan. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
* Address correspondence to Fumie Sakamoto, BSN, MPH, CIC, Center for Quality Improvement, St Luke’s International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, Japan 104-8560. E-mail address: [email protected] (F. Sakamoto). Funding was provided by St Luke’s Life Science Institute (grant number 2012-8), which had no role in study design; collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the manuscript for publication. FS had full access to all of the study data and had final responsibility for the decision to submit the manuscript for publication. Authorship statement: FS designed the study, performed the literature search, and contributed to data collection and interpretation and manuscript preparation. TS contributed to data collection and interpretation and manuscript preparation. SS contributed to study conception and design, data interpretation, and critical
revisions. MTG contributed to data management, analysis, and interpretation, manuscript preparation, and critical revisions. DR performed data management and analysis tasks and contributed to the preparation of the Methods and Results sections of the manuscript. YT contributed to data interpretation of manuscript preparation. Conflict of interest: SS has received numerous honoraria and speaking fees from academic medical centers, hospitals, group-purchasing organizations (eg, VHA, Premier), specialty societies, state-based hospital associations, and nonprofit foundations (eg, Michigan Health and Hospital Association, Institute for Healthcare Improvement) for lectures about CAUTI and implementation science. YT has received numerous honoraria and speaking fees from universities, hospitals, academic societies, and pharmaceutical companies for lectures and workshops on general medicine. None of the other authors has any conflicts of interest to disclose.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.05.018
F. Sakamoto et al. / American Journal of Infection Control 42 (2014) 888-93
Health careeassociated infection (HAI) is a major cause of patient morbidity and mortality. In high- and middle-income countries, HAI affects an estimated 5%-8% of patient populations.1 Major types of HAI include catheter-associated urinary tract infection (CAUTI), central lineeassociated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP).1 It has been reported that as much as 65%-70% of CAUTI and CLABSI and 55% of VAP could be prevented by practicing current evidence-based strategies.2 Starting in 2005, the World Health Organization started an initiative to campaign for patient safety through the 2005-2006 Global Patient Safety Challenge project “Clean Care is Safer Care.” The primary focus of that project was on the prevention of infections associated with health care through the implementation of low-cost, simple, and effective strategies, such as hand hygiene and evidence-based practices, to prevent HAI.3 Although the project started with a focus on hand hygiene, there is an appreciation of the need for attention to additional strategies specific to the prevention of different clinical infections (eg, CAUTI, CLABSI, VAP) to improve patient safety and quality of care in hospitals worldwide. Although Japan did not sign the pledge to support the “Clean Care is Safer Care” campaign until June 2010, guidelines and recommendations to prevent several types of HAI, published by several organizations and government agencies,4-10 have been widely implemented by health care providers in Japan. Despite this, however, data on the use of various strategies to prevent HAI are limited. To date, 2 surveys have been conducted with the goal of describing infection prevention practices in Japan. A survey study conducted in 2004 found a relatively low frequency of use of evidence-based practices, ranging from 20% for HAI surveillance to 39% for maximum sterile barrier precautions.11 That study also found that in more than one-half of the hospitals studied, infection prevention practitioners spent less than 20% of their working hours on infection prevention. A separate survey study targeted a representative sample of hospitals to study the association between CAUTI prevention practices and hospital size, and found that a higher proportion of larger hospitals practiced evidence-based CAUTI prevention measures compared with smaller hospitals.12,13 Although the foregoing surveys provided valuable information regarding infection control in Japan, we are unaware of any other studies that have investigated both the extent to which evidencebased practices are used to prevent multiple types of HAI and factors that predict their use in Japan. As such, we conducted a nationwide survey study to elucidate the use of a comprehensive set of currently recommended infection prevention strategies and to examine various structural and organizational factors affecting their use in hospitals across Japan.
METHODS Survey instrument Between April 1, 2012, and January 31, 2013, we surveyed 971 hospitals in Japan that had at least 1 nurse certified in infection prevention by the Japanese Nursing Association. The survey instrument, developed by Krein, Saint, and colleagues,14-16 was translated into Japanese by a panel of bilingual infection prevention professionals. The translated surveys were mailed to each hospital and addressed to the lead infection preventionist. The survey responses were anonymized. The instrument contained questions about general hospital characteristics, structure and staffing of the infection prevention program, use of general infection prevention practices such as hand hygiene, and use of specific practices related to the prevention and monitoring of CAUTI, CLABSI, and VAP.
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Responses about the frequency of use for each infection prevention practice were assigned a value between 1 (never) and 5 (always). A response of 4 (almost always) or 5 (always) was defined as regular use of the particular prevention practice. All prevention practices examined were dichotomized into binary dependent variables, with regular use coded as 1 and 0 otherwise. A safety score was defined as the summation of responses regarding agreement to 2 statements about safety: “Leadership is driving us to a safety-centered institution” and “I would feel safe being treated here as a patient.” These statements were selected for conceptual reasons stemming from previous work.14 Each of these survey items was scored from 1 (strongly agree) to 5 (strongly disagree), and before responses were combined they were reverse-scored, with a higher score indicating a more safety-centered culture. Statistical analysis Bivariate associations between hospital characteristics and regular use of infection prevention practices were assessed using unadjusted binary logistic regression models. Pearson correlation coefficients were obtained for all pairs of independent variables to avoid multicollinearity in our multivariate analyses. Logistic regression was used to examine multivariable associations between hospital characteristics and the use of the various prevention practices. Several practices were excluded owing to low frequency of use (ie, 95%). The number of acute care hospital beds, presence of infectious disease physicians, presence of hospitalists, safety score, and whether the lead infection preventionist is a registered nurse (RN) were included as independent variables in all models. RESULTS A total of 971 hospitals met the inclusion criteria, of which 685 (71%) responded to the survey. The hospitals included in this study were larger, with an average of 322 acute care beds, compared with a random sample of Japanese hospitals.17 Table 1 presents descriptive characteristics of the responding hospitals. Of the 685 responding hospitals, 41% had hospitalists, 20% had hospital epidemiologists, 18% had infectious disease physicians, and 62% had an RN as the lead infection preventionist. The vast majority (92%) reported participating in a collaborative focusing on HAI prevention. These collaboratives typically were smaller regional collaboratives consisting of only a few hospitals. Nurse staffing issues were reported by many responding hospitals. In addition, very few hospitals reported receiving adequate support from hospital leadership for infection prevention efforts. A total of 49% agreed (reported as “agree” or “strongly agree”) with the statement that “leadership is driving us to be a safety-centered institution,” and 31% agreed with the statement that “I would feel safe being treated here as a patient.” Responses to these 2 statements were positively correlated (r ¼ 0.54; P < .001). Combining the responses for these 2 statements to generate a safety score yielded a mean score of 6.3. Figure 1 shows the percentage of hospitals that reported regular use of the various infection prevention practices examined. For general infection prevention practices, the majority of hospitals had a daily oral care regimen (87%) and used alcohol-based hand rub (85%). Direct monitoring of hand hygiene compliance (29%) and active surveillance cultures for multidrug-resistant organisms (24%) were less frequent. For CAUTI, aseptic technique during
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Table 1 Hospital characteristics (n ¼ 685) Characteristic General Has hospitalists, n (%) Has a hospital epidemiologist, n (%) Has infectious disease physicians, n (%) Lead infection preventionist is an RN, n (%) Medical school affiliation, n (%) Member of a collaborative focusing on HAI prevention, n (%) Number of adult ICU beds, mean SD Number of acute care hospital beds, mean SD Number of full-time infection control professionals, mean SD Facility closed beds/units owing to nurse staffing problems, n (%) Nurse staffing is generally adequate to ensure patient safety, n (%) Very good/excellent infection control program support from leadership, n (%) Safety score (range 2-10),* mean SD CAUTI-specific Has a surveillance system for monitoring CAUTI rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%) CLABSI-specific Has a surveillance system for monitoring CLABSI rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%) VAP-specific Has a surveillance system for monitoring VAP rate, n (%) Moderate/large increase in priority of prevention if nonpayment for HAI introduced in Japan, n (%)
Value 281 (41) 134 (20) 125 (18) 426 (62) 71 (10) 627 (92) 13.4 36.3 321.9 244.4 3.2 4.0 180 (26) 108 (16) 21 (3) 6.3 1.6 240 (35) 268 (39)
458 (67) 355 (52)
215 (31) 297 (43)
SD, standard deviation. *Defined as the combination of the responses to 2 statements about safety: “Leadership is driving us to be a safety-centered institution” and “I would feel safe being treated here as a patient.”
urinary catheter insertion and maintenance was used by nearly all responding hospitals (92%). In contrast, fewer hospitals reported regular use of strategies to shorten the duration of catheter use, such as intermittent catheterization (35%), nurse-initiated catheter discontinuation (34%), and urinary catheter reminder or stop orders (20%). For CLABSI, avoiding routine central line changes (96%) and maximum sterile barrier precautions (76%) were the most common practices. Avoiding catheter insertion into the femoral site (29%) and using chlorhexidine gluconate for skin antisepsis (19%) were much less frequent. For VAP, 65% of hospitals reported regularly using semirecumbent positioning, but only 32% used sedation vacation and 19% used subglottic secretion drainage. The proportion of hospitals conducting surveillance for monitoring infection rates was 35% for CAUTI, 67% for CLABSI, and 31% for VAP. In addition, nearly one-half of the responding hospitals indicated that a moderate to large increase in the priority of infection prevention would be anticipated if nonpayment for device-associated HAI was introduced in Japan. Adjusted odds ratios (aORs) from the multivariable regression analysis are presented in Table 2. The hospital characteristic most commonly associated with the infection prevention practices examined was the safety score, statistically associated with the regular use of 15 different prevention practices across all infection types. All associations were positive, and the aORs varied from 1.1 (95% confidence interval [CI], 1.0-1.3) for direct monitoring of hand hygiene compliance to 1.4 (95% CI, 1.2-1.6) for use of a daily oral care regimen. The safety score was also significantly associated with whether or not a hospital monitored infection rates for all 3 types of HAI (data not shown). The number of acute care beds in the hospital was associated with regular use of 5 different general, CLABSI, and
VAP prevention practices, but with no practices for CAUTI. Having an RN as the lead infection preventionist was associated with 3 prevention practices, 2 for VAP and 1 for general infection prevention.
DISCUSSION In this large-scale, cross-sectional, national survey, less than one-half of responding Japanese hospitals reported regularly using many of the infection prevention practices investigated. Of note, we observed significant variability within each infection type in the regular use of prevention practices recommended in published guidelines or supported by recent systematic reviews.4-10,18 For example, although the majority of hospitals reported using alcoholbased hand rub on a daily basis, less than 30% conducted direct monitoring of hand hygiene compliance. Similarly, for CAUTI, whereas nearly all hospitals reported using aseptic technique during urinary catheter insertion and maintenance, measures to shorten the duration of catheter use were practiced much less frequently. There was also substantial variation in the regular use of the following CLABSI prevention practices: maintaining maximal barrier precautions, avoiding catheter insertion into the femoral site, and using chlorhexidine gluconate antisepsisdall key components of a recommended central line insertion bundle.19 Similar variability in the regular use of VAP prevention practices was observed, with semirecumbent positioning the sole VAP-specific prevention practice used regularly by more than one-half of the responding hospitals. It is also noteworthy that the proportion of hospitals conducting HAI surveillance, which is strongly recommended in major infection prevention guidelines,5-10 was relatively low and varied among the different infection types. Compared with findings from previous surveys conducted in the Unites States and Thailand,14-16,20 we identified several differences and similarities in device-related infection prevention practice use in hospitals across Japan. In all 3 countries, less than one-half of responding hospitals reported the regular use of all CAUTI prevention practices examined, with the exception of aseptic technique for urinary catheter insertion and maintenance. In contrast, there was a pronounced difference in the regular use of many CLABSI prevention practices between Japan and the United States. In particular, the regular use of chlorhexidine gluconate and avoidance of catheter insertion into the femoral site was much higher in the United States than in Japan. Regular use of VAP prevention practices was lowest in Japan compared with the United States and Thailand. The Japanese health care system is decentralized, and intensive care is poorly distributed, with only 1% of beds designated as intensive care unit (ICU) beds.21 A recent survey of health care professionals found that adherence to VAP prevention measures in Japan was low overall, but that compliance was greater in intensivist-led ICUs.22 Unlike the United States, which has a system of nonpayment for certain types of HAI,23 there are not strong financial incentives or penalties for Japanese hospitals to use evidence-based infection prevention practices if they incur any additional costs. One exception is that, as of September 2013, the Japanese health care reimbursement system requires hospitals that receive additional fees for enhanced infection prevention to hire at least 1 full-time infection prevention professional regardless of hospital size and to participate in regional infection prevention collaboratives. Consequently, the level of effort that a hospital chooses to dedicate to facilitate evidence-based infection prevention is dependent on the hospital’s resources and overall attitude toward patient safety. This view is supported by our findings suggesting that numerous infection prevention practices are used more frequently in hospitals
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Fig 1. Reported regular use of infection prevention practices. HCWs, health care workers; IP, infection prevention; MDROs, multidrug-resistant organisms; MRSA, methicillinresistant Staphylococcus aureus.
Table 2 Factors significantly associated with regular use of infection prevention practices Infection General
Practice
Variable
Alcohol-based hand rub Direct monitoring of hand hygiene compliance Active surveillance of cultures for colonization Decolonization of nose and skin in patients with MRSA before surgery Antimicrobial stewardship program Daily oral care regimen Provide education/training in infection prevention in professions other than nurses
CAUTI
Urinary catheter reminder or stop order Nurse-initiated urinary catheter discontinuation Portable bladder ultrasound scan Aseptic technique during insertion or maintenance
CLABSI
Maximal sterile barrier precautions Avoidance of femoral insertion site
VAP
Semirecumbent positioning Subglottic secretion drainage Sedation vacation
Safety score Safety score Number of acute care beds* Safety score Number of acute care beds* Safety score Safety score Safety score RN as lead infection preventionist Safety score Safety score Safety score Safety score Has hospitalists Number of acute care beds* Safety score Number of acute care beds* Safety score Number of acute care beds* Safety score Safety score RN as lead infection preventionist Safety score RN as lead infection preventionist
aOR (95% CI) 1.2 1.1 1.1 1.1 1.1 1.4 1.4 1.3 1.4 1.2 1.2 1.2 1.3 0.5 1.2 1.3 1.1 1.2 1.1 1.2 1.2 1.8 1.2 0.7
(1.1-1.4) (1.0-1.3) (1.0-1.2) (1.0-1.3) (1.0-1.2) (1.2-1.5) (1.2-1.6) (1.1-1.4) (1.0-2.1) (1.1-1.4) (1.1-1.4) (1.0-1.4) (1.1-1$5) (0.3-0.9) (1.1-1.3) (1.2-1.5) (1.1-1.2) (1.0-1.3) (1.0-1.2) (1.0-1.3) (1.0-1.3) (1.1-2.9) (1.1-1.3) (0.5-1.0)
aOR, adjusted odds ratio; MRSA, methicillin-resistant Staphylococcus aureus; RN, registered nurse. *aORs given for a 100-bed increase.
that have more beds and resources, a dedicated RN serving as the lead infection preventionist, and a greater culture of safety. Implementing many, if not all, of the infection prevention practices investigated and conducting HAI surveillance will require additional costs, multidisciplinary teamwork, and assertiveness and/or autonomy of nonphysician health care providers. For example, chlorhexidine gluconate is more expensive than alcohol or povidone-iodine, which has been conventionally used for skin
antisepsis in Japanese hospitals.24 Direct monitoring of hand hygiene compliance, intermittent catheterization, and HAI surveillance requires additional personnel training and working hours. Multidisciplinary teamwork is necessary to practice sedation vacations and avoiding catheter insertion into the femoral site. In addition, nonphysician health care providers, namely nurses, must be assertive and given autonomy to initiate urinary catheter discontinuation. Thus, in today’s health care system in Japan,
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adoption and sustained use of these infection prevention measures may rely heavily on hospital leadership’s willingness to prioritize the development of a sound patient safety culture. Highlighting the importance of leadership in preventing HAIs, Saint et al25 identified various leadership behaviors that may contribute to the successful implementation of HAI prevention strategies. Successful leaders commonly cultivate and communicate a culture of clinical excellence, focus on identifying and overcoming barriers and resistance to change, exhibit enthusiasm and inspirational motivation, and plan strategically while acting locally.25 In addition to having support from hospital leadership, identifying and appointing enthusiastic and motivated individuals who are willing to champion evidence-based infection prevention practices may aid the successful implementation of the technical and behavioral changes that may be required to improve infection prevention efforts.26 Effective championing, infection rate feedback and national comparisons, local comparisons of infection prevention practice compliance, and participation in collaborative efforts focused on reducing HAIs are important considerations to help overcome the active resistance that is frequently met when attempting to implement changes in clinical practice.27 Our study has several important limitations. First, we did not randomly select hospitals from the more than 8000 hospitals in Japan, of which almost 70% have fewer than 200 beds,17 but rather targeted hospitals with at least 1 professional trained in infection prevention. We chose this inclusion criterion because knowledge of both recent evidence-based infection prevention practices and their frequency of use were needed to respond to the survey questions. Second, because our response rate was below 100%, our results are subject to nonresponse bias. These 2 limitations may limit the generalizability of our study results. Third, the frequency of use of infection prevention practices relies solely on selfreported data from the lead infection preventionist at each responding hospital. The respondents might have overestimated or underestimated the true frequencies of use of certain infection prevention practices examined, although we have no reason to believe this has resulted in a systematic error. Fourth, we did not collect data on infection rates, and thus were unable to evaluate associations between the regular use of various infection prevention practices and patient outcomes. Finally, because we did not measure patient-level case mix, our results might have been biased by unknown confounders. Despite these limitations, however, this study is the first to provide a comprehensive description of current infection prevention practices and possible factors affecting their use in hospitals across Japan. We believe that our study provides valuable information and insights for policy makers, hospital administrators, clinicians, and infection prevention professionals who are responsible for HAI prevention in Japanese hospitals. Results from our national survey highlight several areas of HAI prevention that have room for improvement in Japanese hospitals. First, our findings suggest the need for strategies to strengthen hospital leadership to foster a safety culture to implement and sustain the use of evidence-based infection prevention practices. This finding regarding the importance of establishing and nurturing an effective culture of patient safety is similar to results observed in a similar survey conducted in Thailand.20 As such, hospital leadership’s commitment to a safety culture may be a universal driving force for improving infection prevention in health care settings internationally. Second, our results also suggest that substantial financial incentives and/or penalties also may be necessary to facilitate the adoption of resource-intensive preventive measures, given that nearly one-half of the respondents indicated that nonpayment for certain preventable HAIs likely would increase the priority of infection prevention efforts. Finally, appointing champions with
strong motivation, communication skills, and knowledge may play an important role in promoting evidence-based infection prevention practices. Some of the infection prevention practices that were reported less frequently (eg, nurse-initiated removal of unnecessary urinary catheters) require assertiveness and/or autonomy by nonphysician health care providers. The presence of enthusiastic champions likely would help facilitate the adoption of patient safety as a shared value across all professions and departments, thereby making it easier for all to voice concerns about infection prevention regardless of profession or position. HAI prevention is a relatively new practice in the history of Japanese health care.28 Although knowledge of the importance of infection prevention has increased in recent years, more emphasis has been placed on structural elements, (eg, staffing infection prevention professionals and forming regional collaboratives) than on ensuring the adoption of evidence-based infection prevention practices. Consequently, as our results show, there is currently wide variation among Japanese hospitals in the use of practices focused on preventing HAI. Our study emphasizes the strong need to foster an organization-wide atmosphere that prioritizes patient safety, which should in turn promote the adoption of effective measures to improve HAI prevention in Japan. Acknowledgment We thank Andy Hickner, MSI for assistance with manuscript preparation. References 1. World Health Organization. WHO report on the burden of endemic health caree associated infection worldwide. 2011. Available from http://apps.who.int/iris/ bitstream/10665/80135/1/9789241501507_eng.pdf . Accessed August 12, 2013. 2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101-14. 3. Pittet D, Allegranzi B, Storr J, Donaldson L. “Clean Care is Safer Care”: the global patient safety challenge 2005-2006. Int J Infect Dis 2006;10:419-24. 4. World Health Organization. WHO guidelines on hand hygiene in health care: a summary. Available from http://apps.who.int/medicinedocs/documents/ s16320e/s16320e.pdf . Accessed August 12, 2013. 5. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheterassociated urinary tract infections, 2009. Infect Control Hosp Epidemiol 2010; 31:319-26. 6. Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S41-50. 7. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39:S1-34. 8. Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent central lineeassociated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S22-30. 9. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing healthcareeassociated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53:1-36. 10. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S31-40. 11. Kobayashi H, Okubo T, Kizu J, Fujii A, Tomono K, Oie S, et al. Hospital infection control programs in Japan: current practices and activities in 466 teaching hospitals. Kankyo Kansen 2006;21:200-8. 12. Nishida M, Utsumi M, Makimoto K. Nationwide hospital survey on infection control system and urinary catheter care practice in Japan. Kankyo Kansen 2010;25:41-6. 13. Utsumi M, Fujita M, Makimoto K. Hospital size affects infection control system and urinary catheter care practice: a national postal survey, part 2. Kankyo Kansen 2011;26:350-7. 14. Krein SL, Hofer TP, Kowalski CP, Olmsted RN, Kauffman CA, Forman JH, et al. Use of central venous cathetererelated bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672-8.
F. Sakamoto et al. / American Journal of Infection Control 42 (2014) 888-93 15. Krein SL, Kowalski CP, Damschroder L, Forman J, Kaufman SR, Saint S. Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study. Infect Control Hosp Epidemiol 2008;29: 933-40. 16. Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46:243-50. 17. Japan Ministry of Health, Labor, and Welfare. Hospital statistics, 2011. Available from: http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/11/. Accessed August 12, 2013. 18. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and metaanalysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 2010;51:550-60. 19. Institute for Healthcare Improvement. Implement the IHI central line bundle. Available from: http://www.ihi.org/knowledge/Pages/Changes/Implementthe CentralLineBundle.aspx. Accessed September 5, 2013. 20. Apisarnthanarak A, Greene MT, Kennedy EH, Khawcharoenporn T, Krein S, Saint S. National survey of practices to prevent healthcare-associated infections in Thailand: the role of safety culture and collaboratives. Infect Control Hosp Epidemiol 2012;33:711-7.
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21. Sirio CA, Tajimi K, Taenaka N, Ujike Y, Okamoto K, Katsuya H. A cross-cultural comparison of critical care delivery: Japan and the United States. Chest 2002; 121:539-48. 22. Shime N, Morrow LE. Current practices for ventilator-associated pneumonia prevention in Japan: a survey study. Chest 2012;141:281-3. 23. Rosenthal MB. Nonpayment for performance? Medicare’s new reimbursement rule. N Engl J Med 2007;357:1573-5. 24. Japan Ministry of Health, Labor, and Welfare. Drug price list, 2013. Available from: http://www.mhlw.go.jp/topics/2012/03/tp120305-01.html. Accessed August 12, 2013. 25. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol 2010;31:901-7. 26. Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, Saint S, Krein SL. The role of the champion in infection prevention: results from a multisite qualitative study. Qual Saf Health Care 2009;18:434-40. 27. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. How active resisters and organizational constipators affect health careeacquired infection prevention efforts. Jt Comm J Qual Patient Saf 2009;35:239-46. 28. Kobayashi H. History and perspective of hospital infection control. Nippon Rinsho 2002;60:2067-71.
