Infection Control & Hospital Epidemiology
Table 2. Number of Months With CLABSI Rate Percentage Error ≤ ±5% by Sampling Permutation
No. of Months (%) With CLABSI Rate Percentage Error ≤±5%
NICUs
Sample 1 2 3 4 5 6 7
(N=71)
Ped-ONCs (N=34)
PICUs (N=24)
Adult Units (N=66)
Mon 56 (78.9) 29 (85.3) 18 (75.0) 52 (78.8) Tue
58 (81.7) 27 (79.4) 19 (79.2) 51 (77.3)
Wed 52 (73.2) 26 (76.5) 15 (62.5) 52 (78.8) Thu Fri
Sat Sun
53 (74.6) 28 (82.4) 17 (70.8) 54 (81.8) 53 (74.6) 28 (82.4) 18 (75.0) 55 (83.3) 58 (81.7) 28 (82.4) 19 (79.2) 51 (77.3) 52 (73.2) 27 (79.4) 17 (70.8) 51 (77.3)
8Mon–Tue 58 (81.7) 32 (94.1) 20 (83.3) 56 (84.8) 9Mon–Wed 60 (84.5) 29 (85.3) 19 (79.2) 56 (84.8) 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
1213
Fig. 2. Bland-Altman plot of agreement between estimated and actual CLABSI rates for the day-pair permutation Wednesday–Sunday in NICUs.
Mon–Thu 60 (84.5) 31 (91.2) 18 (75.0) 57 (86.4) Mon–Fri 61 (85.9) 33 (97.1) 20 (83.3) 56 (84.8) Mon–Sat 59 (83.1) 28 (82.4) 19 (79.2) 56 (84.8) Mon–Sun 53 (74.6) 29 (85.3) 18 (75.0) 55 (83.3) Tue–Wed 61 (85.9) 28 (82.4) 17 (70.8) 52 (78.8) Tue–Thu 58 (81.7) 29 (85.3) 18 (75.0) 54 (81.8) Tue–Fri 58 (81.7) 30 (88.2) 18 (75.0) 61 (92.4) Tue–Sat 59 (83.1) 31 (91.2) 19 (79.2) 61 (92.4) Tue–Sun 58 (81.7) 30 (88.2) 18 (75.0) 58 (87.9) Wed–Thu 56 (78.9) 27 (79.4) 16 (66.7) 53 (80.3) Wed–Fri 57 (80.3) 28 (82.4) 20 (83.3) 55 (83.3) Wed–Sat 61 (85.9) 30 (88.2) 18 (75.0) 55 (83.3) Wed–Sun 63 (88.7) 28 (82.4) 18 (75.0) 57 (86.4) Thu–Fri 55 (77.5) 28 (82.4) 22 (91.7) 54 (81.8) Thu–Sat 57 (80.3) 31 (91.2) 20 (83.3) 55 (83.3) Thu–Sun 63 (88.7) 29 (85.3) 15 (62.5) 58 (87.9) Fri–Sat 56 (78.9) 31 (91.2) 21 (87.5) 54 (81.8) Fri–Sun 58 (81.7) 31 (91.2) 17 (70.8) 56 (84.8) Sat–Sun 54 (76.1) 28 (82.4) 19 (79.2) 53 (80.3) Week 1 46 (64.8) 23 (67.6) 17 (70.8) 39 (59.1) Week 2 49 (69.0) 25 (73.5) 17 (70.8) 48 (72.7) Week 3 51 (71.8) 23 (67.6) 17 (70.8) 47 (71.2) Week 4 48 (67.6) 23 (67.6) 16 (66.7) 46 (69.7)
Note. CLABSI, central-line–associated bloodstream infection; NICUs, neonatal intensive care units; Ped-ONCs, pediatric oncology units; PICUs, pediatric intensive care units.
austerity measures and public sector cutbacks that also affected infection prevention programs.14 The reallocation of available resources given these new circumstances could be an alternate
approach for infection prevention in hospitals.15 Elimination of the burden of the daily surveillance for monitoring CLABSI rates could be one such adjustment. The purpose of this study was to evaluate different sampling strategies in the estimation of CLABSI rates to reduce the time-consuming daily collection of denomi- nator data needed to calculate such rates. Overall, 32 permutations were evaluated, including 1 fixed day
per week, fixed day-pairs per week, and 1 fixed week per month. Our results show that sampling over 2 fixed days per week pro- vides the most accurate estimates of CLABSI rates. The percen- tage of monthly estimated CLABSI rates with PE ≤5% using the sampling strategy of 2 fixed days per week ranged from 74.6% to 88.7% in NICUs, from 79.4% to 94.1% in Ped-ONCs, from 62.5% to 91.7% in PICUs, and from 80.3% to 92.4% in adult units. These percentages were lower with respect to sampling over 1 fixed day per week and even lower when sampling 1 fixed week per month. Further evaluation with ICCs and Bland-Altman plots indicated that the estimated CLABSI rates by selected day-pair permuta- tions are reliable. Day-pair permutations with more accurate estimates varied
across different types of units, mostly related to patterns of patient admission and discharge throughout the week for each type. Some of the selected strategies included weekend days, whereas the NHSN does not recommend sampling these days.16 In our setting, patient movement in units was high during weekends; hence, excluding these days could lead to less accurate estimates. If denominator collection is not feasible for these days, then these strategies should not be preferred. Once a sampling strategy is selected, the person who collects the data must adhere to this strategy throughout the surveillance period; strategies with ran- dom selections of day-pairs were not evaluated in this study. Our hope is that someday, as electronic methords of record-keeping and documentation mature, manual sampling will not be neces- sary. In resource-limited healthcare systems, such as exists in Greece, no such system has been introduced yet. The recording of denominator data is and will be done by hand for the foreseeable future; this is why sampling is important. Our study focused on the accuracy of the estimated CLABSI
rates as a primary outcome and not on the estimated CLDs, since the latter impacts the prior. The method we used for the estimation of CLDs to calculate CLABSI rates was the same as that proposed by Hammami et al.8 Although this study does not assess the impact of sampling on CLABSI rates, their findings
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