Infection control interventions in small rural hospitals with limited resources: results of a cluster-randomized feasibility trial

Abstract

Background: There are few reports on the feasibility of conducting successful infection control (IC) interventions in rural community hospitals.

Methods: Ten small rural community hospitals in Idaho and Utah were recruited to participate in a cluster-randomized trial of multidimensional IC interventions to determine their feasibility in the setting of limited resources. Five hospitals were randomized to develop individualized campaigns to promote HH, isolation compliance, and outbreak control. Five hospitals were randomized to continue with current IC practices. Regular blinded observations of hand hygiene (HH) compliance were conducted in all hospitals as the primary outcome measure. Additionally, periodic prevalence studies of patient colonization with resistant pathogens were performed. The 5-months intervention time period was compared to a 4-months baseline period, using a multi-level logistic regression model.

Results: The intervention hospitals implemented a variety of strategies. The estimated average absolute change in "complete HH compliance" in intervention hospitals was 20.1% (range, 7.8% to 35.5%) compared to -3.1% (range -6.3% to 5.9%) in control hospitals (p = 0.001). There was an estimated average absolute change in "any HH compliance" of 28.4% (range 17.8% to 38.2%) in intervention hospitals compared to 0.7% (range -16.7 to 20.7%) in control hospitals (p = 0.010). Active surveillance culturing demonstrated an overall prevalence of MRSA carriage of 9.7%.

Conclusions: A replicable intervention significantly improved hand hygiene as a primary outcome measure despite barriers of geographic distance and lack of experience with study protocols. Active surveillance culturing identified unsuspected reservoirs of MRSA colonization and further promoted IC activity.

Figure 1

Absolute changes in probability of (a) “complete compliance” and (b) “any compliance” of hand hygiene during the pre-intervention compared to post-intervention period. a Absolute changes in probability of “complete compliance” of hand hygiene during the pre-intervention compared to post-intervention period. b Absolute changes in probability of “any compliance” of hand hygiene during the pre-intervention compared to post-intervention period.

Figure 2

Rates of methicillin-resistant Staphylococcus aureus infection clinical cases in one selected intervention hospital.