Preventing healthcare-associated transmission of the Middle East Respiratory Syndrome [MERS]: Our Achilles heel

Middle East Respiratory Syndrome [MERS] coronavirus is the most recent among the Coronaviridae family to jump species and infect humans. Major health-care associated MERS outbreaks have occurred in the Middle East and Korea that affected both patients and healthcare workers. These outbreaks were characterized by intra and inter-hospital spread and were exacerbated specifically by overcrowding, delayed diagnosis and appropriate use of personal protective equipment. Recent experience with this virus emphasizes the importance of compliance with infection control practices and with other interventions addressing patient triage, placement and flow within and between healthcare facilities. Our Achilles heel remains compliance with the best infection prevention practices and their harmonization with patient flow. Both infection prevention compliance and maintenance of patient flow are critical in preventing healthcare-associated transmission of many of these emerging infectious diseases, including MERS

impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia

Several guidelines base the empirical therapy of ventilator-associated pneumonia [VAP] on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 [16%] were EO episodes, 331 [84.0%] were LO episodes, 40 [10.1%] were EL episodes and 291 [73.1%] were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP [31.7%], LO-VAP [40.8%], EL-VAP [37.5%] and LL-VAP [43.3%] samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP [OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively]. In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful

Determinants of functional status among survivors of severe sepsis and septic shock: one-year follow-up

Sepsis is a leading cause of intensive care unit [ICU] admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock. This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge. Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale. A total of 209 patients met the eligibility criteria. We found that 38 [18.1%] patients had severe disability before admission, whereas 109 [52.2%] patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge [no/mild disability]. After adjustment of baseline variables, age [adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.01-1.04] and pre-sepsis functional status of severe disability [aOR = 50.9, 95% CI = 6.82-379.3] were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors. We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge [no/mild disability]. Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge

Risk factors, management and outcomes of patients admitted with near fatal asthma to a tertiary care hospital in Riyadh

Near-fatal asthma [NFA] has not been well studied in Saudi Arabia. We evaluated NFA risk factors in asthmatics admitted to a tertiary-care hospital and described NFA management and outcomes. This was a retrospective study of NFA patients admitted to an ICU in Riyadh [2006-2010]. NFA was defined as a severe asthma attack requiring intubation. To evaluate NFA risk factors, randomly selected patients admitted to the ward for asthma exacerbation were used as controls. Collected data included demographics, information on prior asthma control and various NFA treatments and outcomes. Thirty NFA cases were admitted to the ICU in the five-year period. Compared to controls [N= 120], NFA patients were younger [37.5 +/- 19.9 vs. 50.3 +/- 23.1 years, P= 0.004] and predominantly males [70.0% vs. 41.7%, P= 0.005] and used less inhaled steroids/long-acting 32-agonists combination [13.6% vs. 38.7% P = 0.024. Most [73.3%] NFA cases presented in the cool months [October-March]. On multivariate analysis, age [odds ratio [OR] 0.96; 95% confidence interval [Cl], 0.92-0.99, P= 0.015] and the number of ED visits in the preceding year [OR, 1.25; 95% Cl, 1.00-1.55] were associated with NFA. Rescue NFA management included ketamine [50%] and theophylline [19%] infusions. NFA outcomes included: neuromyopathy [23%], mechanical ventilation duration = 6.4 +/-4.7 days, tracheostomy [13%] and mortality [0%]. Neuromuscular blockade duration was associated with neuromyopathy [OR, 3.16 per one day increment; 95% Cl, 1.27-7.83]. In our study, NFA risk factors were younger age and higher number of ED visits. NFA had significant morbidity. Reducing neuromuscular blockade duration during ventilator management may decrease neuromyopathy risk

Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years

Several studies showed that the implementation of the Institute for Healthcare Improvement [IHI] ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia [VAP] rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization. The study was conducted at the adult medical-surgical intensive care unit [ICU] at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention [CDC]/National Healthcare Safety Network [NHSN] methodology while bundle data were collected by a cross-sectional design as per IHI methodology. Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 [P for trend < 0.001]. On the other hand, VAP rate decreased from 3.6 [per 1000 ventilator days] in 2010 to 1.0 in 2013 [P for trend = 0.054] and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 [P for trend < 0.001]. There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate [cross-correlation coefficients -0.63 to 0.07] and ventilator utilization [cross-correlation coefficients -0.18 to -0.63]. More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link

Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia

There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia [VAP]. The contribution of multi-drug resistant [MDR] pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. We conducted a retrospective susceptibility study in the adult intensive care unit [ICU] of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly [60-89%] resistant to all tested antimicrobials, including carbapenems [three- and four-class MDR prevalence were 86% and 69%, respectively]. Pseudomonas aeruginosa was moderately [13-31%] resistant to all tested antimicrobials, including antipseudomonal penicillins [three- and four-class MDR prevalence were 13% and 10%, respectively]. With an exception of ampicillin [fully resistant], Klebsiella spp. had low [0-13%] resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. However not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients' outcomes. Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Knowledge of thromboprophylaxis guidelines pre- and post-didactic lectures during a venous thromboembolism awareness day at a tertiary-care hospital

Didactic lectures are frequently used to improve compliance with practice guidelines. This study assessed the knowledge of health-care providers [HCPs] at a tertiary-care hospital of its evidence-based thromboprophylaxis guidelines and the impact of didactic lectures on their knowledge. The hospital launched a multifaceted approach to improve thromboprophylaxis practices, which included posters, a pocket-size guidelines summary and didactic lectures during the annual thromboprophylaxis awareness days. A self-administered questionnaire was distributed to HCPs before and after lectures on thromboprophylaxis guidelines [June 2010]. The questionnaire, formulated and validated by two physicians, two nurses and a clinical pharmacist, covered various subjects such as risk stratification, anticoagulant dosing and the choice of anticoagulants in specific clinical situations. Seventy-two and 63 HCPs submitted the pre- and post-test, respectively [62% physicians, 28% nurses, from different clinical disciplines]. The mean scores were 7.8 +/- 2.1 [median = 8.0, range = 2-12, maximum possible score = 15] for the pre-test and 8.4 +/- 1.8 for the post-test, P = 0.053. There was no significant difference in the pre-test scores of nurses and physicians [7.9 +/- 1.7 and 8.2 +/- 2.4, respectively, P = 0.67]. For the 35 HCPs who completed the pre- and post-tests, their scores were 7.7 +/- 1.7 and 8.8 +/- 1.6, respectively, P = 0.003. Knowledge of appropriate anticoagulant administration in specific clinical situations was frequently inadequate, with approximately two-thirds of participants failing to adjust low-molecular-weight heparin doses in patients with renal failure. Education via didactic lectures resulted in a modest improvement of HCPs' knowledge of thromboprophylaxis guidelines. This supports the need for a multifaceted approach to improve the awareness and implementation of thromboprophylaxis guidelines

Building capacity for quality and safety in critical care: a roundtable discussion from the second international patient safety conference in April 9-11, 2013, Riyadh, Saudi Arabia

This paper summarizes the roundtable discussion from the Second International Patient Safety Conference held in April 9-11, 2013, Riyadh, Saudi Arabia. The objectives of the roundtable discussion were to: [1] Review the conceptual framework for building capacity in quality and safety in critical care.2] Examine examples of leading international experiences in building capacity.3] Review the experience in Saudi Arabia in this area.4] Discuss the role of building capacity in simulation for patient safety in critical care and [5] Review the experience in building capacity in an ongoing improvement project for severe sepsis and septic shock

-hospital mortality among a cohort of cirrhotic patients admitted to a Tertiary hospital

To determine the mortality rate in a cohort of hospitalized patients with cirrhosis and examine their resuscitation status at admission. A retrospective chart review was conducted of patients with cirrhosis who were admitted to a tertiary care hospital in Riyadh, Saudi Arabia, from January 1, 2009, to December 31, 2009. We reviewed 226 cirrhotic patients during the study period. The hospital mortality rate was 35%. A univariate analysis revealed that worse outcomes were seen in patients with advanced age or who had worse child-turcotte-pugh [CPT] scores, worse model for end-stage liver disease [MELD] scores, low albumin and high serum creatinine. Using a multivariate analysis, we found that advanced age [P=0.004] and high MELD [P=0.001] scores were independent risk factors for the mortality of cirrhotic patients. The end-of-life decision were made in 34% of cirrhotic patients, and the majority of deceased patients were "no resuscitation" status [90% vs. 4%, P<0.001]. The relatively high mortality in cirrhotic patients admitted for care in a tertiary hospital, Saudi Arabia was comparable to that reported in the literature. Furthermore, end-of-life discussions should be addressed early in the hospitalization of cirrhotic patients

Intensive insulin therapy versus conventional insulin therapy for critically ill trauma patients admitted to ICU

The objective of our study was to evaluate the beneficial effect of IIT in reducing mortality and morbidity in critically ill trauma patients admitted to ICU. Nested cohort study within a Randomized Controlled Trial. All trauma patients with GCS

introduction to medical simulation

While medical simulation is no panacea, it offers numerous potential strategies for comprehensive and practical training, safer patient care, and for those keen to attract and retain staff. It is a technique, rather than just a technology that promotes experiential and reflective learning. It is also a key strategy to teach Crisis Resource Management skills. Simulation can benefit the individual learner, the multidisciplinary team, and the hospital as a whole. It has been described as a key driver of patient safety, and even as the "patient safety laboratory" of the future. As such is endorsed by many professional societies in many nations. While challenges remain [and are outlined] there are great opportunities for clinicians, administrators, and educators alike

Magnesium supplementation and the potential association with mortality rates among critically ill non-cardiac patients

Recent literature showed that development of hypomagnesemia is associated with higher mortality. The objective of this study is to evaluate the impact of magnesium supplementation on mortality rates of critically ill patients. All patients admitted to the Intensive Care Unit [ICU] of King Abdul-Aziz Medical City, Riyadh, Saudi Arabia since September 2003 were included. We recorded the demographics data, APACHE score, daily magnesium levels and magnesium supplementation. We collected the data for 30 days or until discharge from ICU. Statistical analysis was performed using the student t-test for continuous data and the Fischers exact test for categorical data. Nothing was carried out to influence the behavior of intensivists in replacing magnesium. During the study period, 71 patients [45 males and 26 females] were admitted to the ICU, the mean age was 54 +/- 18 years for males and 56 +/- 19.2 years for females. The mean magnesium level on admission was 0.78 +/- 0.2 mmol/L and the majority of the patients were medical admissions. Approximately 39.4% had hypomagnesemia on admission and the overall mortality rate was 31%. In able to standardize the supplementation of magnesium among groups, the daily magnesium supplementation index [DMSI = total magnesium supplement in grams/length of stay in days] was calculated. The mortality rates for DMSI with <1 grm/day [low groups] was statistically significant higher than that of DMSI with >1 grm/day [high group] [43.5% versus 17%, p=0.035]. There was no statistically significant differences between magnesium levels of both groups of DMSI except at admission where DMSI group had higher magnesium levels [<1 grm/day]. Daily magnesium supplementation index higher than 1 grm/day is associated with lower mortality rates for critically ill patients. This effect was not found to be independent and may be related to severity of illness. Given that magnesium levels were similar between the 2 groups of DMSI at almost all points of the study, magnesium supplementation per se may be beneficial in lowering mortality rates. The exact cause of this effect is unknown. An aggressive magnesium supplementation protocol may be warranted. A larger scale randomized study is necessary to evaluate this effect

Emergency room to the intensive care unit in Hajj. the chain of life

Hajj, which brings more than 2 million Muslims together, represents a special challenge for healthcare services especially the intensive care unit. The main goal for healthcare providers is to provide the best service to the largest number of patients with the available resources. The purpose of this article is to outline the admission criteria from the emergency room to the intensive care and to review some of the unique features of providing these services during the Hajj season