High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An "Iceberg Effect".

OBJECTIVE: Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs). DESIGN: Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas. SETTING: Twenty-eight NHs in Southern California from 2016 to 2017. PARTICIPANTS: NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care. METHODS: Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents). RESULTS: A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas. CONCLUSIONS AND IMPLICATIONS: In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

Effectiveness of Moving On: an Australian designed generic self-management program for people with a chronic illness.

BACKGROUND: This paper presents the evaluation of "Moving On", a generic self-management program for people with a chronic illness developed by Arthritis NSW. The program aims to help participants identify their need for behaviour change and acquire the knowledge and skills to implement changes that promote their health and quality of life. METHOD: A prospective pragmatic randomised controlled trial involving two group programs in community settings: the intervention program (Moving On) and a control program (light physical activity). Participants were recruited by primary health care providers across the north-west region of metropolitan Sydney, Australia between June 2009 and October 2010. Patient outcomes were self-reported via pre- and post-program surveys completed at the time of enrolment and sixteen weeks after program commencement. Primary outcomes were change in self-efficacy (Self-efficacy for Managing Chronic Disease 6-Item Scale), self-management knowledge and behaviour and perceived health status (Self-Rated Health Scale and the Health Distress Scale). RESULTS: A total of 388 patient referrals were received, of whom 250 (64.4%) enrolled in the study. Three patients withdrew prior to allocation. 25 block randomisations were performed by a statistician external to the research team: 123 patients were allocated to the intervention program and 124 were allocated to the control program. 97 (78.9%) of the intervention participants commenced their program. The overall attrition rate of 40.5% included withdrawals from the study and both programs. 24.4% of participants withdrew from the intervention program but not the study and 22.6% withdrew from the control program but not the study. A total of 62 patients completed the intervention program and follow-up evaluation survey and 77 patients completed the control program and follow-up evaluation survey. At 16 weeks follow-up there was no significant difference between intervention and control groups in self-efficacy; however, there was an increase in self-efficacy from baseline to follow-up for the intervention participants (t=-1.948, p=0.028). There were no significant differences in self-rated health or health distress scores between groups at follow-up, with both groups reporting a significant decrease in health distress scores. There was no significant difference between or within groups in self-management knowledge and stage of change of behaviours at follow-up. Intervention group attenders had significantly higher physical activity (t=-4.053, p=0.000) and nutrition scores (t=2.315, p= 0.01) at follow-up; however, these did not remain significant after adjustment for covariates. At follow-up, significantly more participants in the control group (20.8%) indicated that they did not have a self-management plan compared to those in the intervention group (8.8%) (X²=4.671, p=0.031). There were no significant changes in other self-management knowledge areas and behaviours after adjusting for covariates at follow-up. CONCLUSIONS: The study produced mixed findings. Differences between groups as allocated were diluted by the high proportion of patients not completing the program. Further monitoring and evaluation are needed of the impact and cost effectiveness of the program. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12609000298213.

Measuring students' approaches to learning in different clinical rotations.

BACKGROUND: Many studies have explored approaches to learning in medical school, mostly in the classroom setting. In the clinical setting, students face different conditions that may affect their learning. Understanding students' approaches to learning is important to improve learning in the clinical setting. The aim of this study was to evaluate the Study Process Questionnaire (SPQ) as an instrument for measuring clinical learning in medical education and also to show whether learning approaches vary between rotations. METHODS: All students involved in this survey were undergraduates in their clinical phase. The SPQ was adapted to the clinical setting and was distributed in the last week of the clerkship rotation. A longitudinal study was also conducted to explore changes in learning approaches. RESULTS: Two hundred and nine students participated in this study (response rate 82.0%). The SPQ findings supported a two-factor solution involving deep and surface approaches. These two factors accounted for 45.1% and 22.5%, respectively, of the variance. The relationships between the two scales and their subscales showed the internal consistency and factorial validity of the SPQ to be comparable with previous studies. The clinical students in this study had higher scores for deep learning. The small longitudinal study showed small changes of approaches to learning with different rotation placement but not statistically significant. CONCLUSIONS: The SPQ was found to be a valid instrument for measuring approaches to learning among clinical students. More students used a deep approach than a surface approach. Changes of approach not clearly occurred with different clinical rotations.

Design of an internationally accredited radiation oncology resident training program incorporating novel educational models.

PURPOSE: Our primary aim was to design a new, internationally accredited, comprehensive radiation oncology (RO) training program for Singaporean residents that satisfied the needs of stake holders and incorporated published evidence. METHODS AND MATERIALS: The evidence-based method included Medline literature review and broad-based training needs assessment. RESULTS: Literature review revealed few studies describing or evaluating RO resident training programs. Our program was designed by incorporating available published research and stakeholder views determined by the training needs assessment. The program includes novel evidence-based educational methods, including individually negotiated learning contracts, a mentor program, logbooks, task-based learning, tutorials, and formative plus summative assessments. The content and structure is consistent with most United States, United Kingdom, and Royal Australian and New Zealand College of Radiologist (RANZCR) guidelines, with resident evaluation via RANZCR examinations. The RANZCR accredited the program in January 2002. CONCLUSION: We recommend institutions or countries introducing or revising RO resident training programs use an evidence-based approach, addressing the needs of stake holders (determined by a comprehensive training needs assessment) and incorporating published research. Novel educational methods may be considered in RO training. This new Singapore program is the first to achieve international accreditation by the RANZCR. It is clear that additional research in the design and evaluation of RO resident training programs is required.

What do students want? The types of learning activities preferred by final year medical students.

CONTEXT: A well-aligned curriculum has consistent focus on curricular goals, teaching/learning activities and assessment. Poor alignment affects the way students budget learning time and may interfere with achievement of curricular goals. We noticed students' poor attendance in clinical clerkships prior to final examinations and hypothesised that they were responding to curricular misalignment. OBJECTIVES: To quantify the extent to which students and tutors perceived a mismatch between activities pertaining to their current clerkship and those they thought necessary to prepare for final examinations and internship. SUBJECTS: Medical students in final (sixth) year clerkships in medicine, surgery and critical care and clinical tutors. METHOD: A self-report questionnaire on time spent in clerkship activities was administered 3 months before the final examinations. RESULTS: The amounts of time spent on current activities were fairly evenly spread over teaching, study and self-directed patient contacts, and observing patient care (ward rounds, operating theatre, accident and emergency, outpatient department and clinical meetings). Less time was available for recreation. Students and tutors concurred, independently, that good examination and internship preparation required a shifting of the balance. Examination preparation redistributed time from observing patient care and recreation to study and self-directed patient contacts. Internship preparation redistributed time from teaching and recreation to observing patient care. CONCLUSION: Students and tutors perceived that current activities were not well aligned with assessment requirements but were better aligned with the requirements of internship. If we want students to direct their attention towards curricular goals, we need to bring goals, teaching/learning activities and assessment into alignment.