Oral care practices and hospital-acquired pneumonia prevention: A national survey of Australian nurses.

BACKGROUND: Hospital-acquired pneumonia (HAP) also known as non-ventilator associated pneumonia, is one of the most common infections acquired in hospitalised patients. Improving oral hygiene appears to reduce the incidence of HAP. This study aimed to describe current practices, barriers and facilitators, knowledge and educational preferences of registered nurses performing oral health care in the Australian hospital setting, with a focus on the prevention of HAP. We present this as a short research report. METHODS: We undertook a cross sectional online anonymous survey of Australian registered nurses. Participants were recruited via electronic distribution through existing professional networks and social media. The survey used was modified from an existing survey on oral care practice. RESULTS: The survey was completed by 179 participants. Hand hygiene was considered a very important strategy to prevent pneumonia (n = 90, 58%), while 45% (n = 71) felt that oral care was very important. The most highly reported barriers for providing oral care included: an uncooperative patient; inadequate staffing; and a lack of oral hygiene requisite. Patients' reminders, prompts and the provision of toothbrushes were common ways believed to help facilitate improvements in oral care. CONCLUSION: Findings from this survey will be used in conjunction with consumer feedback, to help inform a planned multi-centre randomised trial, the Hospital Acquired Pneumonia PrEveNtion (HAPPEN) study, aimed at reducing the incidence of HAP. Findings may also be useful for informing studies and quality improvement initiatives aimed at improving oral care to reduce the incidence of HAP.

Risk of organism acquisition from prior room occupants: An updated systematic review.

BACKGROUND: Evidence from a previous systematic review indicates that patients admitted to a room where the previous occupant had a multidrug-resistant bacterial infection resulted in an increased risk of subsequent colonisation and infection with the same organism for the next room occupant. In this paper, we have sought to expand and update this review. METHODS: A systematic review and meta-analysis was undertaken. A search using Medline/PubMed, Cochrane and CINHAL databases was conducted. Risk of bias was assessed by the ROB-2 tool for randomised control studies and ROBIN-I for non-randomised studies. RESULTS: From 5175 identified, 12 papers from 11 studies were included in the review for analysis. From 28,299 patients who were admitted into a room where the prior room occupant had any of the organisms of interest, 651 (2.3%) were shown to acquire the same species of organism. In contrast, 981,865 patients were admitted to a room where the prior occupant did not have an organism of interest, 3818 (0.39%) acquired an organism(s). The pooled acquisition odds ratio (OR) for all the organisms across all studies was 2.45 (95% CI: 1.53-3.93]. There was heterogeneity between the studies (I2 89%, P < 0.001). CONCLUSION: The pooled OR for all the pathogens in this latest review has increased since the original review. Findings from our review provide some evidence to help inform a risk management approach when determining patient room allocation. The risk of pathogen acquisition appears to remain high, supporting the need for continued investment in this area.

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study.

BACKGROUND: Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices. METHODS: The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention. DISCUSSION: Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

New frontiers in healthcare environmental hygiene: thoughts from the 2022 healthcare cleaning forum.

Healthcare environmental hygiene (HEH) has become recognized as being increasingly important for patient safety and the prevention of healthcare-associated infections. At the 2022 Healthcare Cleaning Forum at Interclean in Amsterdam, the academic lectures focused on a series of main areas of interest. These areas are indicative of some of the main trends and avenues for research in the coming years. Both industry and academia need to take steps to continue the momentum of HEH as we transition out of the acute phase of the Covid-19 pandemic. There is a need for new ways to facilitate collaboration between the academic and private sectors. The Clean Hospitals® network was presented in the context of the need for both cross-disciplinarity and evidence-based interventions in HEH. Governmental bodies have also become more involved in the field, and both the German DIN 13603 standard and the UK NHS Cleaning Standards were analyzed and compared. The challenge of environmental pathogens was explored through the example of how P. aeruginosa persists in the healthcare environment. New innovations in HEH were presented, from digitalization to tracking, and automated disinfection to antimicrobial surfaces. The need for sustainability in HEH was also explored, focusing on the burden of waste, the need for a circular economy, and trends towards increasingly local provision of goods and services. The continued focus on and expansion of these areas of HEH will result in safer patient care and contribute to better health systems.

Cost effectiveness of temporary isolation rooms in acute care settings in Singapore.

OBJECTIVES: To estimate the change to health service costs and health benefits from a decision to adopt temporary isolation rooms that are effective at isolating the patient within a general ward environment. We assess the cost-effectiveness of a decision to adopt an existing temporary isolation room in a Singapore setting. METHOD: We performed a model-based cost-effectiveness analysis to evaluate the impact of a decision to adopt temporary isolation rooms for infection prevention. We estimated changes to the costs from implementation, the number of cases of healthcare associated infection, acute care bed days used, they money value of bed days, the number of deaths, and the expected change to life years. We report the probability that adoption was cost-effective by the cost by life year gained, against a relevant threshold. Uncertainty is addressed with probabilistic sensitivity analysis and the findings are tested with plausible scenarios for the effectiveness of the intervention. RESULTS: We predict 478 fewer cases of HAI per 100,000 occupied bed days from a decision to adopt temporary isolation rooms. This will result in cost savings of $SGD329,432 and there are 1,754 life years gained. When the effectiveness of the intervention is set at 1% of cases of HAI prevented the incremental cost per life year saved is $16,519; below the threshold chosen for cost-effectiveness in Singapore. CONCLUSIONS: We provide some evidence that adoption of a temporary isolation room is cost-effective for Singapore acute care hospitals. It is plausible that adoption is a positive decision for other countries in the region who may demonstrate fewer resources for infection prevention and control.

A cost-effectiveness model for a decision to adopt temporary single-patient rooms to reduce risks of healthcare-associated infection in the Australian public healthcare system.

BACKGROUND: The cost-effectiveness of patient isolation as part of an infection prevention effort is poorly understood. The potential to reduce risks of transmission saving costs and improving health outcomes is strong, yet up front investments in patient isolation are required. We report a cost-effectiveness model to inform adoption of a portable single isolation rooms into Australian publicly funded acute hospitals. METHODS: Information is harvested from a range of contemporary sources to reveal the expected changes to total costs and total health benefits measured by life years gain. An Incremental cost-effectiveness ratio is estimated with uncertainty in all model parameters included by probabilistic sensitivity analysis. RESULTS: The adoption decision was found to change total costs per 100,000 occupied bed-days by $1,429,011 and generate health benefits of 436 life years. The mean cost per life year gained is $3278. The probability an adoption decision is cost saving is 2.1%. CONCLUSION: There is some evidence that adoption of rediroom is likely to be a cost-effective solution for Australian hospitals. Important caveats and assumptions need to be considered when interpreting this conclusion.

Environmental hygiene, knowledge and cleaning practice: a phenomenological study of nurses and midwives during COVID-19.

BACKGROUND: Environmental cleanliness is a fundamental tenet in nursing and midwifery but often overshadowed in practice. This study explored nurses' and midwives' knowledge and experiences of infection prevention and control (IPC) processes and cleaning, and perceptions about workplace risk-management during COVID-19. METHODS: Six registered and enrolled nurses (one with dual midwife qualifications) were recruited. In-depth telephone interviews were analyzed using Colaizzi's phenomenological method. RESULTS: Four major themes were identified: Striving towards environmental cleanliness; Knowledge and learning feeds good practice; There's always doubt in the back of your mind; and COVID has cracked it wide open. These articulate the nurses' and midwives' experiences and knowledge of IPC, particularly during COVID-19. DISCUSSION: The findings emphasize the dynamic, interdependent nature of clinical (time, staff knowledge and compliance, work processes, hospital design) and organizational contexts and environmental cleanliness, which must be constantly maintained. COVID-19 opened up critical insights regarding poor past practices and lack of IPC compliance. CONCLUSIONS: COVID-19 has highlighted the criticality of environmental cleanliness within clinical and community settings. Evidence-based, experiential learning is important for nurses and midwives at all career stages, but provides only one solution. Clinician-led hospital design may also reduce the spread of infection; thus, promoting better patient care.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review.

BACKGROUND: This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria. METHODS: A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes. RESULTS: Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult. CONCLUSIONS: A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

Nurses' and midwives' cleaning knowledge, attitudes and practices: An Australian study.

BACKGROUND: As frontline providers of care, nurses and midwives play a critical role in controlling infections such as COVID-19, influenza, multi-drug resistant organisms and health care associated infections. Improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. As nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives' knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments. METHODS: Cross-sectional online survey of 96 nurses (RN/EN) and midwives (RW) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in Australia. RESULTS: Nurses and midwives broadly stated that they understood the importance of cleaning. However, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. Most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism. CONCLUSION: Greater organisational support and improving applied knowledge about infection control procedures is needed. This includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

Control of Candida auris in healthcare institutions: Outcome of an International Society for Antimicrobial Chemotherapy expert meeting.

Candida auris (C. auris) is an emerging fungal pathogen causing invasive infections and outbreaks that have been difficult to control in healthcare facilities worldwide. There is a lack of current evidence for pragmatic infection prevention and control recommendations. The aim of this paper was to review the epidemiology of C. auris and identify best practices with a panel of experts, in order to provide guidance and recommendations for infection prevention and control measures based on available scientific evidence, existing guidelines and expert opinion. The Infection Prevention and Control working group of the International Society of Antimicrobial Chemotherapy organised an expert meeting with infection prevention and mycology experts to review recommendations for healthcare workers on infection prevention and control measures for C. auris at inpatient healthcare facilities. The most common interventions included: screening, standard precautions, cleaning and disinfection, inpatient transfer, outbreak management, decolonisation, and treatment.

Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: A systematic review.

BACKGROUND: Point prevalence studies identify that pneumonia is the most common healthcare associated infection. However, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to date, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used. METHODS: We performed a systematic search to identify research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st January 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle-Ottawa Scale. RESULTS: The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The majority of strategies for NV-HAP prevention focussed on oral care (n = 9). Three studies evaluated a form of physical activity, such as passive movements, two studies used dysphagia screening and management; and another study evaluated prophylactic antibiotics. Most studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials. CONCLUSION: There was considerable heterogeneity in the included studies, including the type of intervention, study design, methods and definitions used to diagnose the NV-HAP. To date, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or movement and dysphagia management.

What Makes a Tweet Fly? Analysis of Twitter Messaging at Four Infection Control Conferences.

OBJECTIVE To examine tweeting activity, networks, and common topics mentioned on Twitter at 4 international infection control and infectious disease conferences. DESIGN A cross-sectional study. METHODS An independent company was commissioned to undertake a Twitter 'trawl' each month between July 1, 2016, and November 31, 2016. The trawl identified any tweets that contained the official hashtags of the conferences for (1) the UK Infection Prevention Society, (2) IDWeek 2016, (3) the Federation of Infectious Society/Hospital Infection Society, and (4) the Australasian College for Infection Prevention and Control. Topics from each tweet were identified, and an examination of the frequency and timing of tweets was performed. A social network analysis was performed to illustrate connections between users. A multivariate binary logistic regression model was developed to explore the predictors of 'retweets.' RESULTS In total, 23,718 tweets were identified as using 1 of the 2 hashtags of interest. The results demonstrated that the most tweets were posted during the conferences. Network analysis demonstrated a diversity of twitter networks. A link to a web address was a significant predictor of whether a tweet would be retweeted (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.9-2.1). Other significant factors predicting a retweet included tweeting on topics such as Clostridium difficile (OR, 2.0; 95% CI, 1.7-2.4) and the media (OR, 1.8; 95% CI, 1.6-2.0). Tweets that contained a picture were significantly less likely to be retweeted (OR, 0.06; 95% CI, 0.05-0.08). CONCLUSION Twitter is a useful tool for information sharing and networking at infection control conferences. Infect Control Hosp Epidemiol 2017;38:1271-1276.

Lessons in implementing infection prevention.

This paper has been developed from a conference presentation given by Professor Alison Holmes at the IPS Learning Labs launch event (2015). In it the implementation of research into clinical practice is discussed with reference to the upcoming Health Foundation Spotlight Report. The difficulties of engaging those in clinical practice are discussed with the importance of involvement of clinical leaders being highlighted. The importance of recognising that implementation science as a social process to bring credibility and legitimacy is also stressed. Following this, the Spotlight Report that is focused on strengthening implementation in the UK is discussed. There remains considerable scope for improvement and the impact of surveillance, targets and fatigue are considered. The tension between top-down and bottom-up approaches to implementation are discussed and a recommendation for a blended approach when implementing measures that are the components of an organisational infection prevention and control strategy is proposed. There also needs to be more scrutiny of the reasons for the failure of research implementation through an examination of the 'soft periphery' that comprises the organisational structure, systems and people that will be responsible for implementing and sustaining an intervention.

Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients.

BACKGROUND: Care bundles are a strategy that can be used to reduce the risk of surgical site infection (SSI), but individual studies of care bundles report conflicting outcomes. This study assesses the effectiveness of care bundles to reduce SSI among patients undergoing colorectal surgery. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials, quasi-experimental studies, and cohort studies of care bundles to reduce SSI. The search strategy included database and clinical trials register searches from 2012 until June 2014, searching reference lists of retrieved studies and contacting study authors to obtain missing data. The Downs and Black checklist was used to assess the quality of all studies. Raw data were used to calculate pooled relative risk (RR) estimates using Cochrane Review Manager. The I(2) statistic and funnel plots were performed to identify publication bias. Sensitivity analysis was carried out to examine the influence of individual data sets on pooled RRs. RESULTS: Sixteen studies were included in the analysis, with 13 providing sufficient data for a meta-analysis. Most study bundles included core interventions such as antibiotic administration, appropriate hair removal, glycemic control, and normothermia. The SSI rate in the bundle group was 7.0% (328/4,649) compared with 15.1% (585/3,866) in a standard care group. The pooled effect of 13 studies with a total sample of 8,515 patients shows that surgical care bundles have a clinically important impact on reducing the risk of SSI compared to standard care with a CI of 0.55 (0.39-0.77; P = .0005). CONCLUSION: The systematic review and meta-analysis documents that use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of SSI.

Surgical site infection: poor compliance with guidelines and care bundles.

Surgical site infections (SSIs) are probably the most preventable of the health care-associated infections. Despite the widespread international introduction of level I evidence-based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence-based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO 'Safe Surgery Saves Lives' checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.