An Interactive E-learning Platform-Based Training to Improve Intensive Care Professionals' Knowledge Regarding Central Venous Catheter-Related Infections.

Introduction The presence of a central venous catheter (CVC) leads to a high risk for blood infections, which are associated with increases in morbidity, mortality, and costs. This study aims to assess intensive care unit (ICU) nurses' and physicians' knowledge regarding the Centers for Disease Control and Prevention (CDC) guidelines for preventing CVC-related infections before and after an interactive distance education delivered through the e-learning platform Teleprometheus. Materials and methods The study was conducted among 85 nurses and physicians in Nicosia's General Hospital Intensive Care Unit (NGH-ICU) and high dependency unit (HDU). A validated questionnaire was used to assess nurses' and physicians' knowledge. Results Prior to the online interactive distance education, the mean total knowledge score was x̄ = 4.8 (SD = 2.46), while after, the mean total knowledge score increased to x̄ = 8.9 (SD = 2.38) (p<0.001). ICU physicians had a higher mean total knowledge score (x̄ = 10.20) than ICU nurses (x̄ = 8.75) after the intervention. There was no correlation between years of experience in the ICU and the level of knowledge (r = 0.048). The interactive distance education was positively evaluated by the participants, through a questionnaire, specially designed for this study. Discussion The most important findings were that (a) the level of knowledge of the participants improved with a statistically significant difference after the completion of the e-course, (b) the level of knowledge of the participants, after the completion of the e-course, was much higher from other studies, (c) there was no correlation between the years of experience of ICU health professionals and their level of knowledge, and (d) the interactive distance e-course was positively evaluated and satisfied the participants. Conclusion The current study demonstrates that in high-intensity work environments, such as ICUs, adopting e-learning approaches seems more necessary than ever.

Exposure to airborne SARS-CoV-2 in four hospital wards and ICUs of Cyprus. A detailed study accounting for day-to-day operations and aerosol generating procedures.

In any infectious disease, understanding the modes of transmission is key to selecting effective public health measures. In the case of COVID-19 spread, the strictness of the imposed measures outlined the lack of understanding on how SARS-CoV-2 transmits, particularly via airborne pathways. With the aim to characterize the transmission dynamics of airborne SARS-CoV-2, 165 and 62 air and environmental samples, respectively, were collected in four COVID-19 wards and ICUs in Cyprus and analyzed by RT-PCR. An alternative method for SARS-CoV-2 detection in air that provides comparable results but is less cumbersome and time demanding, is also proposed. Considering that all clinics employed 14 regenerations per hour of full fresh air inside patient rooms, it was hypothesized that the viral levels and the frequency of positive samples would be minimum outside of the rooms. However, it is shown that leaving the door opened in patient rooms hinders the efficiency of the ventilation system applied, allowing the virus to escape. As a result, the highest observed viral levels (135 copies m-3) were observed in the corridor of a ward and the frequency of positive samples in the same area was comparable to that inside a two-bed cohort. SARS-CoV-2 in that corridor was found primarily to lie in the coarse mode, at sizes between 1.8 and 10 µm. Similar to previous studies, the frequency of positive samples and viral levels were the lowest inside intensive care units. However, if a patient with sufficient viral load (Ct-value 31) underwent aerosol generating procedures, positive samples with viral levels below 45 copies m-3 were acquired within a 2 m distance of the patient. Our results suggest that a robust ventilation system can prevent unnecessary exposure to SARS-CoV-2 but with limitations related to foot traffic or the operations taking place at the time.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus.

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period. METHODS: We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme. RESULTS: There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017. CONCLUSIONS: The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Prevention of Central Line-Associated Bloodstream Infections Through Educational Interventions in Adult Intensive Care Units: A Systematic Review.

Central line-associated bloodstream infections (CLABSIs) represent a severe systemic threat to patients admitted in ICUs and contribute to increased mortality, prolonged length of stay in ICUs, and increased costs. The majority of CLABSIs are preventable. The current systematic review aimed to investigate the effectiveness of educational methods on CLABSI rates in adult ICUs. A systematic literature search was conducted using the electronic databases of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Cochrane Database of Systematic Reviews for studies published from the beginning of 1995 to March 2020. The terms used for the search were as follows: central venous catheters, infection, central line-associated bloodstream infections, intensive care unit, and education intervention in all possible combinations and using the word 'and' between them. Data were extracted independently and crosschecked by two authors using a standard data collection form. The quality of the studies included in the review was assessed using the Methodological Index for Non-randomized Studies (MINORS). The current systematic review included 27 interventional studies of central line insertion or maintenance or both in adult ICU settings with documentation of the CLABSI incidence expressed per 1,000 catheter days. A large deviation between the length of time and type of educational interventions was found. Statistical significance was found in all studies (except one) in terms of CLABSI reduction despite the large variation of the length or the type of the educational intervention. Continuing education on infection prevention may be necessary to maintain the post-intervention results and improve clinical outcomes.

Clinical Characteristics, Management, and Outcome of the First 19 Patients With Pneumonia Due to the 2019 Novel Coronavirus Disease Treated in an Intensive Care Unit in the Republic of Cyprus.

Background The widespread reach of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its consequences have severely affected the consistency of healthcare systems around the world and caused millions of deaths to date. Understanding the coronavirus disease 2019 (COVID-19) manifestation, progression, and management is crucial for the healthcare personnel caring for COVID-19 patients within the intensive care unit (ICU), as well as for the patients' health progression. Methods A prospective observational study was used to investigate the progression of critically ill COVID-19 positive patients who were admitted to the ICU of Nicosia General Hospital from March 10 to May 1, 2020. All patients over the age of 18 were included in the study; their data were anonymously collected using the institution's electronic medical record system and analyzed in Microsoft Excel (Microsoft Corporation, Redmond, WA). Pregnant women, children, and prisoners were excluded. Results During the study period, a total of 19 patients with a positive result on a reverse-transcriptase polymerase chain reaction (RT-PCR) were included in the study; 74% were men and their mean age was 64 years. Sixty-three percent of the patients were obese, 53% had a history of confirmed hypertension, 68% were admitted with severe respiratory failure, and all of them required invasive mechanical ventilation. Patients were categorized into four groups of ventilation based on the H or L ventilation phenotype in association with co-morbidities. Prone position in the first mechanical ventilation days was found to be more advantageous in L than H phenotype patients, 68% required vasopressor support, and 42% developed acute kidney injury (AKI) during their ICU stay. Diarrhea was with a median day of onset of eight days. Lactate levels above 2 mmol/L in the first four days of admission were correlated with a negative outcome. Nine patients (47%) were successfully discharged from the ICU while 10 (53%) died during their stay. Conclusion In critically ill patients, male gender and obesity are significant risk factors for ICU admission due to COVID-19, and early prone position, mechanical ventilation, and low positive end-expiratory pressures (PEEP) values may be beneficial, especially in the L phenotype category patients. Patients' ventilation phenotype during ICU admission and hospitalization seemed to determine the outcome. Clinical improvement might have been higher and possibly ICU mortality lower if remdesivir was available. Hydroxychloroquine did not seem to improve patient outcomes, a consistent find, as suggested by other studies; on the contrary, it may have contributed to increased mortality rates.

When Multidrug-Resistant Organism (MDRO)-Positive ICU Patient Isolation and Cohorting Is Not Feasible, What Comes Next?

Background The need for the implementation of an infection prevention strategy that included patient isolation and a cohorting procedure emerged in our ICU. Yet, isolation, as well as cohorting, were not feasible due to certain barriers associated with a high colonization pressure, open-plan ICU, inadequate bed separation, a limited number of isolation rooms, and nursing shortage. Despite these limitations, we tried to upgrade our ICU's infection prevention efforts by developing the "universal use of contact precautions approach" for infection prevention and control for all the patients with and without multidrug-resistant organisms (MDROs), cohorting, and single room isolation. The study aimed to evaluate the effectiveness of our approach. Methods A prospective cohort study using surveillance screening cultures for Methicillin-resistant Staphylococcus aureus (MRSA) and MDROs for a period of 18 weeks from October 1, 2018, to January 31, 2019. The main purpose of the approach was to isolate all patients (regardless of their MDRO/MRSA status) in their own bed space as if they were in an isolation room for the entire duration of their ICU hospitalization, in such a way as to prevent horizontal transmission of infection (infection acquisition) in our open-plan ICU.  Results Seventy-eight patients were admitted to our ICU for a total of 942 patient-days; a total of 432 swabs were collected during the study period. A total of 17 (21.8%) patients were admitted with a pre-existing infection while two (2.5%) patients acquired an infection during their ICU stay (one with Acinetobacter baumannii andone with Pseudomonas aeruginosa; 1.28 acquisition per 1000 patient-days). No transmission was documented for Klebsiella pneumoniae, Enterococcus faecalis, and Staphylococcus aureus. Conclusions Our MDRO acquisition rates suggested that the implementation of our infection control strategy potentially prevents the horizontal transmission of pathogens in an open-plan ICU, despite the high colonization pressure and the lack of isolation and cohorting procedures.

Nursing quality indicators for adult intensive care: A consensus study.

BACKGROUND: The selection of quality indicators demonstrating the efficiency and relevance of nursing practice in patient outcomes in the intensive care unit remains a challenge. AIM: The aim of this study was to develop a set of potential quality indicators to quantify nursing care provided to critically ill patients through a consensus method. DESIGN: This was a three-phase study including a European survey of intensive care unit (ICU) nurses (phase one) followed by a two-phase face-to-face consensus meeting of experts from Cyprus. METHOD: Two distinct panels of experts were asked to rate each quality indicator using a 4-point Likert scale in phases one and two. The level of consensus was set at 60%. In phase three, scores of the content validity index for items and scales were considered for the final selection of quality indicators. RESULTS: The phase one survey included 139 ICU nurses from 13 European countries, and phases two and three included seven ICU experts from Cyprus. "Consensus in" was achieved for 12 items at the end of phase two. Three of the quality indicators were significantly different by country: (a) falls (P = .006), (b) accidental removal of nasogastric tube (P < .001), and (c) accidental removal of intravascular catheters (P < .001). Only falls was significantly correlated with higher academic qualifications of the participants (P = .002). CONCLUSIONS: Fifteen items have been identified as potential indicators for adult ICU nursing quality. These need to be prospectively studied to determine the extent to which they can accurately capture nursing care quality in this setting. RELEVANCE TO CLINICAL PRACTICE: The study provides a set of relevant quality indicators. A nursing set for the ICU may serve as the basis for nursing management and facilitate the strategy dedicated to the vision of health care quality assurance.

Extensive Testing and Public Health Interventions for the Control of COVID-19 in the Republic of Cyprus between March and May 2020.

Coronavirus disease 2019 (COVID-19) has significantly affected the well-being of individuals worldwide. We herein describe the epidemiology of COVID-19 in the Republic of Cyprus during the first epidemic wave (9 March-3 May 2020). We analyzed surveillance data from laboratory-confirmed cases, including targeted testing and population screening. Statistical analyses included logistic regression. During the surveillance period, 64,136 tests (7322.3 per 100,000) were performed, 873 COVID-19 cases were diagnosed, and 20 deaths were reported (2.3%). Health-care workers (HCWs) represented 21.4% of cases. Overall, 19.1% of cases received hospital care and 3.7% required admission to Intensive Care Units. Male sex (adjusted Odds Ratio (aOR): 3.04; 95% Confidence Interval (CI): 1.97-4.69), increasing age (aOR: 1.56; 95%CI: 1.36-1.79), symptoms at diagnosis (aOR: 6.05; 95%CI: 3.18-11.50), and underlying health conditions (aOR: 2.08; 95%CI: 1.31-3.31) were associated with hospitalization. For recovered cases, the median time from first to last second negative test was 21 days. Overall, 119 primary cases reported 616 close contacts, yielding a pooled secondary attack rate of 12% (95%CI: 9.6-14.8%). Three population-based screening projects, and two projects targeting employees and HCWs, involving 25,496 people, revealed 60 positive individuals (0.2%). Early implementation of interventions with targeted and expanded testing facilitated prompt outbreak control on the island.

Should the CDC's recommendations for promptly removing unnecessary centrally inserted central catheters be enhanced? Ultrasound-guided peripheral venous cannulation to fully comply.

PURPOSE: In an effort to reduce catheter-related bloodstream infection's incidence rates in an intensive care unit, several evidence-based procedures recommended by the Centers for Disease Control and Prevention for centrally inserted central catheters were implemented. A failure to fully comply with the recommendation for prompt removal of the centrally inserted central catheters was attributed, mainly to the difficulties and inadequacies raised from establishing peripheral venous access. METHODS: The ultrasound-guided peripheral venous cannulation method as a supplementary intervention to the Centers for Disease Control and Prevention's recommendations was incorporated and examined during the subsequent year. RESULTS: A significant reduction on catheter-related bloodstream infection incidence rates out of the expected range was found. Centrally inserted central catheters utilization ratios were reduced by 10.7% (p < 0.05; 58%-47%) and the catheter-related bloodstream infection incidence rate was reduced by 11.7 per thousand device-days (15.9-4.16/1000 centrally inserted central catheters days (2015-2016 group, respectively)). CONCLUSION: The reduction of catheter-related bloodstream infection was higher than that described in the published literature. This probably shows that the combination of the five evidence-based procedures recommended by the Centers for Disease Control and Prevention together with that of ultrasound-guided peripheral venous cannulation method can increase the compliance with the Category IA recommendation for removal or avoidance of unnecessary placement of centrally inserted central catheters and decrease the catheter-related bloodstream infections in a more effective way, by affecting the patients' centrally inserted central catheter exposure.

Should the norepinephrine maximal dosage rate be greatly increased in late shock?

Any advanced shock eventually degenerates into vasoplegia, which responds weakly to vasopressors. The highest reported norepinephrine flow rate is 3 µg/kg/min. We present the case of a young explosion victim, who was transferred in late haemorrhagic shock. Apart from usual treatment (hydration, mass transfusion protocol), single-agent norepinephrine was used to maintain a mean arterial pressure (MAP) of >60-65 mm Hg. For several hours, norepinephrine flow was 7-10 times the aforementioned (highest reported) in order to achieve our goal; during which, further hydration or transfusion would not contribute to MAP elevation. Sequential Organ Failure Assessment (SOFA) severity score was 18 (expected mortality >99%). The patient survived without underperfusion-related damage. We conclude that norepinephrine dosages could potentially be greatly increased in late shock. We must resist giving up flow escalation based on its numerical value.

Morvan's syndrome associated with antibodies to multiple components of the voltage-gated potassium channel complex.

We describe a patient presenting with a combination of muscle fasciculations, paresthesias, hyperhidrosis, as well as insomnia, agitation and confusion. He went on to develop psychosis and respiratory failure requiring intensive care. Electromyography confirmed the presence of neuromyotonia and CSF showed mild pleocytosis. Routine testing for voltage-gated potassium channel complex (VGKC-complex) antibodies was highly positive, confirming the clinical diagnosis of Morvan's syndrome. The patient improved after treatment with intravenous immunoglobulin and methylprednisolone. Further investigation of the antigenic targets using immunohistochemistry and cell-based assays revealed that he had autoantibodies targeting Lgi1, Caspr2 and Contactin-2/Tag-1, all proteins known to be complexed with VGKC in peripheral nerves and CNS. This is the first case of Morvan's syndrome from Cyprus and illustrates the clinical features as well as the emerging complexity of antigenic targets involved in the pathogenesis.