Environmental Infection Prevention: Priorities of Patient Safety Collaboration.

Although progress has been made in decreasing health care-associated infections (HAI) in intensive care unit (ICU) patients, there has been an increase in HAI caused by drug-resistant pathogens, particularly those that contaminate the environment such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Pseudomonas spp, Acinetobacter spp, and Clostridium difficile. The ICU environment including sinks and medical equipment has been identified as being at risk for contamination and associated with cross-transmission of pathogens between the health care provider, the environment, and the patient. This article addresses the role of the ICU nurse as a team facilitator collaborating with environmental services, infection preventionists, and others to influence ICU design during preconstruction planning and unit environmental hygiene after construction to promote patient safety and prevent HAI associated with contaminated environments and equipment.

The communication of suicidal intentions: a meta-analysis.

BACKGROUND: Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports. METHOD: Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded. RESULTS: We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% [95% confidence interval (CI) 35.4-53.8], with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed. CONCLUSION: Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.

A community-level effort to motivate physician participation in the National Committee for Quality Assurance Diabetes Physician Recognition Program.

This article presents the results of an exploratory case study that assessed a multistakeholder alliance's initiative to motivate quality improvement in primary care physician (PCP) practices. The initiative utilized a "pay-for participation" strategy that provided incentives to PCPs to participate in the National Committee for Quality Assurance's Diabetes Physician Recognition Program (DPRP). The intervention took place over a 2-year period in 8 practices with large safety-net populations located in the Rochester, New York area. The outcomes of interest were receipt of DPRP recognition and performance on DPRP measurements by the practices, as well as qualitative information regarding practice decisions about quality improvement. Of 79 physicians who participated, 37 (47%) received DPRP recognition. Receipt of recognition was likely the result of a combination of preexisting performance and improvements in processes made during the project. While sample size prevented hypothesis testing, size of practice was unrelated to receipt of DPRP recognition. All practices with an electronic medical record and a patient registry achieved recognition. Strong physician leadership and the presence of a quality improvement infrastructure were believed to be associated with DPRP recognition. The majority of practices cited the program's honorarium and other incentives as key motivators for participation. Our findings suggest that pay-for-participation may be a viable strategy to promote quality improvement in physician practices. However, absent continuing reinforcement, it is uncertain if such programs can lead to sustained quality improvement activities.

Integrating screening and interventions for unhealthy behaviors into primary care practices.

BACKGROUND: Four unhealthy behaviors (tobacco use, unhealthy diet, physical inactivity, and risky alcohol use) contribute to almost 37% of deaths in the U.S. However, routine screening and interventions targeting these behaviors are not consistently provided in primary care practices. METHODS: This was an implementation study conducted between October 2005 and May 2007 involving nine practices in three geographic clusters. Each cluster of practices received a multicomponent intervention sequentially addressing the four behaviors in three 6-month cycles (unhealthy diet and physical inactivity were combined). The intervention included baseline and monthly audits with feedback; five training modules (addressing each behavior plus stages of change [motivational interviewing]); practice facilitation; and bimonthly quality-circle meetings. Nurses, medical assistants, or both were taught to do screening and very brief interventions such as referrals and handouts. The clinicians were taught to do brief interventions. Outcomes included practice-level rates of adoption, implementation, and maintenance. RESULTS: Adoption: Of 30 clinicians invited, nine agreed to participate (30%). IMPLEMENTATION: Average screening and brief-intervention rates increased 25 and 10.8 percentage points, respectively, for all behaviors. However, the addition of more than two behaviors was generally unsuccessful. Maintenance: Screening increases were maintained across three of the behaviors for up to 12 months. For both unhealthy diet and risky alcohol use, screening rates continued to increase throughout the study period, even during the periods when the practices focused on the other behaviors. The rate of combined interventions returned to baseline for all behaviors 6 and 12 months after the intervention period. CONCLUSIONS: It appears that the translational strategy resulted in increased screening and interventions. There were limits to the number of interventions that could be added within the time limits of the project. Inflexible electronic medical records, staff turnover, and clinicians' unwillingness to allow greater nurse or medical-assistant involvement in care were common challenges.

Consideration to culture health care workers related to increased methicillin-resistant Staphylococcus aureus activity in a neonatal intensive care unit.

BACKGROUND: For 2 consecutive years, a care level III neonatal intensive care unit (NICU) in a 700-bed health care facility experienced an increase in health care-associated methicillin-resistant Staphylococcus aureus (MRSA). To decrease transmission, standard infection prevention techniques, active surveillance cultures, and deoxyribonucleic acid typing were done. After control was achieved, members of the organization outside of infection prevention and control requested health care worker (HCW) screening for MRSA, believing that it would decrease chances of future transmission. METHODS: To develop effective tools to communicate with organization members: (1) questions that must be resolved before HCW screening can be done accurately, (2) operational requirements for HCW screening, and (3) a "trigger point" for HCW screening should MRSA activity increase in the future. RESULTS: Developed tools to determine when MRSA screening of HCWs is warranted and for the preparation process when MRSA screening is necessary. Without performing HCW screening in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization for 5 months. CONCLUSION: Proactive consideration of HCW screening can be achieved by designing and implementing tools to illustrate the complexity of the HCW screening process and by defining a "trigger point" for HCW culturing if needed for MRSA control. Decreasing MRSA transmission in this NICU was accomplished without culturing health care workers.

Health-related quality of life following blind rehabilitation.

PURPOSE: The purpose of this study was to investigate the effect of residential blind rehabilitation on patients' vision-targeted health-related quality of life (HRQOL) and general physical and mental function. METHOD: The National Eye Institute 25-item Visual Function Questionnaire (NEI VFQ) plus appendix questions, the 12-item Short-Form Health Survey (SF-12), Hope Scale and Coopersmith self-esteem inventory were administered to 206 legally blind veterans prior to their entering a residential (in-patient) blind rehabilitation program and again to 185 and 176 of the original cohort at 2 and 6 months after completion of the rehabilitation program, respectively. Data on visual acuity, visual field extent, contrast sensitivity and scanning ability were also collected. The duration of the in-patient rehabilitation programs ranged from 11 to 109 days. Questionnaire scores were compared pre-rehabilitation and post-rehabilitation. RESULTS: Following rehabilitation there was a significant improvement in nine of 11 NEI VFQ subscales and in a composite score at both the 2- and 6-month post-rehabilitation intervals. Mental health (SF-12) and self esteem also improved significantly although physical health ratings declined over the course of the study (approximately 10 months). CONCLUSIONS: Residential blind rehabilitation appears to improve patients' self-reported vision-targeted HRQOL, self-esteem and mental health aspects of generic HRQOL.

The Food Stamp Program: history, nutrition education, and impact.

The Food Stamp Program has grown from a modest effort to distribute excess farm commodities during the Great Depression to the nation's largest food assistance and nutrition program, serving almost 27 million persons in fiscal year 2006, at a cost of more than 30 billion dollars to federal taxpayers. In 1990 Congress authorized cost sharing for food stamp nutrition education. Since 1992-when only seven states had approved food stamp nutrition education plans totaling 661,076 dollars in federal dollars-the nutrition education program has grown exponentially. In 2007, there were 52 food stamp nutrition education plans for states and territories approved at a total cost of more than 275 million dollars. The purpose of this review is to give an overview of the Food Stamp Program from its inception in May 1939 through 2006, including program milestones, changes that have occurred as the result of legislation, and the growth and effectiveness of nutrition education to Food Stamp Program participants. Future investigations are needed to study processes for development and validation of evaluation measures as required by the US Department of Agriculture Food and Nutrition Service and to examine the effects of food stamp nutrition education on behavior changes affecting health and nutrition of Food Stamp Program participants.

Infection control consultation in a 150-bed acute care hospital: making this unobserved and unmeasured critical job function visible.

BACKGROUND: One qualified infection control director, reporting directly to administration, was responsible for the Infection Prevention and Control Program of a 150-bed acute care, non-teaching, for-profit hospital. To observe for potential trending, questions (consultations) and determinations related to infectious processes were documented. OBJECTIVE: To explore the possibility of measuring the essential although "hidden" function of the infection control consultation (process), which is a role not formerly linked to infection rates (outcomes). METHODS: A 7-year retrospective study was conducted of all infection control consultations requiring more than a 5-minute intervention, as part of routine job responsibilities. The XmR Statistical Process Control charts (XmR Charts) and Pearson's Correlation Coefficient were used to analyze the activity of infection control consultations. RESULTS: From January 1, 1998 to December 31, 2004, there were 770 infection control consultations logged for 375.1 hours. Beginning with 2003, the variation in both the number and duration of infection control consultations in the XmR Charts become more standardized and has a smaller moving range between data points. The Pearson's Correlation Coefficient shows statistical significance (P <.05) between the number and duration of consultations. CONCLUSIONS: Assessment of infection control consultations at this 150-bed hospital illustrates that this essential component can be measured, and should be formerly tracked to document overall assessment of infection prevention and control interdisciplinary interaction. The consultation process became more efficient over the 7-year study period because, as the number of questions increased, the duration required to achieve closure decreased.

Relationships between feature search and mobility performance in persons with severe visual impairment.

PURPOSE: Because visual search requires both the ability to discriminate visual features and the ability to process information in a large field of view, the association between feature search and mobility of visually impaired (VI) subjects was studied. METHODS: Forty-four subjects with severe visual impairment participated in the study. Feature search performance (2 x 2 deg square target amid 1 x 1 deg square distracters) was measured for 8- to 16- and 32-item set-sizes on 10 x 10, 20 x 20, and 40 x 40 deg fields. Mobility was evaluated on indoor high-density obstacle courses under photopic and mesopic illumination. RESULTS: In feature search, VI subjects were slower and made more errors than normal subjects, but they searched in a parallel fashion. On the mobility task, VI subjects walked slower and made more obstacle contacts than age-matched normal controls. In VI subjects, performances on feature search and mobility tasks were significantly associated, with 37.5% to 66.9 of variations in the mobility measurements being accounted for by visual search speed. CONCLUSIONS: Feature search reaction time can be a good predictor of VI patients' mobility.

Spectrum of foveal development in albinism detected with optical coherence tomography.

BACKGROUND: Optical coherence tomography (OCT) has shown the absence of a foveal depression in an individual with oculocutaneous albinism, type 1 (OCA1) and best-corrected visual acuity (BCVA) of 20/400. However, the presence of an annular light reflex in the macula has been noted with indirect ophthalmoscopy in other patients with albinism who have better vision. We studied macular architecture in albinism with OCT when binocular BCVA was > or = 20/60 and compared this to detection of foveal development with binocular indirect ophthalmoscopy. METHODS: Eleven patients with albinism and BCVA > or = 20/60 were recruited for OCT. Average central macular thickness was recorded. Presence of an oval annular reflex was determined with binocular indirect ophthalmoscopy. RESULTS: Mean binocular BCVA was 20/39 (range: 20/20 to 20/50). Twelve eyes had a rudimentary annular reflex detected with ophthalmoscopy. OCT was reliable in 20 of 22 eyes. A foveal depression was identified with OCT in four eyes. Mean macular thickness for these four eyes was 233 microm (+/- 22.5 microm). We found a weak inverse correlation between BCVA (logMAR) and thickness (r = -0.21). CONCLUSIONS: OCT shows the spectrum of foveal development in albinism, from complete absence of development to a central depression corresponding to a rudimentary annular reflex detected with ophthalmoscopy. The reduced rate of detection of foveal development with OCT compared with ophthalmoscopy is likely related to poor fixation in patients with nystagmus.

Pulmonary arterial disease in cats seropositive for Dirofilaria immitis but lacking adult heartworms in the heart and lungs.

OBJECTIVE: To determine the prevalence and severity of pulmonary arterial lesions in cats seropositive for heartworms (Dirofilaria immitis) but lacking adult heartworms in the heart and lungs during necropsy. ANIMALS: 630 adult cats from an animal control shelter in Florida. PROCEDURE: Cats were tested for adult heartworms in the heart and pulmonary arteries and antibody against heartworms in the serum. Histologic examination was conducted on the right caudal lung lobe of 24 heartworm- and antibody-positive cats; 24 heartworm-negative and antibody-positive cats; and 24 heartworm-, antibody-, and antigen-negative cats. Wall areas of 10 small to medium-sized pulmonary arteries of each cat were measured and expressed as a proportion of total cross-sectional area. RESULTS: Heartworm infection or seropositive status was significantly and strongly associated with seventy of medial hypertrophy of pulmonary arterial walls. Heartworm- and antibody-positive cats and heartworm-negative and antibody-positive cats had a significant increase in wall thickness, compared with wall thickness for heartworm- and antibody-negative cats. Heartworm- and antibody-positive cats had the most severe hypertrophy. The proportion with occlusive medial hypertrophy was significantly higher in heartworm- and antibody-positive cats (19/24 [79%]) and heartworm-negative and antibody-positive cats (12/24 [50%]), compared with heartworm- and antibody-negative cats (3/24 [13%]). CONCLUSIONS AND CLINICAL RELEVANCE: Cats with serologic evidence of exposure to heartworms, including those without adult heartworms in the lungs and heart, have a greater prevalence of pulmonary arterial lesions than heartworm-negative cats without serologic evidence of exposure. Additional studies are needed to define the pathogenesis, specificity, and clinical importance of these lesions.

Traumatic mitral valve avulsion from the annulus fibrosis producing acute left heart failure in a dog.

Traumatic detachment of the mitral valve from the annulus fibrosis occurred in a dog following blunt chest trauma. Euthanasia was elected approximately 7 months posttrauma due to refractory, chronic left heart failure. This is the first reported case of traumatic mitral valve rupture in a dog.

Comparison of serological tests for the detection of natural heartworm infection in cats.

Serological tests were performed on 380 cats with necropsy-confirmed heartworm disease to compare the performance of currently available commercial laboratory and point-of-care heart-worm serological tests in a heartworm-endemic area. Overall, antigen tests detected 79.3% to 86.2% of heartworm infections and were highly specific. Most cats with false-negative antigen tests had a single male worm. Antibody tests detected 62.1% to 72.4% of heartworm infections and had a wider range of false-positive results (1.4% to 19.1%) than antigen tests (0.3% to 2.0%). Serological tests for feline heartworm infection varied in diagnostic performance. Combining results from antigen and antibody tests achieved greater sensitivity than using either test alone.

Survival analysis of dropout patterns in dieting clinical trials.

Subjects who withdraw from diet clinical trials are a drain on limited resources and reduce statistical power. Dropout pattern data, collected during a clinical trial for which the primary findings compared weight loss from three dieting protocols, are examined using survival analysis and found to be exponentially distributed. The predicted probability of remaining in the study is 83% for 30 days and 60% for 84 days. Survival analysis methods consider subjects who did not return after the initial visit and others who may have continued dieting beyond study termination. When applied to clinical trials, this type of analysis provides valuable information for planning and budgeting of future trials. Inclusion of a 1- to 2-week run-in period at the beginning of the study may improve retention. Otherwise, the diet researcher should consider increasing initial randomized sample size by approximately 10% to 25% as an allowance for early withdrawals.

Prevalence and risk factors for heartworm infection in cats from northern Florida.

Necropsies were performed on 630 adult cats in northern Florida to determine the prevalence and risk factors for heartworm infection in cats of this region. Heartworms were identified in 4.9% of cats, and serological evidence of heartworm exposure was present in 17% of cats. Not all cats from which heartworms were recovered were seropositive for heartworm antigen or antibody. There was no association between heartworm infection and co-infection with feline leukemia virus (FeLV) or feline immunodeficiency virus (FIV). Male cats were at higher risk of infection with heartworm, FeLV, or FIV than were females. Because even a single heartworm can cause clinical disease or death in cats, the authors conclude that cats in this region should receive heartworm prophylaxis to prevent heartworm infection.

Influence of reference frames on asymmetries in Troxler's effect.

In 1804, Troxier discovered that, when an observer fixates on a point in central vision and attends to a peripheral stationary stimulus, the peripheral stimulus eventually fades from awareness. This phenomenon is known as Troxler's effect and is allegedly influenced by spatial attention. Asymmetries in Troxler's effect along horizontal and vertical meridian were a recent discovery. However, viewer- and environment-centered reference frames were aligned in prior studies, making it impossible to assess whether asymmetries correspond to viewer- versus environment-centered coordinate systems. This study was undertaken to (a) replicate the asymmetries in the upright condition among 39 participants without health issues and (b) use the asymmetrics to test contrasting predictions made by viewer- and environment-centered coordinate systems when they are decoupled using an experimental head-tilt condition. The horizontal and vertical asymmetries were replicated and consistent with a viewer-centered rather than an environment-centered reference frame.

Otitis media, fluctuant hearing loss, and speech-language outcomes: a preliminary structural equation model.

The goals of this study were to estimate the risk for lowered speech-language outcomes associated with early recurrent otitis media with effusion (OME) with and without hearing loss and to develop a preliminary descriptive-explanatory model for the findings. Three statistical approaches were used to assess associations among OME, hearing loss, and speech-language outcomes. Participants were a subsample of 70 children followed prospectively in the Dallas Cooperative Project on Early Hearing and Language Development (Friel-Patti & Finitzo, 1990). Findings indicated that hearing levels at 12-18 months were significantly associated with speech delay and low language outcomes at 3 years of age. The risk for subclinical or clinical speech delay at 3 years of age was 2% for children with less than 20 dB average hearing levels at 12-18 months and 33% for children with greater than 20 dB average hearing levels at 12-18 months. A structural equation model (Jöreskog & Sörbom, 1993) indicated that the significant and substantial effects of hearing levels at 12-18 months on speech status at 3 years were significantly mediated by language status at 3 years. Discussion includes implications of these findings for alternative speech perception models linking early OME and hearing loss to later speech-language disorder.