Comparison of human and electronic observation for the measurement of compliance with hand hygiene.

BACKGROUND: Monitoring of hand hygiene is an important part of the improvement of hospital quality indicators. METHODS: This study was prospectively performed over a 14-week (electronic observer) period from December 3, 2013-March 9, 2014, to evaluate hand hygiene compliance in an adult step-down unit. We compared electronic handwash counters with the application of radiofrequency identification (RFID - ZigBee; i-Healthsys, São Carlos, Brazil) (electronic observer), which counts each activation of the alcohol gel dispenser to direct observation (human observer) using the iScrub application. RESULTS: For the overall time period of simultaneous electronic and human observation, we found that the electronic observer identified 414 hand hygiene episodes, whereas the human observers identified 448 episodes. Therefore, we found 92% (95% confidence interval [CI], 90%-95%) overall concordance (414/448), with an intraclass correlation coefficient of .87 (95% CI, 0.77-0.92). CONCLUSION: Our RFID (ZigBee) system showed good accuracy (92%) and is a useful method to monitor hand hygiene compliance.

Positive Deviance: A New Tool for Infection Prevention and Patient Safety.

Positive deviance (PD) may have an important role in infection prevention and patient safety in the hospital. There are many descriptions of successful stories of PD in different sectors from public health to education to business. PD has been applied in the healthcare setting to improve hand hygiene compliance, reduce methicillin-resistant Staphylococcus aureus, and reduce bloodstream infections in an outpatient hemodialysis center. PD promotes dialogue among leaders, managers and healthcare workers, which is a key factor in establishing a safety culture. It also enables cultural changes aimed at empowering frontline workers (the positive deviants) to innovate and improve compliance with infection prevention measures. The structure and the process of PD, and its ability to offer a space for experience discussions, changing ideas and making plans that emerge from team participation will also be discussed.

A multicenter study using positive deviance for improving hand hygiene compliance.

BACKGROUND: Positive deviance (PD) can be a strategy for the improvement of hand hygiene (HH) compliance. METHODS: This study was conducted in 8 intensive care units and 1 ward at 7 tertiary care, private, and public hospitals. Phase 1 was a 3-month baseline period (from August to October 2011) in which HH counts were performed by observers using iPods (iScrub program). From November 2011 to July 2012, phase 2, a PD intervention was performed in all the participating centers. We evaluated the consumption of HH products (alcohol gel and chlorhexidine) and the incidence density of health care-associated infections. RESULTS: There was a total of 5,791 HH observations in the preintervention phase and 11,724 HH observations in the intervention phase (PD). A statistically significant difference was found in overall HH compliance with 46.5% in the preintervention phase and 62.0% in the PD phase (P < .001). There was a statistically significant reduction in the incidence of density of device-associated infections per 1,000 patient-days and also in the median of length of stay between the preintervention phase and the PD phase (13.2 vs 7.5 per 1,000 patient-days, respectively, P = .039; and 11.0 vs 6.8 days, respectively, P < .001, respectively). CONCLUSION: PD demonstrated great promise for improving HH in multiple inpatient settings and was associated with a decrease in the median length of stay and the incidence of device-associated HAIs.

Measuring hand hygiene compliance in a hematology-oncology unit: a comparative study of methodologies.

BACKGROUND: In managing hematology-oncology patients, there is a great opportunity for performing hand hygiene (HH). METHODS: Over a 4-month period, we compared HH compliance measurement by 3 different methods: direct observation, electronic handwash counter for alcohol gel, and measuring the volume of product used (alcohol gel) in a 40-bed hematology-oncology unit at a tertiary care, private hospital. RESULTS: There were 388 directly observed opportunities for HH, and the overall HH compliance rate was 84.5%. A total of 235,923 HH episodes was recorded by the electronic devices. The mean HH episodes per patient-day was 77.7. There were 91.1 mL of alcohol gel used per patient-day in the unit. The correlation and P value between the percentage of HH compliance and HH episodes per 1,000 patient-days were ρ = 0.442 and P = .076, respectively. The correlation and P value between HH episodes per patient-days and alcohol gel consumption in milliliters per patient-days were ρ = 0.142 and P = .586. CONCLUSION: HH compliance was high in this unit. Direct observation, although useful, has many drawbacks. Other measures must be considered, such as electronic devices and measurement of volume use per patient-day to stimulate health care workers to increase and sustain HH compliance.

The effect of contact precautions on hand hygiene compliance.

Hand hygiene is one of the most important interventions to prevent health care-associated infections. We compared hand hygiene compliance among health care workers when patients were in contact precautions to compliance when patients were not in contact precautions. Our study failed to show differences in adherence to hand hygiene practices in the care of contact isolation versus noncontact isolation patients.

Hand hygiene compliance in the critical care setting: a comparative study of 2 different alcohol handrub formulations.

BACKGROUND: Hand hygiene (HH) compliance can be affected by the accessibility of products (alcohol-based products or chlorhexidine) and by the formulations of these products. There are few published studies comparing different alcohol-based hand disinfection formulations. METHODS: This study was conducted in a 41-bed medical-surgical intensive care unit at a private tertiary care hospital. Over a 16-week period, we assessed HH compliance by direct observation of practice using iPods and measurement of the amount of product used [alcohol and chlorhexidine] in two 4-room pods in which an alcohol gel product was used compared with two other 4-room pods in which an alcohol-based foam formulation was used. RESULTS: A total of 3,895 opportunities for HH were observed, and the overall rate of HH compliance was 36.9%. No statistically significant differences were found in overall HH compliance or alcohol-based HH compliance between the alcohol foam unit and the alcohol gel unit. However, there was a statistically significant difference in chlorhexidine HH compliance between the alcohol foam unit and the alcohol gel unit (7.0% [130 of 1,853] vs 3.8% [77 of 2,042]; P < .01). CONCLUSIONS: Alcohol handrub use was greater than chlorhexidine use, but HH compliance was low in both units independent of the alcohol formulation available. The similarity of use of both alcohol formulations suggests that health care workers tend to use whatever product is readily available.

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. METHODS: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement's (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. RESULTS: We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. CONCLUSION: These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored.

Microbiological findings from the Haiti disaster.

There are few data regarding microbiological findings from the disaster situation in Haiti. A rapid and accurate diagnosis of infection is necessary for the optimal efficacy of antimicrobial therapy, considering the antimicrobial spectrum and the duration of treatment. Furthermore, understanding the microorganisms and their susceptibility profiles is necessary to implement appropriate infection control policies and to contain the emergence and dissemination of Gram-negative multidrug-resistant pathogens.

Bloodstream Infection in the Intensive Care Unit: Preventable Adverse Events and Cost Savings.

OBJECTIVES: Central line associated bloodstream infections (CLABSIs) impose a significant economic burden for patients admitted to the intensive care unit for adults (AICU). The objectives of the study were to evaluate the excess length of stay and extra costs attributable to CLABSIs diagnosed in the AICU. METHODS: Cases were selected as patients admitted to AICU from 2006 through 2009, who developed a CLABSI episode. These were matched (1:1) with appropriate controls. Matching criteria were selected to exclude other factors that could influence cost and care practices. The length of stay and resources used between AICU admission and discharge and until hospital discharge or death were measured. Incremental costs and lengths of stay were calculated for each pair of patients. RESULTS: Thirty cases and 30 controls were included in the study. A CLABSI episode resulted in an additional 10.5 days in the AICU and 9.1 days after AICU discharge, totaling an additional 19.6 days. The incremental cost associated with a CLABSI episode was US $65,993 in the AICU and US $23,893 after AICU discharge, totaling an incremental cost of US $89,886. CONCLUSIONS: By avoiding CLABSI events, cost offsets would be expected for payers with revenue losses to providers. An approach of sharing the gains resulting from preventive measures could be used to incentivize providers to maintain those investments, benefiting patients who will have a reduced risk of CLABSI development.

Decreasing mortality in severe sepsis and septic shock patients by implementing a sepsis bundle in a hospital setting.

BACKGROUND: The Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis (SS) and septic shock (SSh) have been recommended to reduce morbidity and mortality. MATERIALS AND METHODS: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize SS and SSh shock patients' clinical outcomes were performed by applying sepsis bundles (6- and 24-hour) in May 2006. We compared bundle compliance and patient outcomes before (July 2005-April 2006) and after (May 2006-December 2009) implementation of the interventions. RESULTS: A total of 564 SS and SSh patients were identified. Prior to the intervention, compliance with the 6 hour-sepsis resuscitation bundle was only 6%. After the intervention, compliance was as follows: 8.2% from May to December 2006, 9.3% in 2007, 21.1% in 2008 and 13.7% in 2009. For the 24 hour-management bundle, baseline compliance was 15.0%. After the intervention, compliance was 15.1% from May to December 2006, 21.4% in 2007, 27.8% in 2008 and 44.4% in 2009. The in-hospital mortality was 54.0% from July 2005 to April 2006, 41.1% from May to December 2006, 39.3% in 2007, 41.4% in 2008 and 16.2% in 2009. CONCLUSION: These results suggest reducing SS and SSh patient mortality is a complex process that involves multiple performance measures and interventions.

Preventing catheter-associated urinary tract infection in the zero-tolerance era.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care‒associated infections in the critical care setting. METHODS: A quasi-experimental study involving multiple interventions to reduce the incidence of CAUTI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). Between June 2005 and December 2007 (phase 1), we implemented some Centers for Disease Control and Prevention‒recommended evidence-based practices. Between January 2008 and July 2010 (phase 2), we intervened to improve compliance with these practices at the same time that performance monitoring was being done at the bedside, and we implemented the Institute for Healthcare Improvement's bladder bundle for all ICU and SDU patients requiring urinary catheters. RESULTS: There was a statistically significant reduction in the rate of CAUTI in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], 6.6-8.6) before the intervention to 5.0 per 1,000 catheter-days (95% CI, 4.2-5.8; P < .001) after the intervention. There also was a statistically significant reduction in the rate of CAUTI in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, 13.9-16.6) before the intervention to 12.9 per 1,000 catheter-days (95% CI, 11.6-14.2) after the intervention (P = .014). CONCLUSION: Our findings suggest that reducing CAUTI rates in the ICU setting is a complex process that involves multiple performance measures and interventions that can be applied to SDU settings as well.

Reactive oxygen species independent cytotoxicity induced by radiocontrast agents in tubular cells (LLC-PK1 and MDCK).

PURPOSE: Radiocontrast agents (RAs) cause renal tubular damage by hemodynamic imbalance, which could cause hypoxic stimulus and direct cytotoxicity. However, reactive oxygen species (ROS) could be an important factor in RAs' direct cytotoxicity. This study investigated the involvement of ROS in deleterious effects produced by RAs on normoxic and hypoxic renal tubular cells. MATERIALS AND METHODS: LLC-PK1 and MDCK were exposed to diatrizoate and ioxaglate in normoxic and hypoxic conditions. Apoptotic and necrotic cell death were assessed by acridine orange/ethidium bromide and annexin V methods. Hydrogen peroxide, superoxide anion, and malondialdehyde levels were analyzed by, respectively, 2',7'-dichlorofluorescein, luminal, and thiobarbituric acid. Antioxidant agents were used to prevent cellular RAs damage. RESULTS: Diatrizoate and ioxaglate decreased cellular viability in both cells, and this effect was enhanced by hypoxic conditions. Diatrizoate induced more injury than ioxaglate to both cell lines. LLC-PK1 underwent necrosis, while MDCK cells underwent apoptosis when exposed to diatrizoate. These results could not be attributed to an increase in osmolality. RAs did not increase hydrogen peroxide, superoxide anion or malondialdehyde levels in both cells. Additionally, N-acetyl-L-cysteine (NAC), ascorbic acid, alpha-tocopherol, glutathione, beta-carotene, allopurinol, cimetidine, and citric acid did not protect cells against RAs damage. Surprising, NAC increased the cellular damage induced by ioxaglate in the both cell lines. CONCLUSION: The present study shows that RAs induce damage in cultured tubular cells, especially in hypoxic conditions. ROS were not involved in the observed RAs' cytotoxicity, and NAC increased ioxaglate-induced tubular damage.

Effects of customized bicarbonate buffered solutions for continuous renal replacement therapies on polymorphonuclear leukocytes function and viability.

It has previously been shown that the mixture of bicarbonate and calcium in the solutions used for continuous renal replacement therapy led to crystallization and significant changes in calcium concentration and pH. The aim of this study was to investigate the impact of bicarbonate/calcium and lactate/calcium solutions for Continuous Renal Replacement Therapies (CRRT) on the viability and function of polymorphonuclear cells (PMN). We tested four customized bicarbonate buffered solutions: single bag (bicarbonate and calcium mixed 24 h before testing), double bag (mixed immediately before testing), filtered single bag and double bag solutions, and a commercial lactate buffered solution. Blood from 6 volunteers was incubated with the solutions for 30 min followed by PMN isolation. After overnight incubation, viability, phagocytosis, and peroxide production by PMN were determined by flow cytometry. There was no difference between the test solutions with respect to PMN viability and function. Therefore, the presence of microcrystals and the consequent changes in electrolyte concentrations do not seem to impair PMN function.