Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department

BACKGROUND

Hand hygiene (HH) is essential in preventing nosocomial infection. The emergency department (ED) is an open portal of entry for pathogens into the hospital system, hence the important sentinel function of the ED personnel. The main objective of this study was to assess the effect of a multimodal improvement strategy on hand hygiene compliance in the ED.

METHODS

Our study was a prospective before-and-after study to determine the effect of a multimodal improvement strategy on the compliance of HH in the ED according to the My 5 Moments of Hand Hygiene defined by the World Health Organization. Interventions such as education, reminders, and regular feedback on HH performance and role models were planned during the 3 intervention weeks.

RESULTS

In total, 57 ED nurses and ED physicians were observed in this study, and approximately 1,000 opportunities for handrubs were evaluated during the 3 intervention periods. HH compliance increased significantly from baseline from 18% (74/407) to 41% (77/190) after the first intervention and stabilized to 50% (99/200) and 46% (96/210) after the second and third interventions, respectively.

CONCLUSIONS

Implementing a multimodal HH improvement program significantly improved the HH compliance of ED personnel.

Optogenetic stimulation of the cochlea-A review of mechanisms, measurements, and first models

This review evaluates the potential of optogenetic methods for the stimulation of the auditory nerve and assesses the feasability of optogenetic cochlear implants (CIs). It provides an overview of all critical steps like opsin targeting strategies, how opsins work, how their function can be modeled and included in neuronal models and the properties of light sources available for optical stimulation. From these foundations, quantitative estimates for the number of independent stimulation channels and the temporal precision of optogenetic stimulation of the auditory nerve are derived and compared with state-of-the-art electrical CIs. We conclude that optogenetic CIs have the potential to increase the number of independent stimulation channels by up to one order of magnitude to about 100, but only if light sources are able to deliver confined illumination patterns independently and parallelly. Already now, opsin variants like ChETA and Chronos enable driving of the auditory nerve up to rates of 200 spikes/s, close to the physiological value of their maximum sustained firing rate. Apart from requiring 10 times more energy than electrical stimulation, optical CIs still face major hurdles concerning the safety of gene transfection and optrode array implantation, for example, before becoming an option to replace electrical CIs.

Multidrug-resistant Candida auris: 'new kid on the block' in hospital-associated infections?

Since being first reported in an ear swab in 2009, and in blood cultures in 2011, invasive infections with Candida auris have been reported in many countries across several continents. We review current knowledge of the epidemiology of this emerging multidrug-resistant pathogen. The importance of species identification and the inadequacies of many widely used identification systems are considered. We recommend that hospitals develop their own policies for the prevention and control of infections with this pathogen. Elements of such policies and the limitations of the existing knowledge base are discussed.

Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (bla OXA-23-like, bla OXA-24-like, bla OXA-51-like, and bla OXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The bla OXA-51-like gene was present in all 112 isolates, 75 (67 %) carried bla OXA-23-like, 7 (6.2 %) carried bla OXA-58-like genes, and 5 (4.5 %) carried bla OXA-24-like genes. With a 90 % similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakır. The bla OXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

Orthostatic stress causes immediately increased blood pressure variability in women with vasovagal syncope

The cardiovascular and respiratory autonomic nervous regulation has been studied mainly by hemodynamic responses during different physical stressors. In this study, dynamics of autonomic response to an orthostatic challenge was investigated by hemodynamic variables and by diverse linear and nonlinear indices calculated from time series of beat-to-beat intervals (BBI), respiratory cycle duration (RESP), systolic (SYS) and diastolic (DIA) blood pressure. This study included 16 young female patients (SYN) with vasovagal syncope and 12 age-matched female controls (CON). The subjects were enrolled in a head-up tilt (HUT) test, breathing normally, including 5min of baseline (BL, supine position) and 18min of 70° orthostatic phase (OP). To increase the time resolution of the analysis the time series were segmented in five-minute overlapping windows with a shift of 1min. Hemodynamic parameters did not show any statistical differences between SYN and CON. Time domain linear analysis revealed increased respiratory frequency and increased blood pressure variability (BPV) in patients during OP meaning increased sympathetic activity and vagal withdrawal. Frequency domain analysis confirmed a predominance of sympathetic tone by steadily increased values of low over high frequency power in BBI and of low frequency power in SYS and DIA in patients during OP. The nonlinear analysis by symbolic dynamics seemed to be highly suitable for differentiation of SYN and CON in the early beginning of OP, i.e., 5min after tilt-up. In particular the index SYS_plvar3 showed less patterns of low variability in patients reflecting a steadily increase in both BPV and sympathetic activity. The proposed dynamical analysis could lead to a better understanding of the temporal underlying mechanisms in healthy subjects and patients under orthostatic stress.

Single and Double Beta-Decay Q Values among the Triplet ^{96}Zr, ^{96}Nb, and ^{96}Mo

The atomic mass relations among the mass triplet ^{96}Zr, ^{96}Nb, and ^{96}Mo have been determined by means of high-precision mass measurements using the JYFLTRAP mass spectrometer at the IGISOL facility of the University of Jyväskylä. We report Q values for the ^{96}Zr single and double β decays to ^{96}Nb and ^{96}Mo, as well as the Q value for the ^{96}Nb single β decay to ^{96}Mo, which are Q_{β}(^{96}Zr)=163.96(13), Q_{ββ}(^{96}Zr)=3356.097(86), and Q_{β}(^{96}Nb)=3192.05(16)  keV. Of special importance is the ^{96}Zr single β-decay Q value, which has never been determined directly. The single β decay, whose main branch is fourfold unique forbidden, is an alternative decay path to the ^{96}Zr ββ decay, and its observation can provide one of the most direct tests of the neutrinoless ββ-decay nuclear-matrix-element calculations, as these can be simultaneously performed for both decay paths with no further assumptions. The theoretical single β-decay rate has been re-evaluated using a shell-model approach, which indicates a ^{96}Zr single β-decay lifetime within reach of an experimental verification. The uniqueness of the decay also makes such an experiment interesting for an investigation into the origin of the quenching of the axial-vector coupling constant g_{A}.

Men and women should be separately investigated in studies of orthostatic challenge due to different gender-related dynamics of autonomic response

In studies of autonomic regulation during orthostatic challenges only a few nonlinear methods have been considered without investigating the effect of gender in young controls. Especially, the temporal development of the autonomic regulation has not yet been explicitly analyzed using short-term segments in supine position, transition and orthostatic phase (OP). In this study, nonlinear analysis of cardiovascular and respiratory time series was performed to investigate how nonlinear indices are dynamically changing with respect to gender during orthostatic challenges. The analysis was carried out using shifted short-term segments throughout a head-up tilt test in 24 healthy subjects, 12 men (26  ±  4 years) and 12 age-matched women (26  ±  5 years), at supine position and during OP at 70°. The nonlinear methods demonstrated statistical differences in the autonomic regulation between males and females. Orthostatic stress caused significantly decreased heart rate variability due to increased sympathetic activity mainly in men, already at the beginning and during the complete OP, revealed by (a) increased occurrence of specific word types with constant fluctuations as pW111 from symbolic dynamics, (b) augmented fractal correlation properties by the short-term index alpha1 from detrended fluctuation analysis, (c) increased slope indices (21ati and 31ati) from auto-transinformation and (d) augmented time irreversibility indices demonstrating more temporal asymmetries and nonlinear dynamics in men than in women. After tilt-up, both men and women increased their sympathetic activity but in a different way. Time-dependent gender differences during orthostatic challenge were shown directly between men and women or indirectly comparing baseline and different temporal stages of OP. The proposed dynamical study of autonomic regulation has the advantage of screening the fluctuations of the sympathetic and vagal activities that can be quantified by the temporal behavior of nonlinear indices. The findings in this paper strongly suggest the need for gender separation in studies of the dynamics of autonomic regulation during orthostatic challenge.

Induced schizophrenic like breathing pattern leads to impaired cardiorespiratory coupling in healthy subjects

Schizophrenia is referred to as one of the most severe mental disorders in the world, and patients with this condition are associated with high cardiac mortality rates. However, the reasons for this high mortality rates are still under debate. One major contributing factor seems to be that a dysfunction of the autonomic nervous system (ANS) is evident in schizophrenia. Thereby, recent investigations focused on the analyses of respiration and cardiorespiratory coupling (CRC) in these patients.The objective of this study was to characterize the causal strength and direction of CRC applying the normalized short time partial directed coherence (NSTPDC) approach in healthy subjects (CON). In this study 25 healthy control subjects were enrolled matching in terms of age and gender to schizophrenic patients. CON were measured in resting condition (pre), breathing with schizophrenic like breathing pattern (stress) and resting condition for recovery (post). During stress CON were asked to breathe with a controlled fixed respiratory frequency, inspirationand expiration time. We found during induced stress significantly increased heart rate and reduced heart rate variability, increased breathing rate and reduced respiratory variability as well as impaired CRC for CON. In conclusion, during induced pathological breathing pattern CON exhibit an impaired and altered heart rate and respiratory regulation and CRC as indicators of a vagal withdrawal and sympathetic overdrive by the ANS. CRC analyses revealed impaired coupling strength and direction, with a driver-responder relationship from respiration to heart rate during stress. These findings support the central role of the respiratory dysregulation in schizophrenia and the assumed suppression of higher regulatory centers of the brain stem due to arousals and permanent stress situations in acute schizophrenia.

Temporal analysis of cardiac autonomic regulation during orthostatic challenge by short-term symbolic dynamics

The gradual shift of cardiac autonomic regulation toward sympathetic predominance and vagal withdrawal during graded head-up tilt test in young controls has been demonstrated by parameters from symbolic dynamics obtained from short-term heart rate variability (HRV) analysis. In this study, the influence of gender and vasovagal syncope (VVS) on the autonomic response to an orthostatic challenge was investigated by HRV analysis using short-term symbolic dynamics (STSD). This study included 24 healthy young subjects (12 males; 12 age-matched females) and 16 female patients diagnosed with VVS. All subjects were enrolled in a head-up tilt (HUT) test, breathing normally, including 5 minutes of supine position (baseline) and 20-40 minutes of 70° orthostatic phase. The STSD parameters were obtained following their behavior at different times during the HUT test, i.e., at baseline, early and middle orthostatic phases. Gender differences including increased sympathetic activity in men were already present in baseline and in the middle tilt phase. In baseline there were no differences between female controls and female patients, but parameters from STSD showed highly significantly (p=0.0007) reduced heart rate variability due to increased sympathetic activity in female patients in the middle tilt phase. Furthermore a new nonlinear index for the estimation of sympatho-vagal balance was introduced.

An inductively heated hot cavity catcher laser ion source

An inductively heated hot cavity catcher has been constructed for the production of low-energy ion beams of exotic, neutron-deficient Ag isotopes. A proof-of-principle experiment has been realized by implanting primary (107)Ag(21+) ions from a heavy-ion cyclotron into a graphite catcher. A variable-thickness nickel foil was used to degrade the energy of the primary beam in order to mimic the implantation depth expected from the heavy-ion fusion-evaporation recoils of N = Z (94)Ag. Following implantation, the silver atoms diffused out of the graphite and effused into the catcher cavity and transfer tube, where they were resonantly laser ionized using a three-step excitation and ionization scheme. Following mass separation, the ions were identified by scanning the frequency of the first resonant excitation step while recording the ion count rate. Ion release time profiles were measured for different implantation depths and cavity temperatures with the mean delay time varying from 10 to 600 ms. In addition, the diffusion coefficients for silver in graphite were measured for temperatures of 1470 K, 1630 K, and 1720 K, from which an activation energy of 3.2 ± 0.3 eV could be determined.

A cross-sectional observational study about media and infection control practices: are photographic portrayals of healthcare workers setting a bad example?

Background

Attempts to increase compliance with infection control practices are complex and are - in part - based on attempts to change behaviour. In particular, the behaviour of significant peers (role models) has been shown to be a strong motivator. While role models within the working environment are obviously the most important, some experts suggest that media and public display cannot be ignored. The aim of this present study was to examine the display of technique recommended by current infection control guidelines including the “bare below the elbow” principle, which is considered a basic requirement for good infection control in many countries, in sets of professional stock photos.

Findings

From 20 random photo-stock websites we selected pictures with search terms “doctor and patient” and “nurse and patient”. In all selected photos a doctor or nurse and a patient were presented, healthcare workers (HCWs) were wearing white coats or uniforms, and their arms were visible. Each photo was evaluated with regard to: closure of white coat, sleeve length, personal clothing covered, hairstyle and presence of a wristwatch, bracelet and/or ring. Overall, 1600 photos were evaluated.

The most common mistakes were with regard to HCWs’ white coats/uniforms. Eighty-nine percent of the photos containing doctor’s images were considered incorrect while 28 % of nurse-containing photos were incorrect.

Conclusions

The results seem to reflect the real world with only 40 % displaying correct behaviour with doctors being worse than nurses. It seems that the stereotypical image of a doctor does not agree with the current infection control guidelines. If we aim for higher compliance rates of HCWs, we need to change the social image of doctors and improve production, selection and display of stock photo images.