Assessment of urine collection technique for microbial culture

Two methods of urine collection-clean catch and midstream only-were compared in 200 samples (100 with each technique). There were no significant differences between the two collection methods with regard to number of positive culture results or types and counts of organisms isolated. There is little if any added benefit to special preparation for urine collection for culture.

Factors associated with a significant reduction in hospital-wide infection rates

OBJECTIVE

The purpose of this study was to identify factors associated with a significant reduction in hospital-wide nosocomial infection rates.

METHODS

Methods included a 3-year retrospective and a 10-month prospective follow-up study in a 500-bed hospital with total surveillance, with data collected by two ICPs using Centers for Disease Control and Prevention (CDC) definitions.

RESULTS

Infection rates averaged 3.9% over a decade and dropped in 1993 to 2.6% (p < 0.001). This change was unexplained by changes in surveillance methods. Slightly shorter lengths of stay and fewer inpatient surgeries may have had some impact. Additionally, two factors were temporally and statistically associated with the reduction: hospital-wide introduction of the Occupational Health and Safety Administration (OSHA) Blood-borne Pathogen Exposure Control Plan and Body Substance Isolation, and a barrier hand foam.

CONCLUSIONS

Introduction of the OSHA Control Plan, with concomitant increase in glove use and widespread use of a barrier hand foam were associated with a significant reduction in nosocomial infection rates. Other demographic variables (shorter hospital stays and less inpatient surgery) probably also played a role. Risk-adjusted rates are necessary to make within-hospital comparisons over time.

Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections

BACKGROUND

Because of high proportions of central line-related bloodstream infections (BSIs), an intravascular surveillance and education program (IVSP) was instituted in the study institution in 1987.

METHODS

A 6 1/2-year historical prospective study was conducted to evaluate the effects of the IVSP on incidence of nosocomial BSIs. With use of Centers for Disease Control and Prevention criteria, concurrent data on nosocomial BSIs were collected by two infection control professionals before, during, and for 3 years after the IVSP.

RESULTS

Hospital-wide BSIs during the 3-year IVSP and for 3 years after were 0.9% and 0.9% (p = 0.58) or 1.4 and 1.2/1000 patient-days (p = 0.24). Central line-related BSIs represented 29%, 24%, and 29% of the total BSIs 6 months before, 3 years during, and 6 months after the intervention, respectively (p = 0.62).

CONCLUSIONS

The IVSP resulted neither in a reduction in the total intravascular catheter-related BSIs nor in a change in the proportion of potentially preventable central line-related BSIs. To be successful, an intervention must include the authority to mandate practice changes; education and feedback without such authority were inadequate.

The impact of unlicensed assistive personnel on nursing care delivery

Besieged with fiscal and political constraints in acute care, the addition or substitution of less expensive nursing personnel is quickly gaining popularity. The evolution of nursing care delivery systems in the acute care setting, the factors associated with the increased use of unlicensed assistive personnel, examination and evaluation of the current literature surrounding unlicensed assistive personnel, and recommendations for a future strategy are described.

Geographically overlapping Alzheimer's disease registries: comparisons and implications

In the medical and epidemiologic literature, a registry denotes a data base in which registrants share some common characteristic such as disease category. One criticism of registries is that they frequently collect subjects in a haphazard fashion and, hence, are "nonrepresentative of the population purportedly being represented." In this report, we compare two registries: an incident-based Alzheimer's Disease Patient Registry (ADPR) recruiting subjects for epidemiologic studies from a large health maintenance organization; and an Alzheimer's Disease Research Center (ADRC) registry recruiting subjects for phenomenologic, biologic, and pharmacologic studies. While these registries share personnel, overlap geographically, and use similar diagnostic procedures, they differ substantially in their missions and resulting recruitment strategies. We compared these registries with respect to demographic characteristics and cognitive features at subject entry. Subjects enrolled in the incident-based registry are older and report shorter time between symptom onset and recruitment. They are less demented and mirror the general population demographically more closely than do subjects in the other registry. The ADRC registry contains a much greater proportion of subjects with higher educational attainment.

Intravenous site care practices in critical care: a national survey

OBJECTIVE

To collect and compare written procedures for central line intravenous site care.

DESIGN

Descriptive, stratified, random sample survey.

SETTING

Adult medical-surgical critical care units among hospitals throughout the United States.

SAMPLE

One hundred fifty-two returned surveys.

RESULTS

A 24.6% response rate with underrepresentation from smaller institutions and hospitals in the Mid-Atlantic and West South Central regions of the country. There were wide variations in procedures for intravenous site care related to type of dressing used and frequency of dressing changes.

CONCLUSIONS

Standardization of catheter care is needed to ensure consistent quality of intravenous site care. Lack of standardization may be due to lack of a research data base linking various components of care to outcomes such as infection, patient comfort, or catheter retention.

Compliance with handwashing and barrier precautions

Compliance with handwashing and barrier precautions remains suboptimal in all health care settings and among all types of staff. Interventions to increase compliance include educational and motivational programmes, providing individual and group feedback on performance, modifying and improving equipment available, changing administrative policy and sanctions, and increasing staff commitment with role modelling. Single, isolated interventions are unlikely to meet with sustained success. A theory-based, multifaceted approach is indicated.

Conflict of interest in academia

Conflict of interest in academia has been increasingly recognized over the past decade. Yet, comparatively little is written in respect to this problem. The authors provide an overview of conflict of interest as it applies to nursing research and addresses how it can also affect practice and education. Resources for the development of guidelines to prevent conflicts of interest are presented.

The occupation of play: parent-child interaction in the service of social competence

The occupation of play, as mutually engaged in by parents and young children, is theorized to be central to the development of social competence. Two conceptual heuristics, Vygotsky's zone of proximal development, and Gibson's affordances, frame this examination of play's role in the child's ability to generate adaptive responses and capitalize on environmental opportunities fostering social competence. Research describing mother-child interaction during play is used to illustrate the mother's orchestration and grading of social interactions to stretch the child's emerging abilities and optimize the child's performance. Finally, the practical application of these concepts and specific strategies which occupational therapists can use to "tune" their assistance to the needs of young children and to foster their development are described.

Opinions, knowledge, and self-reported practices related to infection control among nursing personnel in long-term care settings

BACKGROUND

Because educational needs of staff in long-term care facilities regarding infection control have, not been well studied, we conducted this study to measure long-term care staff members' knowledge, self-reported practices, and opinions about infection control and handwashing.

METHODS

A pilot study was conducted with 24 staff members of one long-term care facility to examine psychometric properties of study instruments. All nursing staff members (n = 105) from two additional long-term care facilities then completed a 14-item knowledge questionnaire, 22-item opinion survey, and 26-item survey of self-reported handwashing practices.

RESULTS

Respondents were predominantly female with mean age of 46 years; most had completed high school. Mean length of employment in the study facility was 12.4 years. Registered nurses and licensed practical nurses scored significantly higher on knowledge (p = 0.0002) but significantly lower on self-reported practices (p = 0.01) than did trained nursing assistants. There was no significant correlation between self-reported practices and opinions regarding handwashing (p = 0.55). Neither level of knowledge nor positive opinion about the value of handwashing was associated with self-reported increases in handwashing practices.

CONCLUSION

We conclude that education alone is not likely to be associated with changes in handwashing behavior. Instruments developed and tested in this study can be used in further research to correlate self-reported with observed behavior and to evaluate the effects of interventions on knowledge, opinions, and self-reported handwashing behavior.

HIV infection, exercise, and immune function

Decreased physical endurance is viewed by both HIV-infected people and their primary nurses as a major healthcare problem. There is a widespread belief among HIV-infected people that the way to improve their endurance is through exercise. Yet healthcare providers are divided about the role of exercise. This paper presents an overview of decreased endurance as a major problem in this population, with a review of the literature on exercise in healthy and chronically-ill populations, including those with HIV infection, and its effect on immune function.

A national survey of infection prevention practices on bone marrow transplant units

PURPOSE/OBJECTIVES

To identify and describe bone marrow transplant (BMT)-specific infection prevention measures in the United States.

DESIGN

Survey design using a mailed questionnaire.

SETTING

BMT programs across the United States.

SAMPLE

91 BMT programs (80.5% response rate).

METHODS

A questionnaire containing both closed- and open-ended items was mailed to identified nurse contacts following introductory phone calls. Descriptive statistics were computed on responses to closed-ended questions; content analysis was performed on responses to open-ended questions.

FINDINGS

Although all programs used some type of protected environment, practices varied considerably. Wide variation existed in cover-garment and hand-washing practices, regardless of the type of protected environment in use. Other protective measures included skin decontamination (69%), gut decontamination with oral nonabsorbable antibiotics (30%), antifungal therapy (73%), acyclovir therapy (82%), immunotherapy (73%), granulocyte-macrophage colony stimulating factor therapy (58%), and modified microbial diets (66%). Numerous mouth care regimens, visitor and patient precautions, and environmental maintenance routines were described.

CONCLUSION

Little standardization of infection-prevention practices exists nationwide.

IMPLICATIONS FOR NURSING PRACTICE

Efforts should be made to test the cost effectiveness and benefits of the various measures in use prior to the development of national standards.

Physician assistant training for Native Alaskan community health aides: the MEDEX Northwest experience

BACKGROUND-From 1980 through 1990, 16 Native Alaskan Community Health Aides and 21 non-Native Alaskans began physician assistant training at MEDEX Northwest at the University of Washington. This study was done to assess the outcome of training Native Alaskan health workers as physician assistants, specifically whether Native Alaskan graduates are working in settings that serve Alaska Natives. METHODS-The backgrounds, educational experiences and deployment locations of Native and non-Native Alaskans accepted for training were compared using MEDEX Northwest student records. The 1991 graduate survey was used to compare differences in practice setting, specialty and salary between Native and non-Native graduates working in Alaska in 1991. RESULTS-All of the non-Natives and 81% of the Natives completed the program. Of those completing the program, 100% of the Natives returned to Alaska where 91% found work as primary care physician assistants in clinics serving predominantly Native communities. By comparison 78% of the non-Native graduates returned to Alaska to work as physician assistants, 60% of them in primary care and 15% of them in predominantly Native communities. There were no significant differences in salary or benefits between Native and non-Native graduates. CONCLUSIONS-Physician assistant training for entry level health workers is a viable strategy for increasing the number of under-represented minorities in the health professions. The Native graduates of MEDEX Northwest are returning to communities where they serve Native people both as health care providers and as professional role models.

Exclusion of certain groups from clinical research

Recent evidence indicates that certain groups such as women, ethnic minorities, the elderly, and the poor may be underrepresented in clinical research. A review was conducted of 754 approved research protocols from one tertiary care center over a 2-year period (1989, 1990) to examine demographic characteristics of subjects. Most protocols (81.4%) included both men and women; 56.6% included people over age 65. About three-fourths described exclusionary criteria. Exclusions for which a justification was least frequently explicated were for age (44.9%), socioeconomic status (42.9%), and race (38.1%). In nursing protocols, only 26.6% included a justification for age. In this study, the elderly, poor and ethnic minorities were found to be excluded without identifiable justification from research protocols. While such disparities must be corrected, there are certain research design considerations that should be taken into account to assure that research questions are answered in the most efficient manner for the most representative group.

Use of image analysis to measure handwashing effectiveness

BACKGROUND

This study tested a unique quantification technology (image analysis of fluorescent particles) for the measurement of handwashing effectiveness, comparing an automated system with traditional manual handwashing. In this instance, handwashing "effectiveness" was defined as ability of the technique to remove surface soil, as opposed to removal of microorganisms.

METHODS

Sixty-five subjects washed their hands by manual handwashing (day 1) and automated handwashing (day 2). Hands were coated with an oil-based fluorescent suspension, photographed under controlled conditions, washed for 10 seconds, and rephotographed. Photographs from before and after handwashing were subjected to image analysis.

RESULTS

Manual handwashing removed 73.1% of the particles; the automated method removed 23.2%. Parameters for use of image analysis as a technique to examine removal of gross contamination from the hands are given in the text.

CONCLUSIONS

Although this method will not replace traditional culture methods for examining microbial removal, it is useful for measuring removal of particles (gross contamination) from skin or other surfaces. Under the conditions tested, manual handwashing was found to be decidedly superior to use of an automated system for removal of oil-based soil on the hands.

Selective amylin antagonist suppresses rise in plasma lactate after intravenous glucose in the rat. Evidence for a metabolic role of endogenous amylin

Data presented here provide the first demonstration that circulating amylin regulates metabolism in vivo, and support an endocrine hormonal role that is distinct from its autocrine action at pancreatic islets. When rats were pre-treated with the potent amylin antagonist AC187 (n = 18), and then administered a 2 mmol glucose load, the rise in plasma lactate was less than in rats administered glucose only (n = 27; P < 0.02). When rats were treated so that plasma glucose and insulin profiles were similar (n = 8), the increase in plasma lactate in the presence of AC187 was only 50.3% as high as the increase when AC187 was absent (P < 0.001). These experimental results fit with the view that some of the lactate appearing in plasma after a glucose load comes from insulin-sensitive tissues. The experiments also support the view that an important fraction of the increase in lactate depends on processes inhibited by a selective amylin antagonist, most likely amylin action in muscle.

Assessment of infection control programs in Maryland skilled-nursing long-term care facilities

BACKGROUND

Nosocomial infections cause substantial morbidity and mortality among residents in long-term care facilities (LTCFs). Although infection control programs now exist in many LTCFs in the United States, little has been published regarding the effectiveness of these programs. The 1976 Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control (SENIC) established the effectiveness of infection control programs in acute care facilities. However, a limitation of that study was the exclusion of LTCFs.

METHODS

The purpose of this pilot study was to assess infection control programs in LTCFs through the use of an Infection Surveillance and Control Questionnaire adapted from SENIC. The sample consisted of 123 skilled-nursing LTCFs in the State of Maryland. The questionnaire was completed by the person responsible for infection control activities in each LTCF.

RESULTS

Results of the study show the following: (1) an upward trend in infection control activity in Maryland LTCFs, with the majority having medium activity, and (2) an estimated overall prevalence rate of infection of 4% on the basis of total resident census.

CONCLUSION

The findings indicated that the Infection Surveillance and Control Questionnaire is a reliable instrument to assess infection control programs in LTCFs. A nationwide study is planned to examine the relationship between infection control activity and the risk of nosocomial infection among skilled-nursing LTCFs throughout the United States.

Barrier protection with examination gloves: double versus single

In a series of experiments, the barrier integrity of single and double vinyl and latex examination gloves were tested for dye and water leaks after being placed under stress. A total of 886 examination gloves (385 vinyl: single, 199; double, 186; and 501 latex: single, 290; double, 211) were tested with a standardized clinical protocol designed to mimic patient care activities. Leakage rates for single or double gloving were significantly higher for vinyl than for latex gloves. Single vinyl gloves were significantly more likely to leak than were double vinyl gloves (51.3% and 19.7%, p < 0.0001). However, there were essentially no differences in leakage rates for single or double latex gloves (4.1% and 3.8%, p = 1). Significantly higher rates of leakage were identified with the water leak test than with the dye test for vinyl (p < 0.001) but not for latex (p = 0.22) gloves. For vinyl but not latex gloves, there were significant differences in leakage rates by brand. We conclude that double gloving offers little advantage during routine procedures associated with minimal stress to the gloves or when latex gloves are worn.

Intraorganizational influence in the health care setting: a study of strategies preferred by head nurses and infection control practitioners

BACKGROUND

The purpose of this study was to examine influencing strategy preferences among head nurses (HNs) in the operating room, HNs in critical care and ICPs.

METHODS

A 21-item questionnaire on influencing strategy was used to identify 8 dimensions of influence: assertiveness, sanctions, ingratiation, rationality, bargaining, upward appeal, manipulation, and coalitions. The questionnaires were randomly distributed by regional coordinators in nine geographic regions throughout the United States to an operating room HN, a critical care HN, and an ICP at each of 12 hospitals (six with < 250 beds, six with > 250 beds). Two hundred ninety-seven respondents (92%) participated in the study.

RESULTS

Although both HNs and ICPs rated rationality (logic, information, and appeal to intelligence) highest as the preferred approach to influence behavior, ICPs rated this dimension significantly higher than both operating room HNs and critical care HNs (p < 0.001). The least preferred strategy among all three groups was sanction (threatening job security). Critical care HNs rated manipulation (threatening to stop working with the other person) significantly higher than did both operating room HNs (p = 0.04) and ICPs (p = 0.01). Age was found to be a factor in the preference for sanctions as an influencing strategy, regardless of specialty: respondents younger than 40 years preferred sanctions less as a means to change behavior than did those older than 40 years (p < 0.01).

CONCLUSION

These findings have implications for effective intraorganizational influence in health care settings.