How safe is your dialysis unit?

The author suggests that the physical plan of the dialysis unit be evaluated, along with the training and skill level of the staff, in handling disruptive patients and de-escalating violence. The unit should be safe and secure for those who work in it and all who receive care there.

Clinical predictors of tuberculosis as a guide for a respiratory isolation policy

An expanded respiratory isolation policy was implemented in a public hospital that cares for about 200 patients with active tuberculous each year. This led to proper isolation of > or = 95% of patients with tuberculosis on admission but involved an 8-fold overuse of isolation rooms. We developed a model policy to decrease overisolation of nontuberculous patients. Clinical findings in 295 patients admitted to respiratory isolation during a 3-mo period were evaluated for their usefulness in determining which patients had tuberculosis. Multivariate analysis identified five predictive variables: chest radiograph with upper lobe infiltrate (odds ratio, 5.00; CI, 2.38 to 10.51; p = 0.001) or cavity (odds ratio, 3.93; CI, 1.06 to 14.62; p = 0.041), history of having known someone with tuberculosis (odds ratio, 2.42; CI, 1.10 to 5.32, p = 0.027), self-reported positive tuberculin skin test (odds ratio, 5.67; CI, 1.57 to 22.01; p = 0.009), self-reported isoniazid preventive therapy (odds ratio, 0.18; CI, 0.04 to 0.82; p = 0.027). Using these variables to determine which patients required isolation would have decreased the number of isolated nontuberculous patients from 253 to 95, but it would have missed eight of 42 patients with tuberculosis. Further work is needed to identify clinical predictors that would decrease overuse of isolation beds while maintaining satisfactory sensitivity for patients with tuberculosis.

Prevention and control of varicella-zoster infections in healthcare facilities

Varicella-zoster virus (VZV) is the causative agent of two diseases: varicella (chickenpox) and zoster (shingles). Although varicella generally is a mild disease in children, serious morbidity and mortality are common if infection occurs in neonates, pregnant women, adults, or immunocompromised patients. For this reason, the Centers for Disease Control and Prevention recommends that all the hospitals institute control measures. Healthcare workers should be screened for VZV immunity and, if susceptible, should receive the recently licensed Oka/Merck vaccine (unless contraindicated). This article reviews nosocomial outbreaks associated with VZV and provides detailed algorithms for preexposure immunization and postexposure management of healthcare workers exposed to VZV.

Impact of dialysis room and reuse strategies on the incidence of hepatitis C virus infection in haemodialysis units

BACKGROUND

Despite the advent of screening of blood products for anti-hepatitis C virus (HCV), the incidence of HCV infection among haemodialysis (HD) patients is alarmingly high and suggest transmission within the HD unit. To analyse trends in the prevalence and incidence of HCV infection, and evaluate the impact of dialysis room and reuse policies on the incidence of HCV infection, a hospital survey instrument was sent out to medical directors of all 71 HD units in Portugal in August 1994. Information for the years 1991, 1992 and 1993 was requested with respect to HCV infection, defined as positive anti-HCV test. Sixty-two of 71 units (87%) treating 4232 patients in 1993 responded. Overall, data from 5774 patient-years were available for analyses. Observations over multiple intervals were pooled into a single sample, and pooled logistic regression was used to evaluate the relationship between risk factors/strategies and incidence of HCV infection. By 1993, regular anti-HCV testing of patients and staff was practised by 98% and 82% of units, respectively. There was a significant decline in the incidence of HCV infection from 9.9% in 1991 to 5.7% in 1992 and 5.1% in 1993. The incidence was directly related to the prevalence in the dialysis unit. Units with a prevalence of less than 19% had an annual incidence of 2.5% compared to a 35.3% incidence in units with a prevalence greater than 60%. There was wide variation in the incidence of HCV infection in HD units across the country, with geographical location, unit ownership and socioeconomic factors playing a significant role. The incidence was lowest among units that: (i) were located in the northern regions of the country; (ii) were private hospital-based units; and (iii) used dedicated machines or separate rooms for anti-HCV-positive patients. The incidence among units that reprocessed dialysers (6.1%) was not significantly different from that among units that did not reprocess dialysers (7.4%). However, among units that did reprocess dialysers, the incidence of HCV infection was lowest in: (i) units that used separate rooms for reprocessing dialysers from anti-HCV-positive patients or did not reprocess these dialysers; and (ii) units that used Renalin as the sterilant. These results suggest the transmission of HCV infection in HD units and that use of dedicated machines and isolation of anti-HCV-positive patients and their dialysers may reduce the incidence of HCV infection.

Prevention of nosocomial influenza

OBJECTIVE

To study compliance with preventive strategies at a university hospital during an outbreak of nosocomial influenza A during the winter of 1988, and the rates of vaccination of healthcare workers and of nosocomial influenza following changes in vaccine practices after the outbreak.

DESIGN

Retrospective review of employee health, hospital epidemiology, hospital computing; and clinical microbiology records.

SETTING

A university hospital.

INTERVENTIONS

Unvaccinated personnel with exposure within the previous 72 hours to an unisolated case of influenza were offered influenza vaccine and 14 days of amantadine hydrochloride prophylaxis. Personnel with exposure more than 72 hours before evaluation were offered vaccine. A mobile cart was introduced for vaccinating personnel after the 1988 outbreak.

RESULTS

An outbreak of influenza with 10 nosocomial cases occurred in 1988. Only 4% of exposed employees had been vaccinated previously and 23% of exposed, unvaccinated employees agreed to take vaccine, amantadine, or both. A mobile-cart vaccination program was instituted, and annual vaccination rates steadily increased from 26.3% in 1989 to 1990 to 38% in 1993 to 1994 (P < .0001). The relative frequency of documented cases of influenza in employees with symptoms of influenza decreased significantly during this period (P = .025), but nosocomial influenza rates among patients did not change significantly.

CONCLUSION

A mobile-cart influenza vaccination program was associated with a significant increase in compliance among healthcare workers, but a majority still remained unvaccinated. The rate of nosocomial influenza among patients was not reduced by the modest increase in the vaccination rate, but influenza rates remained acceptably low, perhaps due to respiratory isolation of patients and furlough of employees with influenza.

Rapid identification of respiratory viruses: impact on isolation practices and transmission among immunocompromised pediatric patients

OBJECTIVE

To determine whether empiric isolation of patients with acute respiratory virus infection symptoms could be discontinued when preliminary shell vial cultures were negative, and the impact of this approach on hospital resources.

DESIGN

In 1993, we retrospectively reviewed respiratory virus test results from 1992 to 1993 and extended data collection prospectively through the 1993 to 1994 season. The rapid test and 48-hour shell vial results were compared to a standard of rapid test plus 5-day shell vial culture results to determine the sensitivity and specificity of these "preliminary" results.

SETTING

A 400-bed tertiary referral research hospital.

PATIENTS

Patients from any inpatient unit or clinic with acute respiratory virus infection symptoms who had a specimen submitted for respiratory virus culture. Patients were placed on empiric respiratory isolation pending culture results.

RESULTS

The overall sensitivity of the combined rapid and 48-hour culture results in adults and children was 97%. All 15 pediatric patients with respiratory syncytial virus infection who had specimens submitted on first suspicion of respiratory virus infection were positive by rapid test. Culture results were positive within 48 hours for 100% of patients with influenza A (15 patients), influenza B (6), and parainfluenza (18) viruses. Of 59 pediatric inpatients who were isolated empirically awaiting 5-day culture results, 31 (52%) ultimately were determined to be culture negative.

CONCLUSIONS

Empiric isolation of symptomatic children can be discontinued at 48 hours when both the rapid test and the early culture results are negative. Our institution would have saved 93 days of unnecessary isolation over 2 years had such a policy been in place.

Implementation and evaluation of an algorithm for isolation of patients with suspected pulmonary tuberculosis

OBJECTIVE

To implement and evaluate an algorithm designed to assist in the consistent placement of patients with suspected pulmonary tuberculosis into negative-pressure isolation rooms (NPIRs).

DESIGN

A standard algorithm was designed for the appropriate room placement of patients with suspected pulmonary tuberculosis using clinical, radiographic, and laboratory criteria and reported risk factors. A case-patient was defined as an inpatient who had at least one Mycobacterium tuberculosis culture-positive respiratory specimen from January 1, 1993, through December 31, 1994. Demographic, clinical, laboratory, case contact, and isolation and room placement data were collected prospectively on all case patients.

SETTING

A 900-bed university teaching and referral center.

RESULTS

During 1993 and 1994, 69 patients were evaluated for possible pulmonary tuberculosis, and 31 case-patients were identified. Of the 31 case-patients, 26 (84%) were placed on respiratory isolation in NPIRs, including 19 (61%) who were isolated within 24 hours of admission (1993, 14 of 20 [70%]; 1994, 5 of 11 [45%]). Seven case-patients (23%) were isolated in NPIRs following delays that ranged from 2 to 31 days (median, 9 days), and five case-patients (16%) never were isolated during admissions of from 3 to 28 days (median, 4 days). These 12 case-patients contributed a total of 136 patient-exposure days during their hospitalizations. Misclassification of patient risk status by user error delayed isolation of five (42%) of the 12 improperly isolated case-patients.

CONCLUSIONS

The use of an algorithm incorporating radiographic, laboratory, and clinical criteria and reported risk factors may assist in the rapid isolation of patients with suspected pulmonary tuberculosis.

[Experiences of women in cesium brachytherapy]

The objective of the present study was to determine the main difficulties and problems experienced by patients submitted to sealed internal radiotherapy as well as to provide guidance for nurses to better perceive the difficulties experienced by the patients and act as an element of support while giving care. The problems and difficulties observed and reported by the patients were mainly related to the impositions of treatment, such as isolation, prohibition of visits, hospitalization, bed confinement, restriction of movements, use of the intracavity system, measures of radiological protection, use of a delay bladder tube, and limited personal hygiene. Fear related to treatment and anesthesia, partial or absent orientation and skin lesions were the complaints voiced by most of the patients in the present study. The role of the nurse is important in planning nursing care in sealed internal radiotherapy, especially when nurses understand the problems and difficulties experienced by women submitted to this treatment.

On fighting versus accepting stressful circumstances: primary and secondary control among HIV-positive men in prison

The primacy of primary control over secondary control and ethnic differences in control processes were tested in HIV-positive male state prison inmates. They rated their perceptions of control and psychological distress at an initial interview (N = 95) and 3 months later (N = 78). Regression analyses revealed that primary control had primacy as it had greater adaptive value. However, secondary control did not function as a backup to primary control, and temporal differences in control were not found. No mean differences due to ethnicity (African American vs. White) were found, but there was a strong ethnic difference in the effects of primary control. White participants showed the expected negative relationship between distress and primary control, but African American participants did not. The idea that the benefits of primary control would be the same across various subcultures was not supported.