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Trivedi KK, Schaffzin JK, Deloney VM, Aureden K, Carrico R, Garcia-Houchins S, Garrett JH, Glowicz J, Lee GM, Maragakis LL, Moody J, Pettis AM, Saint S, Schweizer ML, Yokoe DS, Berenholtz S. Implementing strategies to prevent infections in acute-care settings. Infect Control Hosp Epidemiol 2023; 44:1232-1246. [PMID: 37431239 PMCID: PMC10527889 DOI: 10.1017/ice.2023.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.
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Affiliation(s)
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Valerie M. Deloney
- Society for Healthcare Epidemiology of America (SHEA), Arlington, Virginia
| | | | - Ruth Carrico
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | | | - J. Hudson Garrett
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | - Janet Glowicz
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Grace M. Lee
- Stanford Children’s Health, Stanford, California
| | | | - Julia Moody
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | | | - Sanjay Saint
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
| | | | - Deborah S. Yokoe
- University of California San Francisco School of Medicine, UCSF Medical Center, San Francisco, California
| | - Sean Berenholtz
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Pace A, Zobel A, Gearman L, Seitzer D, Larson-Nath C, Somani A. Improving the rate of anthropometric measurements in the pediatric intensive care unit. Nutr Clin Pract 2021; 36:1276-1283. [PMID: 33930222 DOI: 10.1002/ncp.10659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malnutrition occurs in approximately 25% of pediatric intensive care patients and correlates with increased length of stay, prolonged ventilation, and mortality. Anthropometric measurements should be obtained at admission and throughout hospitalization to evaluate nutrition status. We aimed to increase documentation, reporting, and discussion of anthropometric measurements, including height/length, weight, and occipital frontal circumference (OFC) within 24 hours of admission and weekly. METHODS A multifaceted process improvement model was implemented over 1 month. Interventions included education, recruiting nurse champions, process mapping, new equipment, and formal discussion of nutrition status during rounds. A proportions hypothesis test compared frequency of anthropometric measures obtained during each study phase: preintervention, postintervention, and sustainment. RESULTS In terms of admission metrics over respective study phases, the PICU had fluctuation in weights (91%, 98%, and 97%) and height (49%, 73%, and 71%) and increased rates in OFC (36%, 61%, and 65%). The cardiovascular intensive care unit (CVICU) had stable weights (100%, 100%, and 100%) and increased rates in height (87%, 94%, and 95%) and OFC (28%, 64%, and 86%), respectively. In terms of weekly metrics over study phases, the PICU had fluctuation in weights (91%, 89%, and 93%) and increased rates in heights (38%, 69%, and 76%) and OFC (45%, 76%, and 100%). The CVICU had increased rates in weights (98%, 100%, and 100%) and fluctuations in heights (50%, 83%, and 75%), and OFC (48%, 84%, and 75%). CONCLUSIONS Interventions increased rates of measurements. During the sustainment phase, there was regression in rates, although these remained above baseline. Additional interventions may increase compliance and foster change in unit culture.
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Affiliation(s)
- Autumn Pace
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
| | - Amanda Zobel
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Laura Gearman
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Dale Seitzer
- Fairview Health Services, Minneapolis, Minnesota, USA
| | | | - Arif Somani
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
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Abstract
Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
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Vaillant L, Birgand G, Esposito-Farese M, Astagneau P, Pulcini C, Robert J, Zahar JR, Sales-Wuillemin E, Tubach F, Lucet JC. Awareness among French healthcare workers of the transmission of multidrug resistant organisms: a large cross-sectional survey. Antimicrob Resist Infect Control 2019; 8:173. [PMID: 31749961 PMCID: PMC6852912 DOI: 10.1186/s13756-019-0625-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/15/2019] [Indexed: 11/10/2022] Open
Abstract
Background Much effort has been made over the last two decades to educate and train healthcare professionals working on antimicrobial resistance in French hospitals. However, little has been done in France to assess perceptions, attitudes and knowledge regarding multidrug resistant organisms (MDROs) and, more globally, these have never been evaluated in a large-scale population of medical and non-medical healthcare workers (HCWs). Our aim was to explore awareness among HCWs by evaluating their knowledge of MDROs and the associated control measures, by comparing perceptions between professional categories and by studying the impact of training and health beliefs. Methods A multicentre cross-sectional study was conducted in 58 randomly selected French healthcare facilities with questionnaires including professional and demographic characteristics, and knowledge and perception of MDRO transmission and control. A knowledge score was calculated and used in a logistic regression analysis to identify factors associated with higher knowledge of MDROs, and the association between knowledge and perception. Results Between June 2014 and March 2016, 8716/11,753 (participation rate, 74%) questionnaires were completed. The mean knowledge score was 4.7/8 (SD: 1.3) and 3.6/8 (SD: 1.4) in medical and non-medical HCWs, respectively. Five variables were positively associated with higher knowledge: working in a university hospital (adjusted odds ratio, 1.41, 95% CI 1.16–1.70); age classes 26–35 years (1.43, 1.23–1.6) and 36–45 years (1.19, 1.01–1.40); medical professional status (3.7, 3.09–4.44), working in an intensive care unit (1.28, 1.06–1.55), and having been trained on control of antimicrobial resistance (1.31, 1.16–1.48). After adjustment for these variables, greater knowledge was significantly associated with four cognitive factors: perceived susceptibility, attitude toward hand hygiene, self-efficacy, and motivation. Conclusions We found a low level of MDRO awareness and knowledge of associated control measures among French HCWs. Training on hand hygiene and measures to control MDRO spread may be helpful in shaping beliefs and perceptions on MDRO control among other possible associated factors. Messages should be tailored to professional status and their perception. Other approaches should be designed, with more effective methods of training and cognitive interventions. Trial registration Clinical Trials.gov NCT02265471. Registered 16 October 2014 - Retrospectively registered.
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Affiliation(s)
- L Vaillant
- AP-HP, Bichat-Claude Bernard Hospital, Infection Control Unit, 48 rue Henri Huchard, F-75018 Paris, France
| | - G Birgand
- 2Department of Medicine, NIHR, Imperial College London, Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection Imperial College London, South Kensington Campus, London, SW7 2AZ UK
| | - M Esposito-Farese
- AP-HP, Bichat-Claude Bernard Hospital, Unité de Recherche Clinique Paris Nord Val de Seine and CIC-EC 1425, 48 rue Henri Huchard, F-75018 Paris, France
| | - P Astagneau
- 4Medecine Sorbonne University, AP-HP, Regional centre for Prevention of Healthcare-associated infections, 8 rue Maria Helena Vieira da Silva, 75014 Paris, France
| | - C Pulcini
- 5EA 4360 APEMAC, CHRU de Nancy, University of Lorraine, Infectious and Tropical Diseases Unit, 34 Cours Léopold, 54000 Nancy, France
| | - J Robert
- Sorbonne University, U1135, Team E13, CR7 INSERM, AP-HP, Pitié-Salpêtrière Hospital, Bactériologie-Hygiène, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - J R Zahar
- 7AP-HP, Avicenne Hospital, Infection Control Unit, 125 Rue de Stalingrad, 93000 Bobigny, France.,8University of Paris, INSERM, IAME, UMR 1137, Paris, France
| | | | - F Tubach
- INSERM, UMR 1123, AP-HP, Pitié-Salpêtrière Hospital, Centre de Pharmacoépidémiologie (Cephepi), 75013 Paris, France
| | - J C Lucet
- AP-HP, Bichat-Claude Bernard Hospital, Infection Control Unit, 48 rue Henri Huchard, F-75018 Paris, France.,8University of Paris, INSERM, IAME, UMR 1137, Paris, France
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Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients. Anesthesiology 2019; 129:1140-1148. [PMID: 30247201 DOI: 10.1097/aln.0000000000002451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care. METHODS This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration. RESULTS Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 10 to 10 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·10 CFU/ml), and remained between 8·10 (lowest) and 3·10 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash. CONCLUSIONS Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.
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Zahar JR, Blot S. Dilemmas in infection control in the intensive care unit. Intensive Crit Care Nurs 2018; 46:1-3. [PMID: 29395569 DOI: 10.1016/j.iccn.2018.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité; Département de Microbiologie Clinique, Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 rue de Stalingrad, 9300 Bobigny, France
| | - Stijn Blot
- Department of Internal Medicine, Ghent University, Flanders, Belgium; Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
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Abstract
Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7-8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.
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Affiliation(s)
- Jean-Francois Timsit
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Wafa Esaied
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France
| | - Mathilde Neuville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Lila Bouadma
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Bruno Mourvllier
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
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De Wandel D. Key factors for hand hygiene promotion in intensive care units. Intensive Crit Care Nurs 2017; 42:3-4. [PMID: 28760585 DOI: 10.1016/j.iccn.2017.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 11/24/2022]
Affiliation(s)
- David De Wandel
- Faculty of Education, Health and Social Work, University College Ghent, Keramiekstraat 80, B9000 Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, B900 Ghent, Belgium.
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Differential Perceptions of Noninvasive Ventilation in Intensive Care among Medical Caregivers, Patients, and Their Relatives: A Multicenter Prospective Study-The PARVENIR Study. Anesthesiology 2017; 124:1347-59. [PMID: 27035854 DOI: 10.1097/aln.0000000000001124] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Noninvasive ventilation (NIV) requires a close "partnership" between a conscious patient and the patient's caregivers. Specific perceptions of NIV stakeholders and their impact have been poorly described to date. The objectives of this study were to compare the perceptions of NIV by intensive care unit (ICU) physicians, nurses, patients, and their relatives and to explore factors associated with caregivers' willingness to administer NIV and patients' and relatives' anxiety in relation to NIV. METHODS This is a prospective, multicenter questionnaire-based study. RESULTS Three hundred and eleven ICU physicians, 752 nurses, 396 patients, and 145 relatives from 32 ICUs answered the questionnaire. Nurses generally reported more negative feelings and more frequent regrets about providing NIV (median score, 3; interquartile range, [1 to 5] vs. 1 [1 to 5]; P < 0.0001) compared to ICU physicians. Sixty-four percent of ICU physicians and only 32% of nurses reported a high level of willingness to administer NIV, which was independently associated with NIV case-volume and workload. A high NIV session-related level of anxiety was observed in 37% of patients and 45% of relatives. "Dyspnea during NIV," "long NIV session," and "the need to have someone at the bedside" were identified as independent risk factors of high anxiety in patients. CONCLUSIONS Lack of willingness of caregivers to administer NIV and a high level of anxiety of patients and relatives in relation to NIV are frequent in the ICU. Most factors associated with low willingness to administer NIV by nurses or anxiety in patients and relatives may be amenable to change. Interventional studies are now warranted to evaluate how to reduce these risk factors and therefore contribute to better management of a potentially traumatic experience. (Anesthesiology 2016; 124:1347-59).
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Asehnoune K, Mrozek S, Perrigault PF, Seguin P, Dahyot-Fizelier C, Lasocki S, Pujol A, Martin M, Chabanne R, Muller L, Hanouz JL, Hammad E, Rozec B, Kerforne T, Ichai C, Cinotti R, Geeraerts T, Elaroussi D, Pelosi P, Jaber S, Dalichampt M, Feuillet F, Sebille V, Roquilly A. A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project. Intensive Care Med 2017; 43:957-970. [PMID: 28315940 DOI: 10.1007/s00134-017-4764-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/07/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. METHODS Prospective nationwide before-after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013-31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6-8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. RESULTS A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0-80) vs. 67 (0-80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66-82) and 71 (0-80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41-2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56-3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. CONCLUSIONS Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number: NCT01885507.
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Affiliation(s)
- Karim Asehnoune
- Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France.
- Service d'Anesthésie Réanimation, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 1, France.
| | - Ségolène Mrozek
- Department of Anesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Pierre François Perrigault
- Intensive Care Unit, Anesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France
| | - Philippe Seguin
- Intensive Care Unit, Anesthesia and Critical Care Department, Pontchaillou-University Hospital of Rennes, Rennes, France
| | - Claire Dahyot-Fizelier
- Neuro-Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France
| | - Sigismond Lasocki
- Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Angers, Angers, France
| | - Anne Pujol
- Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Tours, Tours, France
| | - Mathieu Martin
- Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Créteil-CHU Henri Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Russel Chabanne
- Department of Anesthesiology and Intensive Care, University Hospital of Clermont Ferrand, Clermont Ferrand, France
| | - Laurent Muller
- Department of Anesthesiology and Intensive Care, University Hospital of Nimes, Nimes, France
| | - Jean Luc Hanouz
- Department of Anesthesiology and Intensive Care, University Hospital of Caen, Caen, France
| | - Emmanuelle Hammad
- Department of Anesthesiology and Intensive Care, University Hospital of Marseille, Marseille, France
| | - Bertrand Rozec
- Intensive Care Unit, Anesthesia and Critical Care Department, Laennec-University Hospital of Nantes, Nantes, France
| | - Thomas Kerforne
- Surgical Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France
| | - Carole Ichai
- Intensive Care Unit , Pasteur 2-University Hospital of Nice, Nice, France
| | - Raphael Cinotti
- Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Djillali Elaroussi
- Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Tours, Tours, France
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST National Cancer Research Institute, University of Genoa, Genoa, Italy
| | - Samir Jaber
- Intensive Care Unit, Anesthesia and Critical Care Department, Saint Eloi University Hospital of Montpellier, Montpellier, France
| | - Marie Dalichampt
- Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France
| | - Fanny Feuillet
- EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences Pharmaceutiques, Nantes University, Nantes, France
| | - Véronique Sebille
- Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France
- EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences Pharmaceutiques, Nantes University, Nantes, France
| | - Antoine Roquilly
- Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Impact of multifaceted preventive measures on ventilator-associated pneumonia at a single surgical centre. Intensive Care Med 2015; 41:2231-2. [PMID: 26359168 DOI: 10.1007/s00134-015-4047-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Goutier JM, Holzmueller CG, Edwards KC, Klompas M, Speck K, Berenholtz SM. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. Infect Control Hosp Epidemiol 2014; 35:998-1005. [PMID: 25026616 DOI: 10.1086/677152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is among the most lethal of all healthcare-associated infections. Guidelines summarize interventions to prevent VAP, but translating recommendations into practice is an art unto itself. OBJECTIVE Summarize strategies to enhance adoption of VAP prevention interventions. METHODS We conducted a systematic literature review of articles in the MEDLINE database published between 2002 and 2012. We selected articles on the basis of specific inclusion criteria. We used structured forms to abstract implementation strategies and inserted them into the "engage, educate, execute, and evaluate" framework. RESULTS Twenty-seven articles met our inclusion criteria. Engagement strategies included multidisciplinary teamwork, involvement of local champions, and networking among peers. Educational strategies included training sessions and developing succinct summaries of the evidence. Execution strategies included standardization of care processes and building redundancies into routine care. Evaluation strategies included measuring performance and providing feedback to staff. CONCLUSION We summarized and organized practical implementation strategies in a framework to enhance adoption of recommended evidence-based practices. We believe this work fills an important void in most clinical practice guidelines, and broad use of these strategies may expedite VAP reduction efforts.
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Affiliation(s)
- Jente M Goutier
- Johns Hopkins Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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Jansson MM, Ala-Kokko TI, Syrjälä HP, Kyngäs HA. Development and psychometric testing of ventilator bundle questionnaire and observation schedule. Am J Infect Control 2014; 42:381-4. [PMID: 24679564 DOI: 10.1016/j.ajic.2013.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/06/2013] [Accepted: 11/11/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS). METHODS The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland. RESULTS The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0. CONCLUSIONS The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.
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Qu X, Xie H, Zhang Q, Zhou X, Shi Z. A survey on oral care practices for ventilator-assisted patients in intensive care units in 3A hospitals of mainland China. Int J Nurs Pract 2014; 21:699-708. [PMID: 24689526 DOI: 10.1111/ijn.12282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Oral hygiene is a critical element of patient care, particularly among patients who need ventilator-assisted equipment. The objective of this study was to explore the current status of oral care practices, attitudes, education and knowledge among intensive care unit (ICU) nurses caring for ventilator-assisted patients in 3A hospitals in mainland China. To achieve this aim, an 18-item self-assessment questionnaire was mailed to head ICU nurses in 189 Grade 3A hospitals. Additional data were collected through in-person interviews at 38 ICUs throughout Sichuan, Shanxi, Jiangsu provinces, as well as Chongqing and Beijing. We found that most ICUs conducted oral examinations at patient admission, and that this care was largely provided by nurses. The most common oral care methods were foam swabs and mouth rinse containing antibiotics or disinfectants. Although the majority of ICUs provided continuing training for oral care, and most training was conducted by head nurses, the content and scope of training were not consistent among the hospitals in the study. The most popular sources of oral care knowledge were academic journals, Internet and professional books. Overall, it is clear that an evidence-based oral care standard manual is urgently needed for oral practice in ICUs in mainland China.
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Affiliation(s)
- Xing Qu
- Hospital Management Department, School of Business, Sichuan University, Chengdu, Sichuan, China.,West China Hospital of Stomatology, Chengdu, Sichuan, China
| | - Huixu Xie
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xuedong Zhou
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Zongdao Shi
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Ardizzone LL, Smolowitz J, Kline N, Thom B, Larson EL. Patient hand hygiene practices in surgical patients. Am J Infect Control 2013. [PMID: 23200260 DOI: 10.1016/j.ajic.2012.05.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Little is known about the hand hygiene practices of surgical patients. Most of the research has been directed at the health care worker, and this may discount the role that hand hygiene of the surgical patient might play in surgical site infections. METHODS A quasiexperimental, pretest/post-test study was conducted in which patients (n = 72) and nurses (n = 42) were interviewed to examine perceptions and knowledge about patient hand hygiene. Concurrently, observations were conducted to determine whether surgical patients were offered assistance by the nursing staff. Following an initial observation period, nursing staff received an educational session regarding general hand hygiene information and observation results. One month after the education session, patient/nurse dyads were observed for an additional 6 weeks to determine the impact of the educational intervention. RESULTS Eighty observations, 72 patient interviews, and 42 nurse interviews were completed preintervention, and 83 observations were completed postintervention. In response to the survey, more than half of patients (n = 41, 55%) reported that they were not offered the opportunity to clean their hands, but a majority of the nursing staff reported (n = 25, 60%) that they offered patients the opportunity to clean their hands. Prior to the educational intervention, nursing staff assisted patients in 14 of 81 hand hygiene opportunities. Following the intervention, nursing staff assisted patients 37 out of 83 opportunities (17.3% vs 44.6%, respectively, [χ(2)1 = 13.008, P = .0003]). CONCLUSION This study suggests that efforts to increase hand hygiene should be directed toward patients as well as health care workers.
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Impact de la position du patient sur le risque de pneumonie acquise sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0681-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study. Crit Care Med 2013; 41:15-23. [PMID: 23222254 DOI: 10.1097/ccm.0b013e318265e874] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.
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Williams TA, Leslie GD, Leen T, Mills L, Dobb GJ. Reducing interruptions to continuous enteral nutrition in the intensive care unit: a comparative study. J Clin Nurs 2013; 22:2838-48. [DOI: 10.1111/jocn.12068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Teresa A Williams
- Discipline of Emergency Medicine (M516); School of Primary; Aboriginal and Rural Health Care (SPARHC); The University of Western Australia and Research Fellow; ICU Royal Perth Hospital; Perth WA Australia
| | - Gavin D Leslie
- School of Nursing & Midwifery; Curtin Health Innovation Research Institute; Faculty Health Science; Curtin University; Perth WA Australia
| | - Tim Leen
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Lauren Mills
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Geoff J Dobb
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
- School of Medicine and Pharmacology ; The University of Western Australia; Perth WA Australia
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Foucrier A, Mourvilier B, Wolff M, Bouadma L. Bundles et prévention des pneumonies acquises sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0334-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ellingson K, Polgreen PM, Schneider A, Shinkunas L, Kaldjian LC, Wright D, Thomas GW, Segre AM, Herman T, McDonald LC, Sinkowitz-Cochran R. Healthcare personnel perceptions of hand hygiene monitoring technology. Infect Control Hosp Epidemiol 2011; 32:1091-6. [PMID: 22011536 DOI: 10.1086/662179] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess healthcare personnel (HCP) perceptions regarding implementation of sensor-based electronic systems for automated hand hygiene adherence monitoring. DESIGN Using a mixed-methods approach, structured focus groups were designed to elicit quantitative and qualitative responses on familiarity, comfort level, and perceived impact of sensor-based hand hygiene adherence monitoring. SETTING A university hospital, a Veterans Affairs hospital, and a community hospital in the Midwest. PARTICIPANTS Focus groups were homogenous by HCP type, with separate groups held for leadership, midlevel management, and frontline personnel at each hospital. RESULTS Overall, 89 HCP participated in 10 focus groups. Levels of familiarity and comfort with electronic oversight technology varied by HCP type; when compared with frontline HCP, those in leadership positions were significantly more familiar with ([Formula: see text]) and more comfortable with ([Formula: see text]) the technology. The most common concerns cited by participants across groups included lack of accuracy in the data produced, such as the inability of the technology to assess the situational context of hand hygiene opportunities, and the potential punitive use of data produced. Across groups, HCP had decreased tolerance for electronic collection of spatial-temporal data, describing such oversight as Big Brother. CONCLUSIONS While substantial concerns were expressed by all types of HCP, participants' recommendations for effective implementation of electronic oversight technologies for hand hygiene monitoring included addressing accuracy issues before implementation and transparent communication with frontline HCP about the intended use of the data.
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Affiliation(s)
- Katherine Ellingson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Bertolini G, Rossi C, Crespi D, Finazzi S, Morandotti M, Rossi S, Peta M, Langer M, Poole D. Is influenza A(H1N1) pneumonia more severe than other community-acquired pneumonias? Results of the GiViTI survey of 155 Italian ICUs. Intensive Care Med 2011; 37:1746-55. [PMID: 21847646 PMCID: PMC7094960 DOI: 10.1007/s00134-011-2339-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 07/24/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Uncertainty about the severity of the A(H1N1) pandemia persists. Information about disease severity can be obtained by investigating intensive care unit (ICU) admissions, especially when historical comparisons can be made with cases of community-acquired pneumonia (CAP). METHODS This prospective observational study was conducted in 155 ICUs contributing to the GiViTI national database. To assess the impact on ICU workload, the occupancy rate during the epidemic phase was compared with influenza periods in previous years. A logistic regression model was developed to assess the prognostic importance of A(H1N1) influenza. RESULTS The characteristics of the 319 A(H1N1) cases were similar to those reported in other studies, confirming the young age of patients (mean 43 years) and the higher prevalence among pregnant women and obese people. At the epidemic's peak (October-December 2009) the occupancy rate did not significantly differ from the same period of the previous year, and was significantly lower than the 2009 seasonal influenza outbreak (January-March 2009). Compared with CAP of other origin (3,678 patients), A(H1N1) pneumonia was associated with a lower risk of death. However, after adjusting for confounding this was no longer the case (OR 0.88; 95% CI 0.59-1.31; p = 0.52). CONCLUSION This study confirmed the specific features of critically ill A(H1N1) patients (i.e., young age, pregnancy, obesity). The pandemic did not increase ICU workload compared with other periods. A(H1N1) pneumonia did not have a higher risk of death than CAP of different origin among patients admitted to the ICU.
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Affiliation(s)
- Guido Bertolini
- Istituto di Ricerche Farmacologiche Mario Negri, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, 24020, Ranica, Bergamo, Italy.
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Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) remains a frequent and severe complication in endotracheally intubated patients. Strict adherence to preventive measures reduces the risk of VAP. The objective of this paper is to review what has come forward in recent years in the nonpharmacological prevention of VAP. RECENT FINDINGS It seems advantageous to implement care bundles rather than single prevention measures. A solid basis of knowledge seems necessary to facilitate implementation and maintain a high adherence level. Continuous educational efforts have a beneficial effect on attitude toward VAP. Intermittent subglottic secretions drainage, continuous lateral rotation therapy, and polyurethane cuffed endotracheal tubes decrease the risk of pneumonia. In an in-vitro setting, an endotracheal tube with a taper-shaped cuff appears to better prevent fluid leakage compared to cylindrical polyurethane or polyvinylchloride cuffed tubes. Cuff pressure control by means of an automatic device and multimodality chest physiotherapy need further investigation, as do some aspects of oral hygiene. SUMMARY New devices and strategies have been developed to prevent VAP. Some of these are promising but need further study. In addition, more attention is being given to factors that might facilitate the implementation process and the challenge of achieving high adherence rates.
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Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med 2011; 37:196-213. [PMID: 21225240 PMCID: PMC3029678 DOI: 10.1007/s00134-010-2123-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/27/2010] [Indexed: 12/14/2022]
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