The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study

The Effect of Clinical Observations on Nursing Students' Compliance with Standard Precautions: A Cross-sectional Study

BACKGROUND

Healthcare-associated infections pose a significant global challenge, highlighting the need for enhanced knowledge and practices among healthcare professionals. This study investigates the impact of clinical observations on nursing students' compliance with standard precautions.

METHODS

Employing a cross-sectional descriptive design, the study surveyed 405 nursing students using a 'Personal Information Form', the 'Nurses' Observations on Infection Control and Prevention Questionnaire', the 'Standard Precautions Scale', and the 'Factors Affecting Compliance with Standard Precautions Scale'.

RESULTS

The mean scores for the Nurses' Observations on Infection Control and Prevention Questionnaire, the Standard Precautions Scale, and the Factors Affecting Compliance with Standard Precautions Scale were 33.39±12.98, 10.93±4.79, and 53.38±10.35, respectively. A significant negative correlation was found between students' observations on infection control and their compliance with standard precautions (r=-.254, p<0.01), with their observations explaining only 6% of the variance in compliance.

DISCUSSION

The findings suggest that the influence of nursing students' observations during clinical practice on their compliance to standard precautions is minimal.

CONCLUSION

This study highlights the necessity of developing more effective strategies to improve nursing students' compliance to standard precautions, extending beyond observational learning alone.

Vancomycin-Resistant Enterococci: Current Understandings of Resistance in Relation to Transmission and Preventive Strategies

Due to the limited treatment options and increased mortality rates, infection prevention and control strategies have been implemented for many years to mitigate dissemination of vancomycin-resistant enterococci (VRE) within healthcare settings. The overview provides an insight into the most recent research, particularly the pathogen's resilience in the healthcare environment, and the critical need for infection control strategies, which are currently being scrutinized by some researchers. The notable resilience of enterococci to various environmental conditions highlights the necessity for investigations into innovative technologies capable of effectively targeting the biofilm produced by enterococci on hospital surfaces. A critical approach to traditional infection control strategies is becoming more accepted worldwide, taking into account the epidemiological situation in the given healthcare setting as well as specific characteristics of a patient. For certain high-risk patient populations, traditional infection control strategies including CP and screening should not be omitted. Additionally, further investigation into the resistance mechanisms of available antimicrobial agents is essential, as is research into their potential association with specific successful clones through WGS genotyping, to pre-emptively mitigate their spread before it escalates.

Epidemiology and drug resistance analysis of bloodstream infections in an intensive care unit from a children's medical center in Eastern China for six consecutive years

BACKGROUND

Children in the intensive care unit (ICU) who suffer from severe basic diseases and low immunity are usually in critical condition. It is crucial to assist clinicians in selecting the appropriate empirical antibiotic therapies for clinical infection control.

METHODS

We retrospectively analyzed data from 281 children with bloodstream infection (BSI). Comparisons of basic data, pathogenic information, and drug resistance of the main bacteria were conducted.

RESULTS

We detected 328 strains, including Gram-positive bacteria (223, 68%), mainly coagulase-negative Staphylococci (CoNS); Gram-negative bacteria (91, 27.7%); and fungi (14, 4.3%). The results of the binary logistic regression analysis showed that the main basic disease was an independent risk factor for death. Compared with Escherichia coli, Klebsiella pneumoniae exhibited a higher proportion of extended-spectrum β-lactamases (ESBLs), and its resistance to some β-lactamides and quinolones antibiotics were lower. Twenty-seven isolates of multidrug-resistant (MDR) bacteria were detected, of which carbapenem-resistant Acinetobacter baumannii (CRAB) accounted for the highest proportion (13, 48.2%).

CONCLUSIONS

CoNS was the principal pathogen causing BSI in children in the ICU of children, and Escherichia coli was the most common Gram-negative pathogen. The main basic disease was an independent risk factor for death. It is necessary to continuously monitor patients with positive blood cultures, pay special attention to detected MDR bacteria, and strengthen the management of antibiotics and prevention and control of nosocomial infections.

Are Contact Precautions "Essential" for the Prevention of Healthcare-associated Methicillin-Resistant Staphylococcus aureus?

The recently updated Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Association of Professionals in Infection Control practice recommendations for methicillin-resistant Staphylococcus aureus (MRSA) prevention in acute care facilities list contact precautions (CPs) for patients known to be infected or colonized with MRSA as an "essential practice," meaning that it should be adopted in all acute care facilities. We argue that existing evidence on benefits and harms associated with CP do not justify this recommendation. There are no controlled trials that support broad use of CP for MRSA prevention. Data from hospitals that have discontinued CP for MRSA have found no impact on MRSA acquisition or infection. The burden and harms of CP remain concerning, including the environmental impact of increased gown and glove use. We suggest that CP be included among other "additional approaches" to MRSA prevention that can be implemented under specific circumstances (eg outbreaks, evidence of ongoing transmission despite application of essential practices).

Monitoring of antimicrobial resistance in respiratory tract pathogens during the COVID-19 pandemic: A retrospective study

To understand the distribution and antimicrobial resistance (AMR) of pathogens in respiratory samples in Changle District People's Hospital in Fujian Province in recent years, and provide empirical guidance for infection control and clinical treatment in the region. A retrospective analysis was conducted on 5137 isolates of pathogens from respiratory samples collected from 2019 to 2022. The AMR patterns were systematically analyzed. For research purposes, the data was accessed on October 12, 2023. A total of 3517 isolates were included in the study, including 811 (23.06%) gram-positive bacteria and 2706 (76.94%) gram-negative bacteria. The top 3 gram-positive bacteria were Staphylococcus aureus with 455 isolates (12.94%), Streptococcus pneumoniae with 99 isolates (2.81%), and Staphylococcus hemolytic with 99 isolates (2.81%). The top 3 gram-negative bacteria were Klebsiella pneumoniae with 815 isolates (23.17%), Pseudomonas aeruginosa with 589 isolates (16.75%), and Acinetobacter baumannii with 328 isolates (9.33%). The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and K pneumoniae fluctuated between 41.9% and 70.5%, and 18.6% and 20.9%, respectively. The resistance rates of E coli, K pneumoniae, P aeruginosa, and A baumannii to carbapenems were 2.36%, 8.9%, 18.5%, and 19.6%, respectively. The prevalence of methicillin-resistant S aureus (MRSA) was 48.55%, but it decreased to 38.4% by 2022. The resistance rate of Staphylococcus haemolyticus to methicillin was 100%, and 1 case of vancomycin-resistant strain was detected. K pneumoniae, P aeruginosa, A baumannii, and S aureus are the main pathogens in respiratory samples. Although the resistance rates of some multidrug-resistant strains have decreased, ESBL-producing Enterobacteriaceae, carbapenem-resistant bacteria have still increased. Therefore, it is necessary to strengthen the monitoring of pathogen resistance, promote rational use of antibiotics, and promptly report findings.

Enhancing Candida auris Surveillance in High-Risk Settings by Implementing a High-Throughput Molecular Assay on the Hologic Fusion Open Access Platform

Candida auris, a resilient pathogenic yeast with frequent multidrug resistance, presents a persistent challenge in healthcare settings. The timely identification of C. auris is crucial for infection control and prevention, especially in facilities facing unique hurdles, such as our institution, which serves four major hospitals and approximately 80% of the Texas inmate population. Understaffing, communal living, and financial constraints exacerbate infection control issues. To address common staff shortages, streamline testing services, and enhance testing efficiency, there was a pressing need for rapid and high-throughput detection of C. auris. This study presents the validation and utility of an assay implemented on the Hologic Fusion Open Access platform using samples collected from high-risk patients' axilla and groin areas, as well as environmental swab samples from patient rooms. Our assay complemented efforts to control C. auris outbreaks within our healthcare system, providing valuable insights into its presence within surveillance samples. This assay demonstrated the value of high-throughput molecular detection platforms in challenging healthcare environments by aiding infection preventionists in containing the spread of C. auris and preventing nosocomial infections. Our research contributes essential data on the suitability and performance of the Hologic Fusion Open Access platform for C. auris detection. These findings hold significant implications for enhancing surveillance and control measures in high-risk settings, making a significant impact on the field of infection control and prevention.

Enhancing competency in infection prevention and control: Identifying priorities for clinical nurse educational needs

BACKGROUND

Healthcare-associated infections (HAIs) have become a significant concern globally, posing risks to patients and imposing social and economic burdens. Competency in infection prevention and control (IPC) practices is essential for nurses to effectively reduce the risk of transmission. However, there is a lack of research on educational needs for competency in IPC practices.

OBJECTIVES

This study aimed to assess and prioritize educational needs for the development of educational content focused on the IPC practices of clinical nurses.

DESIGN

A descriptive cross-sectional design was utilized.

SETTINGS

This study was conducted at six general hospitals located in five urban regions in South Korea, each with 100 to 300 beds.

PARTICIPANTS

A total of 226 nurses were recruited as participants for this study.

METHODS

Data were collected from June to July 2021. A total of 226 nurses participated in this study. After examining the perceived importance and current performance of attributes related to IPC, educational needs were identified by paired-sample t-test, importance-performance analysis, Borich's needs analysis, and the Locus for Focus model.

RESULTS

Items related to IPC were found to have lower performance than importance, highlighting the need for education. Educational needs were the highest for items in the "IPC practices according to microorganisms" category, such as MRSA, VRE, antimicrobial-resistant organisms, Clostridium difficile, scabies, and AIDS. Items in the "isolation precautions" category, including standard precautions, transmission-based precautions, management of isolation rooms, and wearing PPE, also demonstrated high priority in terms of educational needs. The findings suggest the need for training programs for clinical nurses with a focus on specific areas for improving IPC competency.

CONCLUSIONS

The development and implementation of training modules tailored to the educational needs of clinical nurses may enhance their skills, knowledge, and attitudes, ultimately resulting in improved performance.

Adaptation and validation of a quantitative vanA/vanB DNA screening assay on a high-throughput PCR system

Vancomycin resistant enterococci (VRE) are a leading cause of ICU-acquired bloodstream infections in Europe. The bacterial load in enteral colonization may be associated with a higher probability of transmission. Here, we aimed to establish a quantitative vanA/vanB DNA real-time PCR assay on a high-throughput system. Limits of detection (LOD), linear range and precision were determined using serial bacterial dilutions. LOD was 46.9 digital copies (dcp)/ml for vanA and 60.8 dcp/ml for vanB. The assay showed excellent linearity between 4.7 × 101 and 3.5 × 105 dcp/ml (vanA) and 6.7 × 102 and 6.7 × 105 dcp/ml (vanB). Sensitivity was 100% for vanA and vanB, with high positive predictive value (PPV) for vanA (100%), but lower PPV for vanB (34.6%) likely due to the presence of vanB DNA positive anerobic bacteria in rectal swabs. Using the assay on enriched VRE broth vanB PPV increased to 87.2%. Quantification revealed median 2.0 × 104 dcp/ml in PCR positive but VRE culture negative samples and median 9.1 × 104 dcp/ml in VRE culture positive patients (maximum: 107 dcp/ml). The automated vanA/B_UTC assay can be used for vanA/vanB detection and quantification in different diagnostic settings and may support future clinical studies assessing the impact of bacterial load on risk of infection and transmission.

Exploring the Utility of Multiplex Infectious Disease Panel Testing for Diagnosis of Infection in Different Body Sites: A Joint Report of the Association for Molecular Pathology, American Society for Microbiology, Infectious Diseases Society of America, and Pan American Society for Clinical Virology

The use of clinical molecular diagnostic methods for detecting microbial pathogens continues to expand and, in some cases, supplant conventional identification methods in various scenarios. Analytical and clinical benefits of multiplex molecular panels for the detection of respiratory pathogens have been demonstrated in various studies. The use of these panels in managing different patient populations has been incorporated into clinical guidance documents. The Association for Molecular Pathology's Infectious Diseases Multiplex Working Group conducted a review of the current benefits and challenges to using multiplex PCR for the detection of pathogens from gastrointestinal tract, central nervous system, lower respiratory tract, and joint specimens. The Working Group also discusses future directions and novel approaches to detection of pathogens in alternate specimen types, and outlines challenges associated with implementation of these multiplex PCR panels.

Effectiveness of methicillin-resistant Staphylococcus aureus surveillance among exposed roommates in community hospitals: Conventional culture versus direct PCR

BACKGROUND

Roommates of unrecognized nosocomial methicillin-resistant Staphylococcus aureus (MRSA) cases are at a higher acquisition risk; however, optimal surveillance strategies are unknown.

METHODS

Using simulation, we analyzed surveillance testing and isolation strategies for MRSA among exposed hospital roommates. We compared isolating exposed roommates until conventional culture testing on day 6 and a nasal polymerase chain reaction test on day 3 (PCR3) with/without day 0 culture testing (Cult0). The model represents MRSA transmission in medium-sized hospitals using data and recommends best practices from the literature and Ontario community hospitals.

RESULTS

Cult0 + PCR3 incurred a slightly lower number of MRSA colonizations and 38.9% lower annual cost in the base case compared to Cult0 + culture testing on day 6 because the reduced isolation cost compensated for the increased testing cost. The reduction in MRSA colonizations was due to a 54.5% drop in MRSA transmissions during isolation as PCR3 reduced the exposure of MRSA-free roommates to new MRSA carriers. Removing the day 0 culture test from Cult0 + PCR3 increased total cost, the number of MRSA colonization, and missed cases by $1,631, 4.3%, and 50.9%, respectively. Improvements were higher under aggressive MRSA transmission scenarios.

DISCUSSION AND CONCLUSIONS

Adopting direct nasal polymerase chain reaction testing for determining post-exposure MRSA status reduces transmission risk and costs. Day 0 culture would still be beneficial.

Potential causal effect of contact precautions and isolation on Clostridioides difficile infection in the hyperendemic setting: Interrupted time-series analyses before and after implementation

BACKGROUND

Recent studies disputed the effectiveness of efforts to comply with contact precautions and isolation (CPI) considering relatively low intra-hospital transmission rate of healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). We evaluated the potential causal effect of CPI on HCFA-CDI occurrence by comparing the incidence rate (IR) for different time periods with and without CPI implementation.

METHODS

Long-term observational time-series data were separated into three periods (pre-CPI: January 2012-March 2016, CPI: April 2016-April 2021, post-CPI: May 2021-December 2022). CPI was suspended owing to the restriction of isolation rooms during the COVID-19 pandemic. We inferred potential causal outcomes by comparing predicted and observed IRs of HCFA-CDI using interrupted time-series analyses, including the Bayesian structural time-series or autoregressive integrated moving average (ARIMA) model in the R-language or SAS software.

RESULTS

The monthly observed IR (44.9/100,000 inpatient-days) during the CPI period was significantly lower than the predicted IR (90.8) (-50.6% relative effect, P = 0.001). However, the observed IR (52.3) during the post-CPI period was significantly higher than the predicted IR (39.1) (33.6%, P = 0.001). The HCFA-CDI IR decreased during CPI (-14.3, P < 0.001) and increased post-CPI (5.4, P < 0.001) in the multivariable ARIMA model, which controlled for antibiotic usage, handwashing with soap and water, and number of toxin tests.

CONCLUSIONS

Various time-series models revealed that CPI implementation had a potential causal effect on the reduction of HCFA-CDI incidence.

Increasing trend of healthcare-associated infections due to vancomycin-resistant Enterococcus faecium (VRE-fm) paralleling escalating community-acquired VRE-fm infections in a medical center implementing strict contact precautions: An epidemiologic and pathogenic genotype analysis and its implications

OBJECTIVE

To clarify whether there were clandestine intra-hospital spreads of vancomycin-resistant Enterococcus faecium (VRE-fm) isolates that led to specific strain of VRE lingering in the hospital and/or developing outbreaks that rendered a progressively increasing trend of healthcare-associated infections due to VRE-fm (VRE-fm-HAIs).

SETTING

Despite implementing strict contact precautions for hospitalized patients with VRE-fm-infection/colonization, number of VRE-fm-HAIs in a medical centre in southern Taiwan were escalating in 2009-2019, paralleling an increasing trend of community-acquired VRE-fm- infections.

METHODS

We analyzed epidemiologic data and genotypes of non-duplicate VRE-fm isolates each grown from a normally sterile site of 89 patients between December 2016 and October 2018; multilocus sequence typing (MLST) and pulse-field gel electrophoresis (PFGE) typing were performed.

RESULTS

Totally 13 sequence types (STs) were found, and the 3 leading STs were ST17 (44％), ST78 (37％), and ST18 (6％); 66 pulsotypes were generated by PFGE. Four VRE-fm isolates grouped as ST17/pulsotype S, 2 as ST17/pulsotype AS, 2 as ST17/pulsotype AU, and 3 as ST78/pulsotype V grew from clinical specimens sampled less than one week apart from patients staying at different wards/departments and/or on different floors of the hospital.

CONCLUSIONS

Despite possible small transitory clusters of intra-hospital VRE-fm spreads, there was no specific VRE-fm strain lingering in the hospital leading to increasing trend of VRE-fm-HAIs during the study period. Strict contact precautions were able to curb intra-hospital VRE-fm spreads, but unable to curb the increasing trend of VRE-fm-HAIs with the backdrop of progressively increasing VRE-fm-infections/colorizations in the community.

Screening for Asymptomatic Clostridioides difficile Carriage Among Hospitalized Patients: A Narrative Review

Clostridioides difficile infection (CDI) has become the most common healthcare-associated infection in the United States, with considerable morbidity, mortality, and healthcare costs. Assessing new preventive strategies is vital. We present a literature review of studies evaluating a strategy of screening and isolation of asymptomatic carriers in hospital settings. Asymptomatic detection of C. difficile is reported in ~ 10-20% of admitted patients. Risk factors for carriage include recent hospitalization, previous antibiotics, older age, lower functional capacity, immunosuppression, and others. Asymptomatic C. difficile carriers of toxigenic strains are at higher risk for progression to CDI. They are also shedders of C. difficile spores and may contribute to the persistence and transmission of this bacterium. Screening for asymptomatic carriers at hospital admission can theoretically reduce CDI by isolating carriers to reduce transmission, and implementing antibiotic stewardship measures targeting carriers to prevent progression to clinical illness. Several observational studies, summarized in this review, have reported implementing screening and isolation strategies, and found a reduction in CDI rates. Nevertheless, the data are still limited to a few observational studies, and this strategy is not commonly practiced. Studies supporting screening were performed in North America, coinciding with the period of dominance of the 027/BI/NAP1 strain. Additional studies evaluating screening, followed by infection control and antibiotic stewardship measures, are needed.

A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure

Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.

Hospital Practices for Respiratory Isolation for Patients With Suspected Tuberculosis and Potential Application of Prediction Models

Hospitalized persons with suspected pulmonary tuberculosis (PTB) are placed in airborne isolation to prevent nosocomial infection, as recommended by the Centers for Disease Control and Prevention (CDC). There is significant evidence that clinicians overuse this resource due to an abundance of caution when confronted with a patient with possible PTB. Many researchers have developed predictive tools based on clinical and radiographic data to assist clinicians in deciding which patients to place in respiratory isolation. We assessed the isolation practices for an urban hospital serving a large immigrant population and then retrospectively applied seven previously derived prediction models of isolation of PTB to our population. Our current clinical practice results in 76% of patients with PTB being placed in isolation on admission. However, 208 patients without PTB were placed in isolation unnecessarily for a total of 584 days. Four models had sensitivities greater than 90%, and two models had sensitivities of 100%. The use of these models would have potentially saved more than 150 days of patient isolation per year.

Lessons learned from a failed implementation: Effective communication with patients in transmission-based precautions

BACKGROUND

Patient engagement with transmission-based precautions can be an important strategy to prevent adverse events related to isolation. Most patient education is still highly prescriptive and is thus unlikely to help. Effective communication requires behavior change, leading to a meaningful dialog between the parties involved.

OBJECTIVE

evaluate implementation process of a protocol for effective communication with patients in transmission-based precautions (Com-Efe).

METHODS

Implementation research using qualitative methods in 4 sequential phases: (1) nonparticipant observation in inpatient wards; (2) design of the intervention for implementation; (3) adaptation of the Com-Efe through workshops with nurses; (4) final assessment of the implementation results through interviews with nurses. Study was performed in a public, secondary, teaching hospital. Consolidated Framework for Implementation Research was used as the reference for interview design and data analysis, aiming to identify barriers and enablers of the implementation process.

RESULTS

Main factors that could have facilitated adherence were beliefs and perceived advantages in using the Com-Efe by nurses. Main barriers that may have contributed to the failure were the unfavorable climate for implementation, insufficient individual and leadership commitment, and the lack of understanding of the concepts underpinning effective communication.

CONCLUSIONS

Despite using a systematic approach, the Com-Efe protocol was not fully implemented. The lessons learned in this study allowed us to propose suggestions for future protocol implementations in similar contexts.

Genomic epidemiology of Mycobacterium abscessus in a Canadian cystic fibrosis centre

The Mycobacterium abscessus complex causes significant morbidity and mortality among patients with Cystic Fibrosis (CF). It has been hypothesized that these organisms are transmitted from patient to patient based on genomics. However, few studies incorporate epidemiologic data to confirm this hypothesis. We longitudinally sampled 27 CF and 7 non-CF patients attending a metropolitan hospital in Ontario, Canada from 2013 to 2018. Whole genome sequencing along with epidemiological data was used to evaluate the likelihood of transmission. Overall, the genetic diversity of M. abscessus was large, with a median pairwise distance (IQR) of 1,279 (143-134) SNVs between all Ontario M. abscessus isolates and 2,908 (21-3,204) single nucleotide variants (SNVs) between M. massiliense isolates. This reflects the global diversity of this pathogen, with Ontario isolates widely dispersed throughout global phylogenetic trees of each subspecies. Using a maximum distance of 25 SNVs as a threshold to identify possible transmission, we identified 23 (of 276 total) pairs of closely-related isolates. However, transmission was probable for only one pair based on both genomic and epidemiological data. This suggests that person-to-person transmission of M. abscessus among CF patients is indeed rare and reinforces the critical importance of epidemiological data for inferences of transmission.

An Australian interpretive description of Contact Precautions through a bioethical lens; recommendations for ethically improved practice

BACKGROUND

Contact Precautions (CP) were developed to control multi-resistant organisms (MROs) in hospitals. However, MROs persist and harms are associated with CP. Research objectives were to understand the bioethical impact of CP on patients and health-professionals, and make recommendations for ethically-improved management of MRO-colonised patients.

METHOD

Interpretive description methodology scaffolded upon bioethical principles framed this qualitative study. Findings were explored alongside contemporary published reports to make recommendations for practice and research.

RESULTS

9 patients and 24 health professionals participated. Four themes were found: Powerlessness moving to acceptance; You feel a bit of a pariah; Others need protection, but I need looking after too; Doing Contact Precautions is not easy.

DISCUSSION

CP conflict with the principle of respect for autonomy due to non-adherence to informed consent, and sub-optimal communication. Patients experience healthcare inequality, and discriminatory practices breaching the principle of justice. CP elicit stigma for patients, and moral distress and inter-personal conflict for staff, breaching the principle of non-maleficence. Under the principle of beneficence, pluralistic cost-benefit assessment situates CP as low-value practice.

CONCLUSION

CP challenge organisational culture, professional well-being, and person-centred ethical care. Ethical costs of CP outweigh benefits, obliging policy-makers to reconsider CP in managing MRO-colonised patients.

The Efficacy of the BioFire FilmArray Gastrointestinal Panel to Reduce Hospital Costs Associated With Contact Isolation: A Pragmatic Randomized Controlled Trial

BACKGROUND

Molecular syndromic panels can rapidly detect common pathogens responsible for acute gastroenteritis in hospitalized patients. Their impact on both patient and healthcare system outcomes is uncertain compared to conventional stool testing. This randomized trial evaluates the impact of molecular testing on in-hospital resource utilization compared to conventional stool testing.

METHODS

Hospitalized patients with acute diarrheal illness were randomized 1:1 to either conventional or molecular stool testing with the BioFire FilmArray gastrointestinal panel (FGP). The primary outcome was the duration of contact isolation, and secondary outcomes included other in-hospital resource utilization such as diagnostic imaging and antimicrobial use.

RESULTS

A total of 156 patients were randomized. Randomization resulted in a balanced allocation of patients across all three age strata (<18, 18-69, ≥70 years old). The proportion of positive stools was 20.5% vs 29.5% in the control and FGP groups, respectively (p=0.196). The median duration of contact isolation was 51 hours (interquartile range [iqr] 66) and 69 hours (iqr 81) in the conventional and FGP groups, respectively (p=0.0513). There were no significant differences in other in-hospital resource utilization between groups.

CONCLUSIONS

There were no differences in in-hospital resource utilization observed between the FGP and conventional stool testing groups.

Evaluation of COVID-19 Patient Safety Compared to Non-COVID-19 Patients and Predisposing Factors of Nursing Errors

Objectives: The present study aims to determine Patient Safety in hospitalized patients with COVID-19 compared to non-COVID-19 ones and find predisposing factors of nursing errors according to nurses’ perceptions. Methods: This descriptive-comparative research employed data from 800 nurses in eight Iranian hospitals in 2021 using three researcher-made questionnaires of sociodemographic, patient safety indicators, and predisposing factors of nursing errors, with high reliability and validity. The collected data were analyzed using ANOVA, independent t-test, and the SPSS22 software. Results: The mean patient safety scores in patients with and without COVID-19 were 3.42 ± 0.17 and 3.74 ± 0.06, respectively. The highest differences in patient safety were attributed to infection control (0.66) and patient fall (0.56) dimensions. The most common causes of nursing errors were related to management (2.67 ± 1.39), and the most common predisposing factors of nursing errors were high workload, low ratio of nurses to patients, and fatigue. Conclusions: COVID-19 patients have lower safety than non-COVID ones. Also, improper management and high workload lead to nursing errors. Therefore, the authorities must devise appropriate strategies to reduce the nurses’ workload and improve patient safety, especially in COVID-19 patients.

Analysis of Patients With Bed Bugs in the Emergency Department

The objective was to evaluate the clinical characteristics, triage information, diagnostic evaluation, and disposition for emergency department patients with and without bed bug infestation. A retrospective case-control study of patients with and without bed bugs was performed from February 1, 2011, through February 1, 2017. Cases (n = 332) and controls (n = 4,952) were matched by age, sex, and emergency department location. Patient characteristics and clinical information were compared between groups. On univariable and multivariable analysis, patients with bed bugs had higher heart rate, lower systolic blood pressure, higher pain scores, and more frequent tobacco use in the past year. They were also more likely to screen positive in triage for an unsafe home; require an abuse consultation; be diagnosed in the emergency department or inpatient setting with malnutrition, marasmus, and/or cachexia; have more emergency department and hospital visits; and have longer hospital encounter lengths of stay (all p ≤ 0.02). On univariable analysis, patients with bed bugs were also more likely than uninfested controls to be single, be Black, come to the emergency department from home, arrive to the emergency department by ambulance, and not be discharged back to their homes from the hospital.

The lived experience of haemodialysis patients managed with transmission-based precautions for MDRO colonisation: A qualitative study

BACKGROUND

Patients undergoing haemodialysis colonised with multi-drug resistant organisms (MDROs) are commonly managed with transmission-based precautions (TBP) to prevent nosocomial transmission. TBP have been linked to mixed effects on patient psychological well-being and clinical care. This study was designed to report the lived experience of dialysis patients managed with TBP.

METHODS

A qualitative study of 15 patients undergoing haemodialysis managed with TBP was performed. Participants took part in individual semi-structured interviews. Data was analysed utilising an interpretive phenomenological approach.

RESULTS

Four themes were identified. 1. Communication of what MDRO screening meant, the results, and implications of MDRO positivity was perceived by many patients as insufficient and inconsistent. 2. Experiences of care in isolation were described, with both positive (privacy) and negative (reduced interaction) experiences identified. 3. Psychosocial and emotional responses including concern about health implications and stigma were reported, but also screening was described by some as increasing their perception of being cared for by health care workers, as they felt all health risks were being managed. 4. Confusion around perceived inconsistencies of management, particularly across different environments (eg hospital vs home) and staff.

CONCLUSION

TBP have complex positive and negative impacts on patients which should be considered when developing MDRO management policy and communication around such policy. Strategies to improve communication, patient and staff education, and remove (or explain) perceived inconsistencies of practice may reduce the negative consequences of TBP leading to improved delivery of quality, person-centred care.

In-house testing for COVID-19: effects on length of stay, isolation and the need for inpatient rehabilitation

ObjectiveThe COVID-19 pandemic has strained healthcare worldwide. Its direct complications, management and prognosis have been described. Downstream effects, including length of hospital stay (LOS), implications on discharge planning, and effect of in-house testing require formal study.MethodsA retrospective cohort study of patients suspected of COVID-19 infection admitted at a metropolitan Australian hospital was conducted. Outcomes before and after availability of in-house COVID-19 testing were compared.ResultsA total of 129 admissions were analysed. Indications for COVID-testing were dyspnoea (61.2%), fever (19.3%) and delirium (10.8%). All tested negative for COVID-19. Prior to in-house testing, mean LOS was 7.17 days (s.d. ± 4.2), and mean isolation of 1.8 days (s.d. ± 0.8). After availability of in-house testing, mean LOS was 4.78 days (s.d. ± 4.3) with mean isolation of 1.3 days (s.d. ± 0.9), both statistically significant differences. There were five inpatient falls, equivalent to 14.8 falls per 1000 patient/days. Twenty-two patients (17%) required subsequent sub-acute admission, 15 before in-house testing and five after (P = 0.058); however, a sub-group analysis for age >65 years was performed, and the results were significant (P < 0.05), showing all patients who required subacute admissions were aged >65.ConclusionIn-house COVID-19 testing is suggested to significantly reduce the duration patients spend in isolation and overall LOS in hospital. A shorter period of isolation and hospital LOS may reduce the need for subacute transfer in patients aged greater than 65 years, as well as the rates of inpatient falls. Large scale studies are needed to further elucidate these findings.

Evaluation of Patients' Adverse Events During Contact Isolation for Vancomycin-Resistant Enterococci Using a Matched Cohort Study With Propensity Score

IMPORTANCE

Although contact isolation has been widely recommended for multidrug-resistant organisms, contact isolation has raised some concerns that it may bring unintended patient harms.

OBJECTIVE

To compare adverse events between a contact isolation group with vancomycin-resistant Enterococcus (VRE) and a matched comparison group using a relatively large data set from full electronic medical records (EMR) and propensity score-matching methods.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, matched cohort study was conducted at Seoul National University Bundang Hospital (SNUBH) in Korea, a tertiary, university-affiliated hospital that has 1337 inpatient beds. Participants included a total of 98 529 hospitalized adult patients (aged ≥18 years) during 2015 to 2017.

EXPOSURES

Contact isolation in a single or shared double room.

MAIN OUTCOMES AND MEASURES

As adverse contact isolation-related outcomes, falls and pressure ulcers were included. All relevant EMR data were extracted from the SNUBH clinical data warehouse. Risk factors for adverse events were included in the propensity score model based on literature reviews, such as Braden scale score and Hendrich II fall risk score. A fine stratification and weighting (FSW) and a 1:10 nearest neighbor (NN) propensity score matching as a sensitivity analysis were adopted to compare adverse events between the 2 groups for the observation period from the study entry date and the exit date. Time-to-event analyses with a Cox proportional hazard model were conducted in December 2021.

RESULTS

For comparison of outcomes in wards, 177 patients (mean [SD] age, 67.38 [14.12] years; 98 [55.4%] female) with VRE and 93 022 patients (mean [SD] age, 56.44 [16.88] years; 49 462 [53.2%] female) without VRE were included and no difference was found in basic characteristics from the FSW (VRE contact isolation [n = 172] vs comparison [n = 69 434]) as well as from the 1:10 NN (VRE contact isolation [n = 168] vs comparison [n = 1650]). Among 177 patients with VRE contact isolation, 8 pressure ulcers and 3 falls occurred during their hospital stays; incidence rates of adverse events were 2.5 and 0.9 per 1000 patient-days, respectively (pressure ulcer incidence rate from the FSW: 2.53 per 1000 patient-days [95% CI, 1.09-4.99 per 1000 patient-days]; pressure ulcer incidence rate from the 1:10 NN: 2.54 per 1000 patient-days [95% CI, 1.10-5.01 per 1000 patient-days]; fall incidence rate from the FSW: 0.87 per 1000 patient-days [95% CI, 0.18-2.54 per 1000 patient-days]; fall incidence rate from the 1:10 NN: 0.87 per 1000 patient-days [95% CI, 0.18-2.55 per 1000 patient-days]). The hazard ratios for adverse events showed no statistically significant differences for both groups: 1.42 (95% CI, 0.67-2.99) for pressure ulcer and 0.66 (95% CI, 0.20-2.13) for fall from the FSW.

CONCLUSIONS AND RELEVANCE

In this cohort study, no association was found between the likelihood of adverse events and contact isolation using propensity score-matching methods and closely related covariates for adverse events.

COVID-19 Infection and Incidence of Myocarditis: A Multi-Site Population-Based Propensity Score-Matched Analysis

Background

Cardiovascular complications from COVID-19 include myocarditis, acute myocardial infarction, heart failure, and others. Population-level data is lacking about the relationship between COVID-19 and cardiovascular complications; therefore, we conducted a study to examine the incidence of myocarditis, acute myocardial infarction (AMI), heart failure (HF) after COVID-19 infection.

Methods

Retrospective cohort study using de-identified data from 50 health systems across the United States. Cohort groups were created using patients ≥18 who were admitted to hospitals for respiratory illness with COVID-19 in 2020 and respiratory illness without COVID-19 for 2020 and 2019. There were 107,699 patients with COVID-19, 77,499 patients with respiratory illness in 2020, and 112,898 patients in 2019. The COVID-19 group was matched to each respiratory illness group by propensity score. Patients with prior specific cardiovascular events such as myocarditis, AMI, HF were excluded. The primary outcome was myocarditis, and secondary outcomes were AMI and HF.

Results

In the COVID-19 group, 79 (0.12%) patients had new-onset myocarditis compared to 29 (0.04%) patients in the non-COVID-19 control (Pneumonia/flu) group Odd's Ratio (OR), (OR 2.73, CI 95%, 1.78-4.18). In the COVID-19 group, 1512 patients developed HF compared to 2,659 patients in the non-COVID-19 group (OR 0.49, CI 95%, 0.46-0.52). 1125 patients in COVID-19 group had AMI compared to 1243 patients in non-COVID-19 group (OR 0.87, CI 95%, 0.80-0.94).

Conclusion

COVID-19 was associated with a 2-3-fold higher risk of myocarditis. Unexpectedly, lower rates of HF diagnosis reflect challenges faced due to the severity of lung disease leading to obscuring physical exam findings required for HF diagnosis and early mortality before a diagnosis of HF was made.

An evaluation of interventions to improve outcomes for hospitalized patients in isolation: A systematic review

BACKGROUND

Isolation is effective in preventing transmission of infectious disease. However, it has been shown to have negative effects including increased anxiety and poor physical outcomes.

OBJECTIVES

To summarize the effects of interventions to improve safety and outcomes for patients in isolation DESIGN: Systematic review (PROSPERO protocol registration - CRD42020222779).

SETTING

Acute hospital PARTICIPANTS: Intervention studies including patients in preventative or protective isolation in a single room.

METHODS

MEDLINE, Global Health, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Excerpta Medica database were searched from 1996-October 2020. Two independent reviewers screened references and assessed risk of bias. One reviewer extracted data and was checked by another. Main outcomes were Quality of Life and mortality.

RESULTS

We identified 16,698 references and included 6 studies with different study designs. Average age ranged from 4-71 years. Samples sizes were small (range 10-49 participants) apart from one non-randomized controlled trial including >600 participants. Interventions were music therapy (n = 3), psychological counseling (n = 2) and exercise training (n = 1). One study reporting on Quality of Life and found no change after exercise. None of the studies reported on mortality. Due to heterogeneous results no meta-analyses were performed.

CONCLUSIONS

There is a lack of high-quality evidence for effective comprehensive interventions to manage adverse effects associated with isolation. Future studies should investigate the effect of multi-component interventions using rigorous methods to improve outcomes for hospitalized isolated patients.

Coronavirus Disease 2019 (COVID-19) Diagnostic Clinical Decision Support: A Pre-Post Implementation Study of CORAL (COvid Risk cALculator)

BACKGROUND

Isolation of hospitalized persons under investigation (PUIs) for coronavirus disease 2019 (COVID-19) reduces nosocomial transmission risk. Efficient evaluation of PUIs is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs.

METHODS

We conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to infectious diseases (ID) physician review. Before CORAL, ID physicians reviewed all PUI records to guide workup and precautions. After CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeated severe acute respiratory syndrome coronavirus 2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work hours, using linear and logistic regression, adjusted for COVID-19 incidence.

RESULTS

Fewer PUIs underwent repeated testing after an initial negative NAAT after CORAL than before CORAL (54% vs 67%, respectively; adjusted odd ratio, 0.53 [95% confidence interval, .44-.63]; P < .01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference [standard error], -7.4 [0.8] hours per patient), total duration of PUI status (-19.5 [1.9] hours per patient), and average ID physician work-hours (-57.4 [2.0] hours per day) (all P < .01). No patients had a positive NAAT result within 7 days after discontinuation of precautions via CORAL.

CONCLUSIONS

CORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions.

The Impact of COVID-19 on Levels of Adherence to the Completion of Nursing Records for Inpatients in Isolation

The COVID-19 pandemic has led to an increased workload for nurses and organisational and structural changes, which have been necessary to meet the needs of inpatients in isolation.

AIM

To describe the impact of the COVID-19 pandemic on levels of adherence to the completion of nursing records that document the risk of developing pressure ulcers, falling, and social vulnerability among hospitalised patients in isolation.

METHODS

Observational pre-post comparison study. Comparison between nursing records (the Braden, Downton, and Gijón scales) belonging to 1205 inpatients took place in two phases. Phase 1: 568 patients admitted in February 2020, prior to the COVID-19 pandemic, vs. phase 2: 637 patients hospitalised with COVID-19 in March-April 2020, during the peak of the first wave of the pandemic. This research adheres to the STROBE guidelines for the reporting of observational studies.

RESULTS

The degree of completion of the Braden, Downton, and Gijón scales decreased significantly in phase 2 vs. phase 1 (p < 0.001). The mean Downton and Gijón scale scores for patients admitted in phase 1 were higher compared to those of patients admitted in phase 2 (p < 0.001). The mean Braden scale score in phase 2 was higher than in phase 1 (p < 0.05).

CONCLUSION

During the COVID-19 pandemic, there was a decrease in the completion of nursing records in the clinical records of patients in isolation. The levels of risk of developing PUs, falling, and social vulnerability of patients admitted to hospital were lower during the first wave of the pandemic.

Adverse Events Associated with Patient Isolation: A Systematic Literature Revue and Meta-analysis

BACKGROUND

Patient isolation is widely recommended and used in healthcare institutions to prevent transmission of MDRO. However, its risk-benefit ratio is debated.

AIM

We undertook a systematic literature review and meta-analysis since 2009 to assess, based on the newly published studies, whether or not there are physical and psychological adverse events associated with patient isolation.

METHODS

Systematic literature review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies were systematically searched from PubMed, from the 1^st of may 2009 till the 31^st of January 2020. The concepts of the research questions were defined as: "Adverse events", "patient isolation or cohorting", and "multi-drug resistant organisms colonized or infection patients". Three reviewers independently screened studies and extracted data. All statistical analysis was performed with Stata Software and R.

FINDINGS

After screening titles of 15921 articles, abstracts of 196 and reviewing full texts of 50 studies, we included 19 studies. Studies were divided into 3 groups: 4 qualitative studies, 7 observational studies suitable for meta-analysis and 8 other observational studies. Meta-analysis shows no adverse events related to clinical care or patient's experience associated with patient isolation.

CONCLUSIONS

More studies with correct methodology, including a control group and standardized inclusion criteria, must be conducted to confirm our results.

Isolation precautions cause minor delays in diagnostics and treatment of non-COVID patients

Background

Isolation precautions are essential prevent spread of COVID-19 infection but may have a negative impact on inpatient care. The impact of these measures on non-COVID-19 patients remains largely unexplored.

Aim

This study aimed to investigate diagnostic and treatment delays related to isolation precautions, the associated patient outcome, and the predisposing risk factors for delays.

Methods

This observational study was conducted in seven Helsinki region hospitals during the first wave of the COVID-19 pandemic in Finland. The study used data on all non-COVID-19 inpatients, who were initially isolated due to suspected COVID-19, to estimate whether isolation precautions resulted in diagnostic or treatment delays.

Results

Out of 683 non-COVID-19 patients, 33 (4.8%) had delays related to isolation precautions. Clinical condition deteriorated non-fatally in seven (1.0%) patients. The following events were associated with an increased risk of treatment or a diagnostic delay: more than three ward transfers (P = 0.025); referral to an incorrect speciality in the emergency department (P = 0.004); more than three SARS-CoV-2 RT-PCR tests performed (P = 0.022); and where cancer was the final diagnosis (P = 0.018). In contrast, lower respiratory tract symptoms (P = 0.013) decreased the risk.

Conclusions

The use of isolation precautions for patients who did not have COVID-19 had minor negative effects on patient outcomes. The present study underlines the importance of targeting diagnostic efforts to patients with unspecified symptoms and to those with a negative SARS-CoV-2 test result. Thorough investigations to achieve an accurate diagnosis improves the prognosis of patients and facilitates appropriate targeting of hospital resources.

The Value and Institutional Impact of an In-System Laboratory Testing During the COVID-19 Pandemic

In-system clinical laboratories have proven themselves to be a fundamentally important resource to their institutions during the COVID-19 pandemic of the past year. The ability to provide SARS-CoV-2 molecular testing to our hospital system allowed us to offer the best possible care to our patients, and to support neighboring hospitals and nursing homes. In-house testing led to significant revenue enhancement to the laboratory and institution, and attracted new patients to the system. Timely testing of inpatients allowed the majority who did not have COVID-19 infection to be removed from respiratory and contact isolation, conserving valuable personal protective equipment and staff resources at a time that both were in short supply. As 2020 evolved and our institution restarted delivery of routine care, the availability of in-system laboratory testing to deliver both accurate and timely results was absolutely critical. In this article, we attempt to demonstrate the value and impact of an in-system laboratory during the COVID-19 pandemic. A strong in-house laboratory service was absolutely critical to institutional operational and financial success during 2020, and will ensure resiliency in the future as well.

Multidrug-resistant organisms (MDROs) in patients with subarachnoid hemorrhage (SAH)

Patient care in a neurointensive care unit (neuro-ICU) is challenging. Multidrug-resistant organisms (MDROs) are increasingly common in the routine clinical practice. We evaluated the impact of infection with MDROs on outcomes in patients with subarachnoid hemorrhage (SAH). A single-center retrospective analysis of SAH cases involving patients treated in the neuro-ICU was performed. The outcome was assessed 6 months after SAH using the modified Rankin Scale [mRS, favorable (0–2) and unfavorable (3–6)]. Data were compared by matched-pair analysis. Patient characteristics were well matched in the MDRO (n = 61) and control (n = 61) groups. In this center, one nurse was assigned to a two-bed room. If a MDRO was detected, the patient was isolated, and the nurse was assigned to the patient infected with the MDRO. In the MDRO group, 29 patients (48%) had a favorable outcome, while 25 patients (41%) in the control group had a favorable outcome; the difference was not significant (p > 0.05). Independent prognostic factors for unfavorable outcomes were worse status at admission (OR = 3.1), concomitant intracerebral hematoma (ICH) (OR = 3.7), and delayed cerebral ischemia (DCI) (OR = 6.8). Infection with MRDOs did not have a negative impact on the outcome in SAH patients. Slightly better outcomes were observed in SAH patients infected with MDROs, suggesting the benefit of individual care.

Interprofessional perceptions of emotional, social, and ethical effects of multidrug-resistant organisms: A qualitative study

INTRODUCTION

Multi-drug-resistant organisms (MDRO) are usually managed by separating the infected patients to protect others from colonization and infection. Isolation precautions are associated with negative experiences by patients and their relatives, while hospital staff experience a heavier workload and their own emotional reactions.

METHODS

In 2018, 35 participants (nurses, physicians, pharmacists) in an antimicrobial-stewardship program participated in facilitated discussion groups working on the emotional impact of MDRO. Deductive codings were done by four coders focusing on the five basic emotions described by Paul Ekmans.

RESULTS

All five emotions revealed four to 11 codes forming several subthemes: Anger is expressed because of incompetence, workflow-impairment and lack of knowledge. Anxiety is provoked by inadequate knowledge, guilt, isolation, bad prognoses, and media-related effects. Enjoyment is seldom. Sadness is experienced in terms of helplessness and second-victim effects. Disgust is attributed to shame and bad associations, but on the other hand MDROs seem to be part of everyday life. Deductive coding yielded additional codes for bioethics and the Calgary Family Assessment Method.

CONCLUSION

MDRO are perceived to have severe impact on emotions and may affect bioethical and family psychological issues. Thus, further work should concentrate on these findings to generate a holistic view of MDRO on human life and social systems.

Risk of acute deterioration and care complexity individual factors associated with health outcomes in hospitalised patients with COVID-19: a multicentre cohort study

BACKGROUND

Evidence about the impact of systematic nursing surveillance on risk of acute deterioration of patients with COVID-19 and the effects of care complexity factors on inpatient outcomes is scarce. The aim of this study was to determine the association between acute deterioration risk, care complexity factors and unfavourable outcomes in hospitalised patients with COVID-19.

METHODS

A multicentre cohort study was conducted from 1 to 31 March 2020 at seven hospitals in Catalonia. All adult patients with COVID-19 admitted to hospitals and with a complete minimum data set were recruited retrospectively. Patients were classified based on the presence or absence of a composite unfavourable outcome (in-hospital mortality and adverse events). The main measures included risk of acute deterioration (as measured using the VIDA early warning system) and care complexity factors. All data were obtained blinded from electronic health records. Multivariate logistic analysis was performed to identify the VIDA score and complexity factors associated with unfavourable outcomes.

RESULTS

Out of a total of 1176 patients with COVID-19, 506 (43%) experienced an unfavourable outcome during hospitalisation. The frequency of unfavourable outcomes rose with increasing risk of acute deterioration as measured by the VIDA score. Risk factors independently associated with unfavourable outcomes were chronic underlying disease (OR: 1.90, 95% CI 1.32 to 2.72; p<0.001), mental status impairment (OR: 2.31, 95% CI 1.45 to 23.66; p<0.001), length of hospital stay (OR: 1.16, 95% CI 1.11 to 1.21; p<0.001) and high risk of acute deterioration (OR: 4.32, 95% CI 2.83 to 6.60; p<0.001). High-tech hospital admission was a protective factor against unfavourable outcomes (OR: 0.57, 95% CI 0.36 to 0.89; p=0.01).

CONCLUSION

The systematic nursing surveillance of the status and evolution of COVID-19 inpatients, including the careful monitoring of acute deterioration risk and care complexity factors, may help reduce deleterious health outcomes in COVID-19 inpatients.

Counteracting Throwaway Culture in Daily Clinical Practice

Since his election in March 2013, Pope Francis has brought significant attention to the concept of "throwaway culture." This moral paradigm-which has been defined by Francis in various speeches and the encyclical Laudato si'-characterizes a present-day culture in which food, disposable objects, and even human beings themselves are "discarded as 'unnecessary.'" As Catholic physicians, it is our duty to ensure that we are working to counteract throwaway culture in our daily clinical practice by embracing and exhibiting a culture of encounter. When throwaway culture is discussed within the context of medical practice, it is easy to think of major life and systemic issues including abortion, assistive reproductive technology, physician assisted suicide, and so on. However, rejection of throwaway culture has much broader implications for Catholic physicians. We are called to resist this perverse culture whenever we experience a situation that requires special attention to the respect of human dignity. In this article, we present two common situations encountered in clinical practice in which it is essential to counteract throwaway culture and embrace a culture of encounter: in working with patients who are isolation settings and those who require translation services. Various studies are cited which demonstrate a lack of respect for human dignity that can be seen when working with these patient populations, and recommendations are provided which illustrate how to embrace a culture of encounter in each scenario. The authors conclude that through adoption of a culture of encounter, Catholic physicians as a community can be role models for coworkers, trainees, and students, promoting a culture in which we validate human dignity and ensure the quality and just care of even our most vulnerable patients.

SUMMARY

Pope Francis had defined a "throwaway culture" in which "Human life, the person, are no longer seen as a primary value to be respected and safeguarded." In this article we present two common situations encountered in clinical practice in which it is essential to counteract throwaway culture and embrace a culture of encounter: in working with patients who are isolation settings and those who require translation services. We conclude that, as Catholic physicians, it is our duty to ensure that we are working to counteract throwaway culture in our daily clinical practice by embracing and exhibiting a culture of encounter.

A new therapeutic communication model "TAGEET" to help nurses engage therapeutically with patients suspected of or confirmed with COVID-19

AIM

To design and present a new communication model "TAGEET" to help nurses engage therapeutically with patients suspected of or confirmed with COVID-19.

BACKGROUND

COVID-19 is a highly contagious disease that brings with it fear and anxiety for all involved inclusive of nurses and patients. New guidelines for nurses to follow such as attention to physical distance coupled with the wearing of defined personal protective equipment, gloves, long-sleeved disposable gown, FFP2 face mask and eye protection place additional strain on nurses to engage therapeutically with patients. Evidence suggests that the wearing of face masks and personal protective equipment acts as barriers to effective therapeutic engagement with patients. We found an absence of communication models to help nurses engage therapeutically with patients.

DESIGN

This is a position paper that draws on previous research to inform the design of a new model for nurses to engage therapeutically with patients suspected of or confirmed with COVID-19.

METHOD

We reviewed the literature on caring for patients in isolation, the barriers to therapeutic communication and the psychological impact of infectious diseases on nurses and patients.

CONCLUSION

Remaining emotionally present to self, whilst being present to others can be challenging for nurses in a pandemic environment. We believe that the "TAGEET" model (T-Tune-in, A-Approach and introduce, G-Ground self, E-Engage and respond, E-End encounter, T-Tune-out), although devised for nurses to engage therapeutically with patients suspected of or confirmed with COVID-19 could be used by all healthcare professionals in any challenging clinical environment.

RELEVANCE TO CLINICAL PRACTICE

This new therapeutic communication model will provide support for nurses with how to manage self in the context of caring for others in a COVID-19 environment.

Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study

OBJECTIVE

To determine whether isolated patients admitted to hospital have a higher incidence of adverse events (AEs), to identify their nature, impact and preventability.

DESIGN

Prospective cohort study with isolated and non-isolated patients.

SETTING

One public university hospital in the Valencian Community (southeast Spain).

PARTICIPANTS

We consecutively collected 400 patients, 200 isolated and 200 non-isolated, age ≥18 years old, to match according to date of entry, admission department, sex, age (±5 years) and disease severity from April 2017 to October 2018.

EXCLUSION CRITERIA

patients age <18 years old and/or reverse isolation patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome as the AE, defined according to the National Study of Adverse Effects linked to Hospitalisation (Estudio Nacional Sobre los Efectos Adversos) criteria. Cumulative incidence rates and AE incidence density rates were calculated.

RESULTS

The incidence of isolated patients with AEs 16.5% (95% CI 11.4% to 21.6%) compared with 9.5% (95% CI 5.4% to 13.6%) in non-isolated (p<0.03). The incidence density of patients with AEs among isolated patients was 11.8 per 1000 days/patient (95% CI 7.8 to 15.9) compared with 4.3 per 1000 days/patient (95% CI 2.4 to 6.3) among non-isolated patients (p<0.001). The incidence of AEs among isolated patients was 18.5% compared with 11% for non-isolated patients (p<0.09). Among the 37 AEs detected in 33 isolated patients, and the 22 AEs detected in 19 non-isolated patients, most corresponded to healthcare-associated infections (HAIs) for both isolated and non-isolated patients (48.6% vs 45.4%). There were significant differences with respect to the preventability of AEs, (67.6% among isolated patients compared with 52.6% among non-isolated patients).

CONCLUSIONS

AEs were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAIs as the primary cause. It is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.

Multidrug-Resistant Organisms in Palliative Care: A Systematic Review

Background: Multidrug-resistant organisms (MDROs) are an important health care issue. Patients in Western societies often present an increased morbidity of chronic conditions accompanied by poor immune status and the use of devices. In particular, patients in palliative care (PC) are at greater risk of MDRO colonization, due to accompanying special devices and being hospitalized. Objective: To gain an overview of the literature regarding MDROs in PC. Design: Systematic review Data sources: On the 19th of October 2019 the databases " PubMed" and " CINAHL" were used to identify studies reporting on MDROs in PC; the search was updated on 16th of May 2020. Results: Seventeen out of 486 articles were included. Six represent qualitative data, 10 quantitative data, and one a mixed methods approach. Prevalence data range from 4.0% to 18%. MDRO colonization has a negative impact on patients and families. It leads to uncertainties and higher workload by staff members. Strategies for the management of MDROs in the field of PC are predominantly available for methicillin-resistant Staphylococcus aureus. Not even half of institutions utilize existing protocols. Recommendations for dealing with MDROs indicate required staff and time resources as well as information, communication, and specific knowledge. Conclusion: There is a great need for studies examining the prevalence of all MDROs in the PC setting. Additionally, not only patients but also a public enlightenment on MDROs should be provided to decrease knowledge gaps and therefore reduce transmission on MDROs.

Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals?

The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.

Psychological outcomes of MRSA isolation in spinal cord injury rehabilitation

STUDY DESIGN

Retrospective secondary analysis with a quantitative, matched-pairs design. Patients isolated due to methicillin-Resistant Staphylococcus aureus (MRSA) were matched with controls without MRSA infection admitted to a multi-bedded ward, based on: gender, injury level, injury severity (AIS grade), age at the time of injury and year of admission.

OBJECTIVES

Determine the implications of MRSA-related infection isolation on spinal cord injury patients' anxiety, depression, appraisals of disability, perceived manageability and pain intensity. Hypotheses predicted patients who were isolated due to MRSA during inpatient stay would demonstrate poorer psychological health outcomes at discharge in comparison with non-isolated matched controls.

SETTING

National Spinal Injuries Centre, England, UK.

METHODS

Secondary analyses were conducted on pre-existing data based on patients' first admission for primary rehabilitation. Psychometric scales were used to measure outcome variables. Assessments were repeated at the time of admission and discharge.

RESULTS

Nonparametric longitudinal analyses using the nparLD package in R were conducted. Relative treatment effects demonstrated that there were no significant differences between groups across all outcome measures. There was a significant effect of time (admission vs discharge) on perceived manageability and pain intensity, indicating improved outcomes at discharge. There was no difference in the overall length of stay between the isolated and non-isolated groups.

CONCLUSIONS

Isolation experienced by rehabilitation inpatients with spinal cord injury with MRSA had no effect on a series of psychological outcomes. Engaging with rehabilitation had a positive impact in reducing pain unpleasantness and increasing perceived manageability of spinal cord injury, irrespective of infection isolation.

Clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control: A systematic review

AIM

To review and synthesize literature examining clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control.

BACKGROUND

Isolation precautions are a common infection prevention and control strategy which may have impact on safety and quality of care.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided this systematic review, which was registered with PROSPERO [CRD42019131573].

DATA SOURCES

A search of Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature was conducted for studies published in English up to 5 April 2019.

REVIEW METHODS

Risk of bias was determined using Critical Appraisal Skills Program tools. Quality appraisal was performed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. The primary outcomes of interest were clinical deterioration events and hospital-acquired complications. In-hospital death and hospital length of stay were secondary outcomes. Data were synthesized using a narrative approach.

RESULTS

The search yielded 785 citations after removal of duplicates, of which, six studies were relevant. Certainty of evidence for outcomes of interest was low to very low.

CONCLUSION

There is no strong evidence that adult medical and surgical ward patients in isolation precautions for infection control are more or less likely to experience clinical deterioration or hospital-acquired complications.

IMPACT

What problem did the study address? Are patients in isolation precautions more likely to experience clinical deterioration or hospital-acquired complications than non-isolated patients? What were the main findings? There is no strong evidence that clinical deterioration and hospital-acquired complications are more likely to occur to patients in isolation precautions for infection control. This research is of relevance to acute care nurses.

Barrier Precautions in the Era of Multidrug Pathogens

Purpose of review

There is a continuing debate regarding contact precaution (CP) usage for endemic multidrug-resistant organisms (MDROs). In this review, we examine current recommendations for CP and highlight differences in CP use between endemic and non-endemic MDROs.

Recent findings

The discontinuation of CP had no effect on the incidence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci. The evidence regarding CP for extended-spectrum beta-lactamase producing Enterobacteriaceae is inconclusive, highlighting the need for more research to determine best infection control strategies. Carbapenem-resistant Enterobacteriaceae maintains a sporadic pattern in the USA, supporting current recommendations to use CP for colonized and infected patients. MDR Acinetobacter baumannii (MDR-AB) is extremely virulent and responsible for outbreaks in healthcare settings, emphasizing the need for CP use with MDR-AB infected patients. Candida auris (C. auris) is often misdiagnosed; it is resistant to UV light and quaternary ammonium low-level disinfection. Because little is known about the transmission of C. auris, significant caution and CP use are necessitated. There is little research on vancomycin-resistant S. aureus (VRSA) control strategies due to its rarity; thus, CP is strongly recommended.

Summary

Contact precautions are frequently part of a bundled infection control approach that involves meticulous hand hygiene, patient decolonization, chlorhexidine gluconate bathing, and reducing the use of invasive devices. Healthcare facilities should continue to utilize CP for non-endemic MDROs and the presence of endemic MDROs; however, CP may not add benefit to the current infection prevention bundle approach.