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Bentvelsen RG, Laan BJ, Bonten T, van der Vaart R, Hetem DJ, Soetekouw R, Geerlings SE, Chavannes NH, Veldkamp KE. Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study. J Hosp Infect 2024; 147:98-106. [PMID: 38040039 DOI: 10.1016/j.jhin.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters. AIM To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation. METHODS In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178. FINDINGS Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001). CONCLUSION Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.
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Affiliation(s)
- R G Bentvelsen
- Clinical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands; Microvida Laboratory for Microbiology and Immunology, Amphia Hospital Breda, Breda, The Netherlands.
| | - B J Laan
- Infectious Diseases, Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - T Bonten
- Public Health and Primary Care, National eHealth Living Lab, Leiden University Medical Centre, Leiden, The Netherlands
| | - R van der Vaart
- Unit of Health, Medical and Neuropsychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden, The Netherlands
| | - D J Hetem
- Clinical Microbiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - R Soetekouw
- Internal Medicine, Spaarne Gasthuis, Haarlem/Hoofddorp, The Netherlands
| | - S E Geerlings
- Infectious Diseases, Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - N H Chavannes
- Public Health and Primary Care, National eHealth Living Lab, Leiden University Medical Centre, Leiden, The Netherlands
| | - K E Veldkamp
- Clinical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
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Gray J, Rachakonda A, Karnon J. Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTIs) in adult inpatients. J Hosp Infect 2023; 136:55-74. [PMID: 37015257 DOI: 10.1016/j.jhin.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Urinary tract infections (UTIs) are one of the most common hospital-acquired complications. Insertion of a urinary catheter and the duration of catheterization are the main risk factors, with catheter-associated UTIs (CAUTIs) accounting for 70-80% of hospital-acquired UTIs. Guidance is available regarding the prevention of hospital-acquired CAUTIs; however, how best to operationalize this guidance remains a challenge. AIM To map and summarize the peer-reviewed literature on model-of-care interventions for the prevention of CAUTIs in adult inpatients. METHODS PubMed, CINAHL and SCOPUS were searched for articles that reported UTI, CAUTI or urinary catheter outcomes. Articles were screened systematically, data were extracted systematically, and interventions were classified by intervention type. FINDINGS This review included 70 articles. Interventions were classified as single component (N=19) or multi-component (N=51). Single component interventions included: daily rounds or activities (N=4), protocols and procedure changes (N=6), reminders and order sets (N=5), audit and feedback interventions (N=3), and education with simulation (N=1). Overall, daily catheter reviews and protocol and procedure changes demonstrated the most consistent effects on catheter and CAUTI outcomes. The components of multi-component interventions were categorized to map common elements and identify novel ideas. CONCLUSION A range of potential intervention options with evidence of a positive effect on catheter and CAUTI outcomes was identified. This is intended to provide a 'menu' of intervention options for local decision makers, enabling them to identify interventions that are relevant and feasible in their local setting.
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Affiliation(s)
- J Gray
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
| | - A Rachakonda
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - J Karnon
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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Zhao T, Du G, Zhou X. Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S4-S13. [PMID: 35559693 DOI: 10.12968/bjon.2022.31.9.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Urinary tract infections (UTIs) comprise the second most common type of healthcare-associated infections, with up to 80% of UTIs caused by indwelling urinary catheters. Current research suggests that the best way to prevent catheter-associated UTIs (CAUTIs) is to reduce unnecessary catheterisation. Few reviews have focused on the prevalence, risk factors and preventive measures for inappropriate catheterisation. This article, consequently, sought to evaluate the current evidence on the prevalence, risk factors and measures that can be taken to prevent inappropriate urinary catheterisation.
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Affiliation(s)
- Tao Zhao
- Department of Hospital Infection Management, The First People's Hospital of Guiyang, Guiyang City, Guizhou Province, China
| | - Guiqin Du
- Department of Hospital Infection Management, The First People's Hospital of Guiyang, Guiyang City, Guizhou Province, China
| | - Xuan Zhou
- Department of Science and Education, The First People's Hospital of Guiyang, Guiyang City, Guizhou Province, China
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Katayama K, Meddings J, Saint S, Fowler KE, Ratz D, Tagashira Y, Kawamura Y, Fujikawa T, Nishiguchi S, Kayauchi N, Takagaki N, Tokuda Y, Kuriyama A. Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study. BMC Infect Dis 2022; 22:175. [PMID: 35189844 PMCID: PMC8862324 DOI: 10.1186/s12879-022-07162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals. METHODS This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review. RESULTS We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients. CONCLUSION This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.
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Affiliation(s)
- Kohta Katayama
- Department of General Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba, 286-8520, Japan.
| | - Jennifer Meddings
- Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Sanjay Saint
- Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karen E Fowler
- Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - David Ratz
- Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Yasuaki Tagashira
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yumi Kawamura
- Department of General Internal Medicine and Emergency Medicine, Mimihara General Hospital, Sakai, Osaka, Japan
| | - Tatsuya Fujikawa
- Department of General Internal Medicine, Mitoyo General Hospital, Kanonji, Kagawa, Japan
| | - Sho Nishiguchi
- Department of General Internal Medicine, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Naomi Kayauchi
- Department of Infection Control, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
| | | | - Yasuharu Tokuda
- Muribushi Okinawa Center for Teaching Hospitals, Urasoe, Okinawa, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
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Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections. Infect Control Hosp Epidemiol 2021; 41:680-683. [PMID: 32127059 DOI: 10.1017/ice.2020.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.
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Liu L, Shi H, Yu H, Yan S, Luan S. The recent advances in surface antibacterial strategies for biomedical catheters. Biomater Sci 2021; 8:4095-4108. [PMID: 32555809 DOI: 10.1039/d0bm00659a] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
As one of the most common hospital-acquired infections, catheter-related infections (CRIs) which are caused by microbial colonization lead to increasing morbidity and mortality of patients and life threat for medical staffs. In this case, a variety of efforts have been made to design functional materials to limit bacterial colonization and biofilm formation. In this review, we focus on the recent advances in surface modification strategies of biomedical catheters used to prevent CRIs. The tests for the evaluation of the performances of modified catheters are listed. Future prospects of surface antibacterial strategies for biomedical catheters are also outlined.
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Affiliation(s)
- Lin Liu
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China. and University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Hengchong Shi
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China.
| | - Huan Yu
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China. and University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Shunjie Yan
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China. and National Engineering Laboratory of Medical Implantable Devices & Key Laboratory for Medical Implantable Devices of Shandong Province, WEGO Holding Company Limited, Weihai 264210, P. R. China
| | - Shifang Luan
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China. and University of Science and Technology of China, Hefei, 230026, P. R. China
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Bentvelsen RG, Veldkamp KE, Chavannes NH. A Smartphone App for Engaging Patients With Catheter-Associated Urinary Tract Infections: Protocol for an Interrupted Time-Series Analysis. JMIR Res Protoc 2021; 10:e28314. [PMID: 33755026 PMCID: PMC8086777 DOI: 10.2196/28314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are the main cause of health care-associated infections, and they increase the disease burden, antibiotic usage, and hospital stay. Inappropriate placement and unnecessarily prolonged usage of a catheter lead to an elevated and preventable risk of infection. The smartphone app Participatient has been developed to involve hospitalized patients in communication and decision-making related to catheter use and to control unnecessary (long-term) catheter use to prevent CAUTIs. Sustained behavioral changes for infection prevention can be promoted by empowering patients through Participatient. OBJECTIVE The primary aim of our multicenter prospective interrupted time-series analysis is to reduce inappropriate catheter usage by 15%. We will evaluate the efficacy of Participatient in this quality improvement study in clinical wards. Our secondary endpoints are to reduce CAUTIs and to increase patient satisfaction, involvement, and trust with health care services. METHODS We will conduct a multicenter interrupted time-series analysis-a strong study design when randomization is not feasible-consisting of a pre- and postintervention point-prevalence survey distributed among participating wards to investigate the efficacy of Participatient in reducing the inappropriate usage of catheters. After customizing Participatient to the wards' requirements, it will be implemented with a catheter indication checklist among clinical wards in 4 large hospitals in the Netherlands. We will collect clinical data every 2 weeks for 6 months in the pre- and postintervention periods. Simultaneously, we will assess the impact of Participatient on patient satisfaction with health care services and providers and the patients' perceived involvement in health care through questionnaires, and the barriers and facilitators of eHealth implementation through interviews with health care workers. RESULTS To reduce the inappropriate use of approximately 40% of catheters (currently in use) by 15%, we aim to collect 9-12 data points from 70-100 patients per survey date per hospital. Thereafter, we will conduct an interrupted time-series analysis and present the difference between the unadjusted and adjusted rate ratios with a corresponding 95% CI. Differences will be considered significant when P<.05. CONCLUSIONS Our protocol may help reduce the inappropriate use of catheters and subsequent CAUTIs. By sharing reliable information and daily checklists with hospitalized patients via an app, we aim to provide them a tool to be involved in health care-related decision-making and to increase the quality of care. TRIAL REGISTRATION Netherlands Trial Register NL7178; https://www.trialregister.nl/trial/7178. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/28314.
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Affiliation(s)
- Robbert Gerard Bentvelsen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands.,Microvida Laboratory for Medical Microbiology, Amphia Hospital, Breda, Netherlands
| | - Karin Ellen Veldkamp
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
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Vorobev V, Beloborodov V, Golub I, Frolov A, Kelchevskaya E, Tsoktoev D, Maksikova T. Urinary System Iatrogenic Injuries: Problem Review. Urol Int 2021; 105:460-469. [PMID: 33535218 DOI: 10.1159/000512882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum. METHODS The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%). RESULTS Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences. DISCUSSION/CONCLUSION Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.
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Affiliation(s)
- Vladimir Vorobev
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation,
| | - Vladimir Beloborodov
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
| | - Igor Golub
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
| | - Aleksandr Frolov
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
| | - Elena Kelchevskaya
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
| | - Darizhab Tsoktoev
- Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
| | - Tatyana Maksikova
- Department of Propedeutics of Internal Diseases, Irkutsk State Medical University, Irkutsk, Russian Federation
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Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. BMJ Qual Saf 2020; 29:265-270. [DOI: 10.1136/bmjqs-2019-009731] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 12/16/2022]
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10
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Niederhauser A, Züllig S, Marschall J, Schweiger A, John G, Kuster SP, Schwappach DL. Change in staff perspectives on indwelling urinary catheter use after implementation of an intervention bundle in seven Swiss acute care hospitals: results of a before/after survey study. BMJ Open 2019; 9:e028740. [PMID: 31662357 PMCID: PMC6830685 DOI: 10.1136/bmjopen-2018-028740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate changes in staff perspectives towards indwelling urinary catheter (IUC) use after implementation of a 1-year quality improvement project. DESIGN Repeated cross-sectional survey at baseline (October 2016) and 12-month follow-up (October 2017). SETTING Seven acute care hospitals in Switzerland. PARTICIPANTS The survey was targeted at all nursing and medical staff members working at the participating hospitals at the time of survey distribution. A total of 1579 staff members participated in the baseline survey (T0) (49% response rate) and 1527 participated in the follow-up survey (T1) (47% response rate). INTERVENTION A multimodal intervention bundle, consisting of an evidence-based indication list, daily re-evaluation of ongoing catheter need and staff training, was implemented over the course of 9 months. MAIN OUTCOME MEASURES Staff knowledge (15 items), perception of current practices and culture (scale 1-7), self-reported responsibilities (multiple-response question) and determinants of behaviour (scale 1-7) before and after implementation of the intervention bundle. RESULTS The mean number of correctly answered knowledge questions increased significantly between the two survey periods (T0: 10.4, T1: 11.0; p<0.001). Self-reported responsibilities with regard to IUC management by nurses and physicians changed only slightly over time. Perception of current practices and culture in regard to safe urinary catheter use increased significantly (T0: 5.3, T1: 5.5; p<0.001). Significant changes were also observed for determinants of behaviour (T0: 5.3, T1: 5.6; p<0.001). CONCLUSION We found small but significant changes in staff perceptions after implementation of an evidence-based intervention bundle. Efforts now need to be targeted at sustaining and reinforcing these changes, so that restrictive use of IUCs becomes an integral part of the hospital culture.
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Affiliation(s)
| | | | - Jonas Marschall
- Swissnoso National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, Bern, Switzerland
| | - Alexander Schweiger
- Swissnoso National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, Basel University Hospital, Basel, Switzerland
| | - Gregor John
- Department of Internal Medicine, Hopital neuchatelois, Neuchatel, Switzerland
| | - Stefan P Kuster
- Swissnoso National Center for Infection Control, Bern, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital Zurich, Zurich, Switzerland
| | - David Lb Schwappach
- Swiss Patient Safety Foundation, Zurich, Switzerland
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Hopmans TEM, Smid EA, Wille JC, van der Kooi TII, Koek MBG, Vos MC, Geerlings SE, de Greeff SC. Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys. J Hosp Infect 2019; 104:181-187. [PMID: 31626863 DOI: 10.1016/j.jhin.2019.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs). AIM To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016. METHODS In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals. FINDINGS PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)). CONCLUSION Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.
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Affiliation(s)
- T E M Hopmans
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
| | - E A Smid
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - J C Wille
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - T I I van der Kooi
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - M B G Koek
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - S E Geerlings
- Department of Infectious Diseases, University Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - S C de Greeff
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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12
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Menegueti MG, Ciol MA, Bellissimo-Rodrigues F, Auxiliadora-Martins M, Gaspar GG, Canini SRMDS, Basile-Filho A, Laus AM. Long-term prevention of catheter-associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study. Medicine (Baltimore) 2019; 98:e14417. [PMID: 30813142 PMCID: PMC6407993 DOI: 10.1097/md.0000000000014417] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Removing an indwelling urinary catheter as soon as possible is the cornerstone of catheter-associated urinary tract infections (CAUTI) prevention. However, implementing this measure may be challenging in clinical settings. To evaluate the impact of implementing a healthcare workers (HCWs) educational program and a daily checklist for indwelling urinary catheter indications among critical patients on the incidence of CAUTI. METHODS This was a quasi-experimental study performed in a general intensive care unit of a tertiary-care hospital over a 12 years period, from January 1, 2005 to December 31, 2016. Rates of urinary catheter use and incidence density of CAUTI were monthly evaluated following the Centers for Disease Control and Prevention (CDC) criteria throughout the study period. Phase I (2005-2006) was the pre-intervention period. In phase II (2007-2010), HCWs routine training on CAUTI prevention was performed twice-a-year. In phase III (2011-2014), we implemented a daily checklist for indwelling urinary catheter indications, in addition to the biannual training. In phase IV, (2015-2016) the biannual training was replaced by training only newly hired HCWs and the daily checklist was maintained. RESULTS The mean rate of urinary catheter utilization decreased from phase I to phase IV (73.1%, 74.1%, 54.9%, and 45.6%, respectively). Similarly, the incidence density of CAUTI decreased from phase I to phase IV (14.9, 7.3, 3.8, and 1.1 per 1000 catheter-days, respectively). CONCLUSIONS HCWs education and daily evaluation of indwelling urinary catheter indications were highly effective in reducing the rates of catheter utilization as well as the incidence density of CAUTI.
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Affiliation(s)
| | - Marcia A. Ciol
- Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington
| | | | - Maria Auxiliadora-Martins
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School
| | - Gilberto Gambero Gaspar
- Infection Control Service, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School
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Quality Improvement Foley Project to Reduce Catheter-Related Trauma in a Large Community Hospital. J Healthc Qual 2018; 40:51-57. [DOI: 10.1097/jhq.0000000000000108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim B, Pai H, Choi WS, Kim Y, Kweon KT, Kim HA, Ryu SY, Wie SH, Kim J. Current status of indwelling urinary catheter utilization and catheter-associated urinary tract infection throughout hospital wards in Korea: A multicenter prospective observational study. PLoS One 2017; 12:e0185369. [PMID: 28991927 PMCID: PMC5633151 DOI: 10.1371/journal.pone.0185369] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 09/12/2017] [Indexed: 11/30/2022] Open
Abstract
To evaluate the frequency and appropriateness of indwelling urinary catheters (IUC) use and the incidence of catheter-associated urinary tract infections (CA-UTI), and explore the risk factors for CA-UTI in hospitals as a whole, we conducted a study. This study was divided into two parts; a point-prevalence study on Dec 12th 2012 and a prospective cohort study from Dec 13th 2012 to Jan 9th 2013 were performed in six hospitals in Korea. All hospitalized patients with newly-placed IUCs were enrolled and monitored weekly for 28 days after IUC placement. In the point-prevalence study, the IUCs were present in median 14.9/100 hospitalized patients (1Q 14, 3Q 16) across the six hospitals. In the prospective cohort study, the median IUC-days per patient was 5 (1Q 3, 3Q 10) and the median CA-UTI prevalence per 1,000 catheter days was 1.9 (1Q 0.7, 3Q 3.8) with significant inter-hospital variation. The proportion of patients with inappropriate IUC maintenance increased with number of IUC-days (8.5% on day 7, 9.4% on day 14, 16.3% on day 21, and 23.1% on day 28). Urinary output monitoring (23/36, 63.9%) was the most common indication for inappropriate use after 1 week of ICU placement. In multivariate analysis, IUC-days was significantly associated with the development of CA-UTI (odds ratio 1.122, 95% confidence interval 1.074–1.173, P< 0.001). IUC-days and CA-UTI rates vary between hospitals. IUC-days is a risk factor for CA-UTI, and is correlated with inappropriate use.
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Affiliation(s)
- Bongyoung Kim
- Department of Internal Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Won Suk Choi
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Yeonjae Kim
- Department of Infectious Disease, National Medical Center, Seoul, Korea
| | - Ki Tae Kweon
- Department of Infectious Disease, Patima Hospital, Daegu, Korea
| | - Hyun Ah Kim
- Department of Internal Medicine, Gyemyeong University College of Medicine, Daegu, Korea
| | - Seong Yeol Ryu
- Department of Internal Medicine, Gyemyeong University College of Medicine, Daegu, Korea
| | - Seong-heon Wie
- Department of Internal Medicine, St. Vincent Hospital, Suwon, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- * E-mail:
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Lauck SB, Kwon JY, Wood DA, Baumbusch J, Norekvål TM, Htun N, Stephenson L, Webb JG. Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study. Eur J Cardiovasc Nurs 2017. [DOI: 10.1177/1474515117716590] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI. Methods: We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time. Results: Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027). Conclusion: The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.
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Affiliation(s)
- Sandra B Lauck
- Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Jae-Yung Kwon
- University of British Columbia, Vancouver, BC, Canada
| | - David A Wood
- Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen Norway
| | - Nay Htun
- Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Leo Stephenson
- Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
| | - John G Webb
- Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
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Laan BJ, Spijkerman IJB, Godfried MH, Pasmooij BC, Maaskant JM, Borgert MJ, Opmeer BC, Vos MC, Geerlings SE. De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study. BMC Infect Dis 2017; 17:53. [PMID: 28068924 PMCID: PMC5223587 DOI: 10.1186/s12879-016-2154-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/22/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy. METHODS In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. DISCUSSION This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. TRIAL REGISTRATION Dutch trial registry: NTR6015 . Registered 9 August 2016.
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Affiliation(s)
- Bart J Laan
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ingrid J B Spijkerman
- Department of Medical Microbiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mieke H Godfried
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Berend C Pasmooij
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jolanda M Maaskant
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marjon J Borgert
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Neoh KG, Li M, Kang ET, Chiong E, Tambyah PA. Surface modification strategies for combating catheter-related complications: recent advances and challenges. J Mater Chem B 2017; 5:2045-2067. [DOI: 10.1039/c6tb03280j] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.
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Affiliation(s)
- Koon Gee Neoh
- Department of Chemical and Biomolecular Engineering
- National University of Singapore
- Singapore 119077
| | - Min Li
- Department of Chemical and Biomolecular Engineering
- National University of Singapore
- Singapore 119077
| | - En-Tang Kang
- Department of Chemical and Biomolecular Engineering
- National University of Singapore
- Singapore 119077
| | - Edmund Chiong
- Department of Surgery
- National University of Singapore
- Singapore 119077
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Al-Hazmi H. Role of duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections. Res Rep Urol 2015; 7:41-7. [PMID: 25848551 PMCID: PMC4378875 DOI: 10.2147/rru.s75419] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Our aim is to prove that duration of catheterization and length of hospital stay (LOS) are associated with the rate of hospital-acquired urinary tract infections (UTI), while taking into account type of urinary catheter used, the most common organisms found, patient diagnosis on admission, associated comorbidities, age, sex, precautions that should be taken to avoid UTI, and comparison with other studies. Methods The study was done in a university teaching hospital with a 920-bed capacity; this hospital is a tertiary care center in Riyadh, Saudi Arabia. The study was done on 250 selected patients during the year 2010 as a retrospective descriptive study. Patients were selected as purposive sample, all of them having been exposed to urinary catheterization; hospital-acquired UTI were found in 100 patients. Data were abstracted from the archived patients’ files in the medical record department using the annual infection control logbook prepared by the infection control department. The data collected were demographic information about the patients, clinical condition (diagnosis and the LOS), and possible risk factors for infection such as duration of catheterization, exposure to invasive devices or surgical procedures, and medical condition. Results There was a statistically significant association between the rate of UTI and duration of catheterization: seven patients had UTI out of 46 catheterized patients (15%) at 3 days of catheterization, while 30 patients had UTI out of 44 catheterized patients (68%) at 8 days of catheterization (median 8 days in infected patients versus 3 days in noninfected patients; P-value <0.05), which means that the longer the duration of catheterization, the higher the UTI rate. There was a statistically significant association between the rate of UTI and LOS: three patients had UTI out of 37 catheterized patients (8%) at 10 days LOS, while 42 patients had UTI out of 49 catheterized patients (85.7%) at 18 days LOS. The longer the LOS, the higher the UTI rate: LOS for each patient (median 18 days for infected patients versus 10 days for noninfected patients; P-value <0.05), and number of hospital-acquired catheter-related UTI (100 patients had UTI out of 250 catheterized patients, P=0.04). Conclusion Reduction of the duration of catheterization and LOS of the patient have a positive impact in reduction of catheter-related UTI.
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Affiliation(s)
- Hamdan Al-Hazmi
- Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Blodgett TJ, Gardner SE, Blodgett NP, Peterson LV, Pietraszak M. A Tool to Assess the Signs and Symptoms of Catheter-Associated Urinary Tract Infection: Development and Reliability. Clin Nurs Res 2014; 24:341-56. [PMID: 25246536 DOI: 10.1177/1054773814550506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this pilot study was to determine the inter-rater reliability of four clinical manifestations of catheter-associated urinary tract infections (CAUTI) among hospitalized adults with short-term indwelling urinary catheters using a tool developed for this purpose: the CAUTI Assessment Profile (CAP). Study participants included 30 non-pregnant English-speaking adults, recruited from two community hospitals. Three nurses assessed each participant for fever, suprapubic tenderness, flank tenderness, and delirium using standardized techniques. Based on the generalized Kappa statistic and 95% confidence intervals, there was evidence of strong inter-rater reliability for fever (K = 1.00, 0.793-1.207), suprapubic tenderness (K = 0.39, 0.185-0.598), and delirium (K = 0.58, 0.379-0.792), but not for flank tenderness (K = 0.29, -0.036 to 0.617). This study provides preliminary evidence that the CAP can be used to consistently identify these clinical signs and symptoms of CAUTI in hospitalized adults.
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Meddings J. Interventions to reduce urinary catheter use: it worked for them, but will it work for us? BMJ Qual Saf 2013; 22:967-71. [PMID: 24050982 DOI: 10.1136/bmjqs-2013-002331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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