The Clean Care Contest: promoting hand hygiene among healthcare and medical students

INTRODUCTION

Despite continuing efforts, compliance rates and knowledge of best practices in hand hygiene remain disappointing. Recognizing that conventional educational tools seem out of touch with young people and that the med and messages contents need refreshing, the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health devised a novel approach to promote the creation of innovative educational tools for improving knowledge of, and compliance with, hand hygiene rules among healthcare and medical students.

METHODS

A contest in creating educational material on hand hygiene practices involved university students of nursing and medicine, and of other healthcare degrees. Students from the universities of the GISIO network were invited to create educational material (e.g., videos, posters, presentations, leaflets, and screensavers) to be presented by May 5th 2019 during the World Hand Hygiene Day / Save Lives: Clean Your Hands Global Annual Initiative of the World Health Organization). A local and a national winners were awarded.

RESULTS

Three different local and national contests were performed during 2016, 2017 and 2018. During the three-year period, more than 270 educational tools have been developed: 130 (48%) were judged useful for hand hygiene promotion campaigns. The most frequent projects participating in the contests were videos (39%), posters (29%), leaflets (14%), and others (18%) submitted by more than 1,500 students of nursing (40%), medicine (31%), dentistry (7%), and of other healthcare courses in 14 universities. Products were evaluated by a local committee and, subsequently, local winners represented their University in a national contest.

CONCLUSIONS

The contest provided a framework for the creation of innovative and potentially effective educational tools via an engaging approach that leveraged student creativity. Given the need to improve compliance rates, this study suggests that new ways can be advantageously explored to teach hand hygiene procedures and increase awareness of the importance of their consistent use among healthcare and medical students.

The prevention of doping and the improper use of drugs and food supplements in sports and physical activities: a survey on the activity of the prevention departments of Italian local health authorities

INTRODUCTION

Doping is an important public health problem widespread not only among elite athletes, but also among amateur and recreational athletes and the general population. In Italy the introduction of doping prevention within the Essential Levels of Care (LEA) with the DPCM 12/1/2017 represents a crucial step towards the implementation of education and health promotion interventions. In this context, the Departments of Prevention (DP) of the Local Health Authorities (LHA) have to play a fundamental role, becoming the cultural and operational reference on this issue. As part of the "Doping prevention: development of a permanent educational tool coordinated by the National Health Service Prevention Departments" project, funded by the Italian Ministry of Health, a survey was conducted on the activities carried out by the DP regarding doping prevention and improper use and abuse of drugs and food supplements in sports and physical activities, as a basis for the harmonization of organizational structures and prevention programs and the creation of a collaboration network at a regional and national level.

METHODS

A semi-structured questionnaire consisting of 11 questions, prepared on an electronic platform, was sent to the DP of all the Italian LHA.

RESULTS

A total of 38 DP out of 131 (29%) completed the questionnaire, with representation from all regions. 42.1% of DP carried out or are still running programs for the prevention of doping, a percentage that decreases to 27% considering the programs for the prevention of misuse and abuse of drugs and food supplements in sports and in physical activities; in less than half of the DP, 37.5% and 41.7%, respectively, dedicated funds have been allocated. The professionals most involved in prevention of doping are the Specialists in Sport Medicine (81.3%) followed by Specialists in Hygiene (43.8%) and Psychologists (37.5%), while Health Care Assistants (50%) are the professionals most involved in the prevention of the improper use of drugs and food supplements, followed by Specialists in Hygiene and Specialists in Sport Medicine (40%). Most of the DP (71.9%) believe that the introduction of programs to prevent and counteract doping in the LEA will have repercussions on their approach against doping.

CONCLUSIONS

The survey, although conducted on a limited sample, has provided an important framework relating to programs for the prevention of doping and the misuse and abuse of drugs and food supplements in sports and in the physical activities carried out by DP. A remarkable heterogeneity has been highlighted, both at national and regional level. It is urgent to provide DP with homogeneous and effective organizational models and adequate operational tools, paying particular attention to the training of all the professionals involved. It is also essential to implement permanent monitoring tools.

Implementation of Acute Flaccid Paralysis Surveillance in Emilia-Romagna, Italy: 2018-2019 analysis

Problem

Acute flaccid paralysis (AFP) active surveillance is the gold standard in polio eradication process. Italy was classified in 2017 at intermediate risk of poliovirus reintroduction based on suboptimal poliovirus surveillance. The aim of this study was to restore an adequate level of AFP surveillance in Emilia-Romagna Region.

Description of the Problem

The Emilia-Romagna's Reference Centre for AFP surveillance, in collaboration with the regional Public Health Service identified a collaborative network for AFP Surveillance by analysing the 2015-2017 Hospital Discharge Registers in all region's hospitals. The surveillance protocol was reviewed with the development of a computerized system of Active Surveillance-Zero Reporting sent by e-mail to doctors in the network every 15 days since October 2018. The goal was to restore the AFP notification system to meet WHO requirements sensitivity, completeness of case investigation, completeness of follow-up and to monitor the active surveillance program adherence.

Results

The active surveillance network was composed by 49 doctors from both hospital administrations and clinical wards from 4 University Hospitals and 7 Local Health Authorities throughout the region. By the end of 2019, the mean response to each e-mail was 48.5% (SD 7.5%); 7 AFP cases have been reported; 85.7% received a full clinical and virological investigation and 83.3% completed the 60 day's follow-up. The final diagnosis of the cases was: 3 Guillain-Barre, 1 transient polyneuritis after HAV vaccination, 1 neuromyopathy from chronic disease, 1 acute myelitis in patient with DADA2. In 2 cases the paralysis persisted after 60 days.

Lessons

In 2019, the active surveillance system reached sensitivity, completeness of case investigation and follow-up required. Intervention had no expenses, is easily reproducible, created a direct collaboration between clinical colleagues in the network and the reference center which restored adherence to AFP surveillance.

Key messages

This work proposes how to improve AFP surveillance in a setting with low polio risk perception due to the absence of cases. Additionally, it reinforces the importance of direct collaboration/teamwork between institutions, regional reference centres and clinicians.

Transforming waiting pauses into opportunity for physical activity: the “Activate your Wait” project

Physical activity is recognised as a major health determinant, with positive effects on health, environmental sustainability and economy. However, worldwide, 1 in 4 adults, and 3 in 4 adolescents do not currently meet the recommendations for physical activity set by the World Health Organization. Notably, the prevalence of inactivity varies considerably within and between countries, and can be as high as 80% in some adult subpopulations. From the urgent need to implement strategies to fight sedentary behaviour, and considering that physical activity is defined as any bodily movement produced by skeletal muscles that require energy expenditure, the project “Activate your Wait” was born. The project aim is to transform the waiting pauses during everyday life into opportunities to perform simple stretching and active mobilization exercises. The pilot study was carried out in September 2019 at the Terme S. Egidio, Suio Terme Castelforte (Italy). It was divided in three phases: in the pre-intervention phase a questionnaire evaluated the interest in the project (96 responders); during the intervention phase, lasting three days, examples of simple exercises that people can do by themselves were illustrated and undertaken by about 120 participants; in the post-intervention an evaluation questionnaire was administered (71 responders). The intervention aroused great participation and high approval (97%), and resulted in an increase both in willingness to perform exercises during daily waiting breaks (68% vs 94%) and belief in positive results of physical activity on health (74% vs 96%). In a context where the opportunities for physical activity are decreasing and a sedentary lifestyle has reached a high level, this project represents a contribution to the increase in the awareness of the importance of physical activity and the promotion of the culture of movement in the entire population, with an opportunity of easy accessibility in different contexts of life, at all ages.

Key messages

Physical activity is a major determinant of health, therefore it is fundamental to take all possible opportunities to be active. Waiting pauses are the perfect chance to exercise.

Erice 2018 Charter on the role of the National Health Service in the prevention of doping

The Erice 2018 Charter was unanimously approved at the conclusion of the 53rd Residential Course of the International School of Epidemiology and Preventive Medicine “Adapted Physical Activity in Sport, Wellness and Fitness; the role of the Departments of Prevention and of the National Health Service in doping prevention and health promotion”, held on 15-19 May 2018 in Erice, Italy, at the “Ettore Majorana” Foundation and Centre for Scientific Culture, and promoted by the Study Group on “Movement Sciences for Health” of the Italian Society of Hygiene, Preventive Medicine and Public Health. The event was part of a larger project supported by the Ministry of Health aimed at preventing doping in the general population involved in sport and physical activities. After an intense discussion the participants focused on ten statements involving the following critical issues: responsibility, priority, message, alphabetization, networks and alliances, school promoting health, player and opportunities, competences, know-how, programming and acting. These statements provide hints to approach doping within a public health frame and summarize the role of the Departments of Prevention and NHS in promoting and coordinating preventive actions with other institutions and stakeholders. Doping represents a complex phenomenon related to cultural, social, economic and legal issues. In addition to regulatory or repressive actions, education to health and legality is proposed as the fundamental strategy to contrast doping by promoting healthy lifestyles, based on scientific knowledge and respect for legality.

A multicentre study on epidemiology and prevention of needle stick injuries among students of nursing schools

INTRODUCTION

Among the health professions with a long period of training, the students of the Nursing Bachelor's Degree are the most exposed to biological risk resulting from accidents, in particular with needles and cutting edges. The aim of the study was to estimate the frequency and the circumstances for the occurrence of needle stick injuries, as a knowledge base for targeted prevention interventions.

METHODS

The study was carried out between May and July 2017 in 11 Universities in Italy and 1 in Albania (associated with the "Tor Vergata" University of Rome). An anonymous semi-structured questionnaire was proposed to 1st (second semester), 2nd and 3rd year students of Nursing Bachelor's Degree.

RESULTS

A total of 2742 questionnaires were collected. The average age of participants was 22.9 years (median 22, range 19-60 years), 73% of whom were females. A total of 381 injuries were reported. Three hundred and sixteen students (11.8%) underwent at least 1 injury (12.7% among females, 9.7% among males); 41 students declared two or more injuries; four students did not report the number of injuries occurred. The first injury occurred, as an average, 17 days after the start of the internship (median 15 days) and, in 25% of the cases, during the first 9 days. The highest percentage of accidents occurred during the first internship (25.3% of the total) and decreased with the progress of the training path. The injuries occurred in 38% of cases during drug preparation, 24% when disposing of sharp devices, 15% while re-capping needles, 13% during blood sampling and 10% in other circumstances. In 51.2% of cases, the needle was not sterile. Among the nursing students who suffered a needle stick injury, 58.1% declared that they had performed the post-exposure prophylaxis. 96% of students stated to be vaccinated against Hepatitis B virus. Amongst the students who had their serological status checked (74%), 18% stated the antibody titre was not protective. 49.8% of students answered to have been trained in advance on the correct procedures to avoid needle stick and cutting edges injuries in each clinical ward attended, 41.2% referred that this occurred only in some wards and 10% in no ward at all.

CONCLUSION

The results of this study show a high percentage of needle stick injuries in students of the Nursing Bachelor's Degree. Therefore, there is a need for careful reflection on the most effective methods of targeted training acquisition of knowledge, skills and behavioural models useful for the exercise of the profession.

Hospital Hygiene and Infection Prevention and Control in Italy: state of the art and perspectives

Although hospital hygiene has a long history in Italy it is necessary to reflect about it because of the innovation in healthcare systems and because of the evolution due to European Union related activities. Different traditions exist in European countries about hospital hygiene and European Centre for Disease Prevention and Control (ECDC) adopted the term of "infection control and hospital hygiene" which includes all the engaged European healthcare professionals. We propose to modify hospital hygiene as "healthcare organisation hygiene" in order to focalise the attention to all care settings not only hospitals and to adopt the following definition: "all activities aimed to guarantee, in an appropriate, scientifically sound and efficient way, that structures and processes support healthcare practices in a safe comfortable and healthy environment both for patients, caregivers and healthcare workers". Hospital hygiene and its professionals, besides the long tradition, still remain a relevant pillar in guaranteeing quality and safety of healthcare in Italy.

Knowledge, experiences, and attitudes toward Mantoux test among medical and health professional students in Italy: a cross-sectional study

BACKGROUND

The World Health Organization's Action Framework for tuberculosis elimination in low-tuberculosis incidence countries includes the screening for active and latent tuberculosis in selected high-risk groups, including health care workers. In this context, medical and health profession students, exposed to nosocomial tuberculosis transmission during training and clinical rotations, are target populations for tuberculosis screening. No updated data are available on tuberculosis screening practice and knowledge of medical and health profession students in Italy.

METHODS

Within the activities Italian Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health, we carried out a multicentre cross-sectional study to assess knowledge, attitude and practices on tuberculosis prevention and control among Medical, Dentistry, Nursing and other health professions' students. Students were enrolled in the study on a voluntary basis and were administered a previously piloted structured questionnaire. Logistic regression models were applied to explore knowledge on tuberculosis prevention by selected socio-demographic variables and University-based tuberculosis prevention practice.

RESULTS

Students of seventeen Universities across Italy participated in the study, and 58.2% of them received compulsory tuberculin skin test either at enrollment or while attending clinical practice. A total of 5,209 students filled the questionnaire. 37.7% were medicine and dentistry students (Group 1), 44.9% were nursing students (Group 2) and 17.4% were other health professions' students (Group 3). Age and gender had different distributions by groups, as well as knowledge and practice on tuberculin skin test. 84.4% of the study population (95% CI = 83.3-85.3) was aware of the existence of the tuberculin skin test, 74.4% (95% CI = 73.2-75.6) knew what is the first-level screening test for latent tuberculosis and only 22.5% (95% CI = 21.4-23.6) knew how to proceed after a positive tuberculin skin test result. Overall, knowledge on tuberculosis prevention was higher in Group 2 and lower Group 3, as compared to Group 1.

CONCLUSION

In Italy, the knowledge on tuberculosis screening among University students is generally good. To reduce some of the criticalities found among the different study courses, it would be appropriate to harmonize both the regulations on tuberculosis screening practices for admission to University courses, and the educational activities on the topic of tuberculosis, to be extended to all workers involved in health care setting.

Essential strategies in HAI prevention and control: performance assessment through the implementation of the HAI-CoSIP tool of the GISIO-SItI group. A pilot study in a sample of Italian Organizations

BACKGROUND

Healthcare-Associated Infections are a great concern for worldwide healthcare systems and represent a considerable threat to patient safety, leading to adverse clinical outcomes. A defined panel of indicators represents a key element to guide Healthcare Organizations towards identification of main gaps, implementation of effective actions and continuous improvements on Healthcare-Associated Infections prevention and control activities. A review on accreditation systems conducted by the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene Preventive Medicine and Public Health revealed a substantial heterogeneity of implemented standards and led to the development of a core set of indicators and requirements for Healthcare-Associated Infections' prevention and control within the hospital setting. The main aim of the study was to test the feasibility of the Healthcare-Associated Infections' prevention and control within the hospital setting tool to calculate performance scores on a sample of Italian Healthcare Organizations and to identify major critical issues. The potential benefits of the possibility of future implementation of the tool within Institutional Accreditation Programs is discussed.

STUDY DESIGN

Cross sectional pilot survey.

METHODS

The Healthcare-Associated Infections' prevention and control within the hospital setting included 96 criteria and 20 key areas including an area for outcomes indicators. For applicable criteria, standards fulfilment was evaluated according to a 4 point Likert scale. A composite score was calculated for each Healthcare Organization and five performance levels were identified. Data were further analysed by computing performance scores at the level of each area and requirement.

RESULTS

20 Healthcare Organizations agreed to take part in this pilot study including two rehabilitative Healthcare Organizations. Among the whole sample a mean of 12.20% of requirements resulted not fulfilled, leaving space for further improvements. Critical areas were easily identified and the instrument was able to capture substantial differences between Healthcare Organizations. Only a few number of standards resulted "Not Applicable" (Mean = 4.71%) and most of them regarded Rehabilitative Healthcare Organizations. Mean composite performance index resulted 74.06% (SD = 16.96, range 36.30 - 94.27%); area of outcome indicators obtained a mean score of 56.17.

CONCLUSION

The Healthcare-Associated Infections' prevention and control within the hospital setting resulted an useful tool to assess Healthcare Organizations' performance in the field of Healthcare-Associated Infections prevention and control and to identify necessary actions for further improvements. The distribution of total scores by Healthcare Organizations showed a high heterogeneity. Implementation of the Healthcare-Associated Infections' prevention and control within the hospital setting tool as an institutional accreditation tool may help to drive the required harmonization at a national level of Healthcare-Associated Infections management and control strategies and overcome current substantial regional differences.

Epidemiology of intensive care unit-acquired sepsis in Italy: results of the SPIN-UTI network

BACKGROUND

Sepsis is the major cause of mortality from any infectious disease worldwide. Sepsis may be the result of a healthcare associated infection (HAI): the most frequent adverse events during care delivery especially in Intensive Care Units (ICUs). The main aim of the present study was to describe the epidemiology of ICU-acquired sepsis and related outcomes among patients enrolled in the framework of the Italian Nosocomial Infections Surveillance in ICUs - SPIN-UTI project.

STUDY DESIGN

Prospective multicenter study.

METHODS

The SPIN-UTI network adopted the European protocols for patient-based HAI surveillance.

RESULTS

During the five editions of the SPIN-UTI project, from 2008 to 2017, 47.0% of HAIs has led to sepsis in 832 patients. Overall, 57.0% episodes were classified as sepsis, 20.5% as severe sepsis and 22.5% as septic shock. The most common isolated microorganisms from sepsis episodes were Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa. The case fatality rate increased with the severity of sepsis and the mean length of ICU-stay was significantly higher in patients with ICU-acquired sepsis than in patients without.

CONCLUSION

Our study provides evidence that ICU-acquired sepsis occurs frequently in Italian ICU patients and is associated with a high case fatality rate and increased length of stay. However, in order to explain these findings further analyses are needed in this population of ICU patients.

The effectiveness of educational interventions in university training on hospital hygiene: results of action research

BACKGROUND

The Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health promoted and conducted a study on teaching hospital hygiene, with particular reference to the prevention and control of healthcare-associated infections, with the aim of developing effective educational material starting from the results collected.

MATERIAL AND METHODS

First of all, a survey was carried out, targeting lecturers in hospital hygiene, with the purpose of investigating their perceptions regarding this issue. The available scientific literature was also reviewed in order to identify effective educational/teaching strategies for the prevention of healthcare-associated infections, so that valid training interventions could be subsequently developed. Finally, a trial-training intervention was implemented, and specific audio-visual teaching material was also tested.

RESULTS

The overall response rate to the survey was 42%, with good country-wide representativeness. The level of awareness of hospital hygiene issues by students resulted higher among trainee nurses (65%) than among medical students (44%). The teaching staff identified alternative educational methodologies to substitute the classical lecture (e.g.: case discussions) and, in most cases, the alternative solution appeared to be preferable. The teaching of hospital hygiene was better integrated with other disciplines and professional training activities in the degree courses for nurses than in those for doctors; the total number of hours assigned to such teaching was variable. The literature review highlighted that various educational approaches are used. The most common are presentations or lectures, but videos, posters, questionnaires and e-learning strategies are also used. Combining different instruments when designing an educational programme has proven to be an effective strategy. The training activity tested was positively evaluated by the participants; the possibility of multidisciplinary exchange of knowledge was particularly appreciated.

CONCLUSION

Having considered the issue of teaching hospital hygiene from the points of view of the different protagonists involved (educators and students), this enabled us to develop useful training material and a proposal for a shared educational intervention. The subject of hospital hygiene, in particular the one related to the prevention of healthcare-associated infections, is addressed in various courses and with different modalities; it is, therefore, important to standardize course contents and teaching methods, in order to facilitate multidisciplinary debate, especially starting from case studies.

The commitment of the GISIO-SItI to contrast Healthcare-Associated Infections and the experience of prevalence studies in Sicily

Surveillance of Healthcare-Associated Infections (HAIs) is essential to improve the quality of health services. The aim of this paper is to report the commitment of the Italian Study Group of Hospital Hygiene (GISIO) of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) describing some experiences to contrast HAIs and antimicrobial resistance. Particularly, the commitment to contrast HAIs in intensive care with the SPIN-UTI project - Italian Nosocomial Infections Surveillance in ICUs, and in surgery with the ISCHIA project - Infections of Surgical Site in Arthroplasty Interventions - were described. Furthermore, some activities conducted in Sicily using repeated prevalence studies were reported. The experiences reported confirmed that surveillance is essential to provide health services with information, guidance and tools to manage effectively the risk of HAI and antimicrobial resistance and to monitor the level of achievement of control programmes.

Peer Education strategies for promoting prevention of doping in different populations

BACKGROUND

In the field of doping prevention, alongside the traditional functions of repression and control of the phenomenon, educational aspects are becoming increasingly important. Article 18 of the World Anti doping Code obliges the signatories to invest in anti-doping education with the aim of preserving the spirit of sport. The educational commitment should involve young people in health promotion interventions for the prevention of risk behaviors. Therefore, our attention has focused on finding the mechanisms that lead people to make certain behavioral choices.

MATERIAL AND METHODS

In the context of preventive programs, to counter the doping phenomenon through health promotion programs, the most recognized method is peer education, particularly with adolescents. It is an educational method according to which some members of a group are empowered and trained to carry out specific activities with their peers. It is constituted as an example of equal relationship and finds its basis in cooperation and solidarity with the aim of increasing empowerment and a healthy development of the identity and collective dimension in young people.

RESULTS

Numerous experts - biologists / nutritionists, hygienists, sports coaches, psychologists, teachers of physical education in secondary schools and other stakeholders have actively participated in the co-construction of a training package aimed at activating cascade training processes on the knowledge and skills of peer education in contexts of youth aggregation, such as schools, gyms, sports associations, social gatherings of all kinds. The path allowed to define a peer education model capable of enabling the participants to activate health promotion interventions for the prevention of doping risk behaviors, each in their own setting.

CONCLUSIONS

In conclusion, we can say that prevention programs are the more effective the more they are addressed to young people and adolescents and provide interactive and action-oriented interventions. Successful initiatives aim to emphasize the development of life skills and to influence numerous determinants of behavior, including individual attitudes, knowledge, motivations, interpersonal relationships and social norms. If the aim is to act on the change of behavior, the efforts will be more successful if the content of the intervention will give due consideration to the context in which it applies and the target population, involving it and addressing its specific needs and values.

Procedures in endoscope reprocessing and monitoring: an Italian survey

BACKGROUND

The high diffusion of endoscopes worldwide and the need for effective reprocessing methods requested the development of guidelines and implementation of surveillance procedures at local level.

STUDY DESIGN

In order to collect data on everyday's practice and adherence to available guidelines, endoscopy units from different public institutions were surveyed using a dedicated questionnaire.

METHODS

Between July and November 2015 a survey was carried in 12 main hospitals from 10 different Italian regions, involving 22 endoscopy units. The state of the art of national and international guidelines was investigated to compare the protocols adopted at local level.

RESULTS

In all the surveyed hospitals, the reprocessing activity is based on pre-established protocols in adherence with principal guidelines. Enzymatic detergents, which are recommended by the international guidelines, are used in 55.6% of units and peracetic acid is currently the most widely used chemical disinfectant. Discrepancies were observed in the application of periodic quality controls.

CONCLUSION

Updated guidelines are generally applied in reprocessing practice. Quality controls may represent a critical issue to improve effectiveness and surveillance. The whole of acquired data can promote a positive trend towards the application of best practices.

Definition of criteria and indicators for the prevention of Healthcare-Associated Infections (HAIs) in hospitals for the purposes of Italian institutional accreditation and performance monitoring

BACKGROUND

Healthcare-associated infections (HAIs) are an important issue in terms of quality of care. HAIs impact patient safety by contributing to higher rates of preventable mortality and prolonged hospitalizations. In Italy, analysis of the currently available accreditation systems shows a substantial heterogeneity of approaches for the prevention and surveillance of HAIs in hospitals. The aim of the present study is to develop and propose the use of a synthetic assessment tool that could be implemented homogenously throughout the nation.

METHODS

An analysis of nine international and of the 21 Italian regional accreditation systems was conducted in order to identify requirements and indicators implemented for HAI prevention and control. Two relevant reviews on this topic were further analyzed to identify additional evidence-based criteria. The project team evaluated all the requirements and indicators with consensus meeting methodology, then those applicable to the Italian context were grouped into a set of "focus areas".

RESULTS

The analysis of international systems and Italian regional accreditation manuals led to the identification respectively of 19 and 14 main requirements, with relevant heterogeneity in their application. Additional evidence-based criteria were included from the reviews analysis. From the consensus among the project team members all the standards were compared and 20 different thematic areas were identified, with a total of 96 requirements and indicators for preventing and monitoring HAIs.

CONCLUSIONS

The study reveals a great heterogeneity in the definition of accreditation criteria between the Italian regions. The introduction of a uniform, synthetic assessment instrument, based on the review of national and international standards, may serve as a self-assessment tool to evaluate the achievement of a minimum standards set for HAIs prevention and control in healthcare facilities. This may be used as an assessment tool by the Italian institutional accreditation system, also useful to reduce regional disparities.

Aerobiological monitoring and mapping of Ambrosia plants in the province of Parma (northern Italy, southern Po valley), a useful tool for targeted preventive measures

BACKGROUND

Ambrosia is an annual anemophilous weed producing allergenic pollen affecting public health in European countries. In Italy, the most infested region is Lombardy where, in some areas, it is the major cause of hay fever. In the Parma district, until 2007, Ambrosia seemed to be very rare, despite an observed increase of Seasonal Pollen Index (SPI), of pollen peak value and of asthma among ragweed sensitized patients. The aims of this study were to calculate ragweed pollen season and trends from 1996 to 2015, to assess the relationships between pollen season characteristics and selected meteorological data, to map plants in the territory and to evaluate the presence of beetle Ophraella communa (Ophraella), known as an eater of Ambrosia leaves.

METHODS

The following pollination parameters: start, end, duration, peak concentration date, peak values, SPI and the following climatic parameters: temperature, relative humidity, rainfall, were analyzed. The ragweed plants sites were mapped and the presence of Ophraella was assessed during naturalistic activities.

RESULTS

Significant SPI and pollen peak value increase until 2011 were observed, but recently, 2012-2015 vs 2009-2011, a strong reduction (about 50%) of these parameters was observed. The spring average air temperature increased significantly. The results of the correlation analysis showed Ambrosia season characteristics significantly related. We identified the sites source of Ambrosia, even downtown at the confluence between Parma and Baganza rivers. Ophraella was observed for the first time in 2014.

CONCLUSIONS

The results showed the spread of ragweed plants over the territory and the risk of allergy increase that ragweed could cause. It remains to evaluate the role of the Ophraella in the reduction of Ambrosia pollen concentration. It is important to consider the potential risk Ophraella may represent for sunflower and other taxonomically related crop plants and other native and exotic species. The lack of initiatives by the Health Authorities to prevent and to contrast the spread of Ambrosia in the Parma area could cause public health consequences and an increase in health expenditures.

Risk of surgical site infections following hip and knee arthroplasty: results of the ISChIA-GISIO study

BACKGROUND

Surgical Site Infection (SSI) is one of the major complications following insertion of hip or knee prosthesis. The aim of the present study was to describe rates of SSIs and associated risk factors during hip and knee prosthesis procedures in Italian hospitals.

METHODS

Italian hospitals were invited to join the ISChIA (Surgical Site Infections in Arthroplasty Surgery) project and participated in the study on a voluntary basis. SSI surveillance was performed according to the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) -SSI protocol. The study population consisted of all patients who had a prosthetic knee or hip joint replacement between March 2010 and February 2011. Only elective operations were include.

RESULTS

A total of 14 hospitals and 1285 surgical procedures were included. SSI cumulative incidence was 1.3 per 100 hip and 2.4 per 100 knee surgical procedures; a significant positive trend of SSI incidences was observed with increasing SSI risk index. In multivariate analysis, considering hip procedures, the single independent risk factor associated to SSI was operation length (RR: 4.54; 95%CI: 1.06-19.48). For knee procedures, no significant risk factor was identified.

CONCLUSIONS

In the present study, SSI cumulative incidence was in the range of European data. However, a larger number of operations is needed to better estimate SSI rates. A second edition of the ISChIA project has been already conducted and results of the two surveys will provide new insight to further our knowledge for infection control.

Water safety in healthcare facilities. The Vieste Charter

The Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health (GISIO-SItI) and the Local Health Authority of Foggia, Apulia, Italy, after the National Convention "Safe water in healthcare facilities" held in Vieste-Pugnochiuso on 27-28 May 2016, present the "Vieste Charter", drawn up in collaboration with experts from the National Institute of Health and the Ministry of Health. This paper considers the risk factors that may affect the water safety in healthcare facilities and reports the current regulatory frameworks governing the management of installations and the quality of the water. The Authors promote a careful analysis of the risks that characterize the health facilities, for the control of which specific actions are recommended in various areas, including water safety plans; approval of treatments; healthcare facilities responsibility, installation and maintenance of facilities; multidisciplinary approach; education and research; regional and national coordination; communication.

A multidisciplinary approach to the study of cultural heritage environments: Experience at the Palatina Library in Parma

The aim of this paper is to describe a multidisciplinary approach including biological and particle monitoring, and microclimate analysis associated with the application of the Computational Fluid Dynamic (CFD). This approach was applied at the Palatina historical library in Parma. Monitoring was performed both in July and in December, in the absence of visitors and operators. Air microbial monitoring was performed with active and passive methods. Airborne particles with a diameter of ≥0.3, ≥0.5, ≥1 and ≥5 μm/m3, were counted by a laser particle counter. The surface contamination of shelves and manuscripts was assessed with nitrocellulose membranes. A spore trap sampler was used to identify both viable and non-viable fungal spores by optical microscope. Microbiological contaminants were analyzed through cultural and molecular biology techniques. Microclimatic parameters were also recorded. An infrared thermal camera provided information on the surface temperature of the different building materials, objects and components. Transient simulation models, for coupled heat and mass-moisture transfer, taking into account archivist and general public movements, combined with the related sensible and latent heat released into the environment, were carried out applying the CFD-FE (Finite Elements) method. Simulations of particle tracing were carried out. A wide variability in environmental microbial contamination, both for air and surfaces, was observed. Cladosporium spp., Alternaria spp., Aspergillus spp., and Penicillium spp. were the most frequently found microfungi. Bacteria such as Streptomyces spp., Bacillus spp., Sphingomonas spp., and Pseudoclavibacter as well as unculturable colonies were characterized by molecular investigation. CFD simulation results obtained were consistent with the experimental data on microclimatic conditions. The tracing and distribution of particles showed the different slice planes of diffusion mostly influenced by the convective airflow. This interdisciplinary research represents a contribution towards the definition of standardized methods for assessing the biological and microclimatic quality of indoor cultural heritage environments.

Swimming pools and health-related behaviours: results of an Italian multicentre study on showering habits among pool users

OBJECTIVES

Showering before entering a swimming pool is highly recommended to reduce the risk of biological and chemical contamination. This study evaluated the behaviour of indoor swimming pool users; analysed the variables associated with lack of showering; and assessed awareness of the importance of showering.

STUDY DESIGN

Cross-sectional study.

METHODS

A self-administered questionnaire was used to collect data about users of swimming pools located in five different Italian cities. The association between specific variables and the lack of showering was assessed. P < 0.05 was considered to indicate statistical significance.

RESULTS

In total, 4356 questionnaires were analysed. Sixty-five percent of interviewees always showered before entering the pool. The main reason given for pre-swim showering was 'to wash oneself' (50.5%); or 'to get used to the temperature of the water' (44.3%); and 5.2% answered 'for both reasons'. Risk factors significantly associated with lack of showering were: female sex (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.2-1.59), age 14-17 years (OR 5.09, 95% CI 3.40-7.64); not reading the swimming pool rules (OR 1.24, 95% CI 1.10-1.41); living in Central Italy (OR 3.3, 95% CI 2.65-4.1) or Southern Italy (OR 1.35, 95% CI 1.18-1.55); and previous/current attendance of a swimming course (OR 1.7, 95% CI 1.48-1.97).

CONCLUSIONS

The results revealed low compliance with the rule of showering before entering a swimming pool, and little awareness of the preventive role of showering in the hygienic management of swimming pools. There is a need for targeted educational interventions to inform swimming pool users of the reasons for the importance of showering before entering a pool.

Building a benchmark through active surveillance of intensive care unit-acquired infections: the Italian network SPIN-UTI

The Italian Nosocomial Infections Surveillance in Intensive Care Units (ICUs) (SPIN-UTI) project of the Italian Study Group of Hospital Hygiene (GISIO - SItI) was undertaken to ensure standardisation of definitions, data collection and reporting procedures using the Hospital in Europe Link for Infection Control through Surveillance (HELICS)-ICU benchmark. Before starting surveillance, participant ICUs met in order to involve the key stakeholders in the project through participation in planning. Four electronic data forms for web-based data collection were designed. The six-month patient-based prospective survey was undertaken from November 2006 to May 2007, preceded by a one-month surveillance pilot study to assess the overall feasibility of the programme and to determine the time needed and resources for participant hospitals. The SPIN-UTI project included 49 ICUs, 3053 patients with length of stay >2 days and 35 498 patient-days. The cumulative incidence of infections was 19.8 per 100 patients and the incidence density was 17.1 per 1000 patient-days. The most frequently encountered infection type was pneumonia, Pseudomonas aeruginosa being the most frequent infection-associated micro-organism, followed by Staphylococcus aureus and Acinetobacter baumannii. Site-specific infection rates for pneumonia, bloodstream infections, central venous catheter-related bloodstream infections and urinary tract infections, stratified according to patient risk factors, were below the 75th centile reported by the HELICS network benchmark. The SPIN-UTI project showed that introduction of ongoing surveillance should be possible in many Italian hospitals. The study provided the opportunity to participate in the HELICS project using benchmark data for comparison and for better understanding of factors influencing risks.

[Evolution and practical application of the concept of clinical governance in Italy]

Clinical Governances' roots in the United Kingdom's National Health Service and the following introduction of "Governo Clinico" in Italy are analyzed. Some definitions of Clinical Governance and "Governo clinico" are presented and discussed, by highlighting the main characteristics and differences, both conceptual and semiological. Finally, legal bases for the official empowerment of Healthcare Governance in Italy are described, by focusing on the Region Emilia-Romagna, whose recent Social and Sanitary Plan for 2008-2010 has developed concepts of integration, multidisciplinarity, responsibility and quality of socio-sanitary services.

A mobile laminar airflow unit to reduce air bacterial contamination at surgical area in a conventionally ventilated operating theatre

The aim of this study was to evaluate the efficacy of a mobile laminar airflow (LAF) unit in reducing bacterial contamination at the surgical area in an operating theatre supplied with turbulent air ventilation. Bacterial sedimentation was evaluated during 76 clean urological laparotomies; in 34 of these, a mobile LAF unit was added. During each operation, settle plates were placed at four points in the operating theatre (one at the patient area and three at the perimeter), a nitrocellulose membrane was placed on the instrument table and an additional membrane near the wound. During four operations, particle counting was performed to detect particles > or =0.5 microm. Mean bacterial sedimentation on the nitrocellulose membrane on the instrument table was 2730 cfu/m(2)/h under standard ventilation conditions, whereas it decreased significantly to a mean of 305 cfu/m(2)/h when the LAF unit was used, i.e. within the suggested limit for ultraclean operating theatres (P=0.0001). The membrane near the wound showed a bacterial sedimentation of 4031 cfu/m(2)/h without the LAF unit and 1608 cfu/m(2)/h with the unit (P=0.0001). Particle counts also showed a reduction when the LAF unit was used. No significant difference was found at the four points in the operating theatre between samplings performed with, and without, the LAF unit. Use of a mobile LAF unit with turbulent air ventilation can reduce bacterial contamination at the surgical area in high-risk operations (e.g. prosthesis implant).

[Hygienic risks in swimming pool: knowledge and behaviours of consumers of three structures in Crema, Parma and Naples]

The swimmers health's protection and the maintenance of good safety standards of structures can be guaranteed under observance of rules and the well management of the structures and activities. An anonymous questionnaire, with 38 items, was used in order to analyse and better understand the knowledge and behaviour of the users of three swimming pools in Crema, Naples and Parma. Socio-demographic features were similar in the three centres. One of the most important result was that the necessity of showers and foot-bath before entering the swimming pool is not well understood (77% and 78% respectively); caps and foot bath are, instead, almost always worn (98% and 97%). Knowledge on infection diseases transmitted by water is very poor, warts and mycosis being the best known. Sport structures are places where health and wellness can be affected. It is important to underline the role of behavioural rules as the use of showers, caps, and proper shoes. Authors recognize the swimming pool regulations as a valid tool for health promotion. It must be clear and easily understood and it has to be linked to a proper education pathway of all users and employees.

Water treatment in domiciliary hemodialysis equipment: ultraviolet irradiation and Sartobind membrane

Water is a fundamental element in any hemodialysis device. It must be safe, free not only of micro-organisms but also of any organic or inorganic chemical contaminant. Up to now ion exchanger, reverse osmosis, activate carbon and chlorine are generally used for this purpose. The results are not satisfactory. Microbial contaminants survive and at some points multiply. Pyrogens and endotoxins are not completely eliminated. Chlorine itself adds more risk factors because of the compounds deriving from its interaction with organic molecules. A system to obtain safe water in hemodialysis equipment is described. It is based on the use of ultraviolet irradiation to eliminate any microbial contaminant and on Sartobind membranes to eliminate pyrogens, endotoxins, proteins and other unwanted molecules. Mobile domiciliary hemodialysis equipment was used. Ultraviolet lamps (30 mW/cm2) were applied at two points: after the ion exchange and after the reverse osmosis. Three Q100 Sartobind membranes were positioned immediately before the monitor. The values of cfu/mL counted in the water after the ion exchange ranged from 450 to 1,990, whereas before the monitor they dropped from 0.01 to 0.09 cfu/mL. The LAL test, positive before the Sartobind membrane, was negative thereafter. The system proposed has shown to be effective in guaranteeing safe water free of micro-organisms and endotoxins.

Clonal spread of Acinetobacter baumannii in a general intensive care unit

The epidemiological characterization of multiply resistant Acinetobacter baumannii isolates from a six-bed Intensive Care Unit (ICU) is described. Investigations for A. baumannii were performed in three subsequent surveillance studies. In the first study, surveillance cultures were taken from patients, health care personnel and the environment; in the second study surveillance cultures were taken at 0, 4, and 7 days from all patients admitted consecutively to the ward; and in the third study surveillance cultures were taken from patients, health care personnel and the environment. During the first study all four hospitalized patients were found to harbour A. baumannii. Hand cultures did not grow any A. baumannii when staff entered the ward from home, but 7 positive health care workers were identified out of 25 samples taken during work, and two cultures of environmental specimens grew A. baumannii. During the second study, 4 of 86 (4.6%) patients resulted colonized with A. baumannii. In the third epidemiological study, no A. baumannii was cultured from either patients, health care personnel or the environment. All isolates recovered from various patients or sources produced conserved macrorestriction Pulsed-Field Gel Electrophoresis (PFGE) patterns and showed the same antibiotic resistance; therefore, they can be considered indistinguishable. The same antibiotic resistance and macrorestriction patterns were observed in previously isolated A. baumannii strains in the ward during May 1997, suggesting the persistence of a single A. baumannii in the ICU. The present study confirms that molecular typing is an essential tool in the epidemiology and control of nosocomial infections, showing here the persistence of a single A. baumannii clone in the ICU. The origin of this strain remains unknown but, when basic infection control measures were reinforced, emphasizing the importance of hand antisepsis and judicious use of gloves, control of A. baumannii spread in the ward was achieved.

[Microbial air monitoring in operating theatre: active and passive samplings]

Microbial air contamination was evaluated in 11 operating theatres using active and passive samplings. SAS (Surface Air System) air sampling was used to evaluate cfu/m3 and settle plates were used to measure the index of microbial air contamination (IMA). Samplings were performed at the same time on three different days, at three different times (before, during and after the surgical activity). Two points were monitored (patient area and perimeter of the operating theatre). Moreover, the cfu/m3 were evaluated at the air inlet of the conditioner system. 74.7% of samplings performed at the air inlet and 66.7% of the samplings performed at the patient area before the beginning of the surgical activity (at rest) exceeded the 35 cfu/m3 used as threshold value. 100% of IMA values exceeded the threshold value of 5. Using both active and passive sampling, the microbial contamination was shown to increase significantly during activity. The cfu values were higher at the patient area than at the perimeter of the operating theatre. Mean values of the cfu/m3 during activity at the patient area ranged from a minimum of 61+/-41 cfu/m3 to a maximum of 242+/-136 cfu/m3; IMA values ranged from a minimum of 19+/-10 to a maximum of 129+/-60. 15.2% of samplings performed at the patient area using SAS and 75.8% of samplings performed using settle plates exceeded the threshold values of 180 cfu/m3 and 25 respectively, with a significant difference of the percentages. The highest values were found in the operating theatre with inadequate structural and managerial conditions. These findings confirm that the microbiological quality of air may be considered a mirror of the hygienic conditions of the operating theatre. Settle plates proved to be more sensitive in detecting the increase of microbial air contamination related to conditions that could compromise the quality of the air in operating theatres.

[Multicentric survey on hygienic aspects in private dental practice]

The aim of this research was to evaluate the knowledge of cross-infection hazards in private dental practices, and their control procedures. The survey, carried out by questionnaire in 11 Italian cities, showed that dental personnel do not completely follow the main procedures for infection control. The interviewed subjects usually wear gloves (95.5%), masks (90.1%) and glasses (91.2%), less frequently caps (23.9%) and coats (54.9%). They use steam sterilizers (92.9%) and periodically check the effectiveness (80.6%). Regarding individuals protection, 20.5% is not vaccinated against HBV and only 55.2% of those previously vaccinated has checked their immunity. Moreover, the majority of subjects underestimate the infection hazards especially for air-transmitted diseases.

[Hygiene education in the Laureate Course of Dentistry and Dental Prosthetics: evaluation of student knowledge about the risk of infection in a dental practice environment]

Hygiene education for dental students is crucial in order to control and reduce the risk of infections in their future professional practices. The aim of this study was to evaluate the improvement in university students' knowledge of infectious disease prevention, dental instruments and environmental decontamination following the Course in Dental Hygiene and Prevention. 595 questionnaires were submitted to dental students at twelve Italian Universities; 335 were filled out before the Course began and 260 at the end of the same course. The students in both the PRE-course and at the POST-course evaluations demonstrated adequate knowledge regarding the transmission of infections in dental practices, knowledge improved following the Hygiene course.

Lack of influence of body exhaust gowns on aerobic bacterial surface counts in a mixed-ventilation operating theatre. A study of 62 hip arthroplasties

Aerobic bacterial surface contamination was studied with and without the use of body exhaust gowns in an operating room equipped with mixed/turbulent ventilation and separate operating and anaesthetic areas during 62 hip joint arthroplasties. In 31 operations conventional gowns were used, and 31 were performed with body exhaust gowns. Bacterial surface contamination was monitored in the operating and anaesthetic area using 9 cm diameter settle plates (1+1) and nitrocellulose membranes (2+2) transferred after sampling to nutrient pads. Compared with conventional clothing, the use of body exhaust gowns did not significantly reduce the microbial contamination (P=0.1-0.7). On the settle plates 1 m from the patient 279+/-326 cfu/m(2)/h were observed with conventional clothing compared with 142+/-227 cfu/m(2)/h with body exhaust gowns. The first membrane located on the patient in the sterile area detected 250+/-590 cfu/m(2)/h with conventional clothing and 210+/-320 cfu/m(2)/h with exhaust gowns. For the second membrane on the floor, the counts were 1790+/-2700 and 1590+/-1590 cfu/m(2)/h. For all operations the settle plates yielded 210+/-287 cfu/m(2)/h in the operating area and 720+/-564 cfu/m(2)/h in the anaesthetic area (P=0.01). Compared with the membrane placed on the anaesthetic equipment the counts on the membrane placed on patient were also significantly lower (P=0.01) while the membranes placed on the floor in each area showed no difference in counts. In conclusion, compared with conventional clothing, the use of body exhaust gowns could not be proven to provide more protection against microbial contamination. The low number of colony forming units found in the operating area was similar to that expected from an ultraclean laminar airflow unit, although achieved with a cheaper and more energy saving system.

Factors influencing hospital infection control policies in Italian hospitals

A study was undertaken to determine the resources available in Italian hospitals for the control of nosocomial infections and the factors favouring a successful approach. During January-May 2000 a questionnaire about infection control was sent to the hospital health director of all Italian National Health System hospitals treating acute patients and with more than 3500 admissions in 1999. An active programme was defined as a hospital infection control committee (HICC) meeting at least four times in 1999, the presence of a doctor with infection control responsibilities, a nurse employed in infection control and at least one surveillance activity and one infection control guideline issued or updated in the past two years. There was a response rate of 87.5% (463/529). Almost fifteen percent (69/463) of hospitals had an active programme for Infection Control and 76.2% (353/463) had a HICC. Seventy-one percent (330/463) of the hospitals had a hospital infection control physician and 53% (250/463) had infection control nurses. Fifty-two percent (242/463) reported at least one surveillance activity and 70.8% (328/463) had issued or updated at least one guidance document in the last two years. The presence of regional policies [odds ratio (OR) 8.7], operative groups (OR 4.2), at least one full-time nurse (OR 4.6) and a hospital annual plan which specified infection control (OR 2.1) were statistically associated with an active programme in the multivariate analysis.

Burkholderia cepacia complex in cystic fibrosis and non-cystic fibrosis patients: identification of a cluster of epidemic lineages

This study was performed in order to compare Burkholderia cepacia complex strains from cystic fibrosis (CF) and non-CF patients at the genomovar, genetic and epidemiological levels. A total of 92 B. cepacia respiratory tract isolates were obtained from patients attending the following CF centres: Catania and Palermo, Sicily; Gualdo Tadino, Central Italy, and Milan, Northern Italy. A total of 23 B. cepacia isolates were obtained from blood, surgical wound, and intravenous catheter sources of patients without CF, hospitalized in Catania and Varese, Northern Italy. Genomovar status identification, clonality and genetic relatedness determination, antibiotic susceptibility pattern determination and electron microscopy were performed. Transmission of infection was shown in both CF and non-CF patients by identifying clonality of responsible strains. In total 13 clones were involved in cross-transmission episodes. No outbreak was described involving both CF and non-CF patients. The present study indicates the existence of a distinct cluster of strains responsible for epidemics in CF and non-CF patients, based on their genetic relatedness, distinct from strains associated with no or negligible transmissibility. This result suggests that transmissibility is not only associated with a specific genomovar in CF patients, but also with a group of genetically related lineages in CF and non-CF patients. A key role is shown for both segregation measures and careful surveillance of infection, based on selective culture, molecular identification and epidemiological characterization of individual isolates.

The index of microbial air contamination

The standard index of microbial air contamination (IMA) for the measurement of microbial air contamination in environments at risk is described. The method quantifies the microbial flow directly related to the contamination of surfaces coming from microbes that reach critical points by falling on to them. The index of microbial air contamination is based on the count of the microbial fallout on to Petri dishes left open to the air according to the 1/1/1 scheme (for 1h, 1m from the floor, at least 1m away from walls or any obstacle). Classes of contamination and maximum acceptable levels have been established. The index of microbial air contamination has been tested in many different places: in hospitals, in food industries, in art galleries, aboard the MIR space station and also in the open air. It has proved to be a reliable and useful tool for monitoring the microbial surface contamination settling from the air in any environment.