Oral hygiene in critically ill patients at a tertiary hospital in São Paulo, Brazil: a best practice implementation project

OBJECTIVES

This project aimed to promote evidence-based practices relat. ed to the oral health of critically ill patients in an intensive care unit in Brazil.

INTRODUCTION

The oral hygiene of patients on mechanical ventilation is an essential component of nursing care quality, and well-defined guidelines ensure appropriate care. Mechanical ventilation is associated with the risk of ventilator-associated pneumonia, which can increase mortality, length of stay, time on mechanical ventilation, and hospital costs.

METHODS

This project was guided by the JBI Evidence Implementation Framework, which consists of seven stages: (1) identification of the area of practice to be changed, (2) involvement of change agents, (3) context assessment and readiness for change, (4) review of practices against evidence-based audit criteria, (5) implementation of practice changes, (6) reassessment of practices using a follow-up audit and (7) consideration of the sustainability of changes in practice.

RESULTS

Four audit criteria were developed to evaluate compliance with best practices. In the follow-up audit, Criteria 1, 2, and 3 obtained compliance of ≥ 80%. Thus, for Criterion 1, all the patients on mechanical ventilation for more than 24 hours were evaluated by the oral medicine team, resulting in 100% compliance. For Criterion 2 on appropriate oral hygiene measures, a compliance rate of 80% was achieved. For Criterion 3, 39 professionals (90.7%) participated in educational activities related to the oral health protocol for critically ill patients, obtaining 90.7% compliance. For Criterion 4 regarding patients being evaluated before receiving any oral health care, improvement was low (only 50%), revealing the need for further improvement.

CONCLUSION

This best practice project improved the professional practice of nursing staff and increased compliance with best practices for the oral health of critically ill patients.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A175.

Evaluation of cleaning process efficacy of instruments for robotic surgery using the adenosine triphosphate test

BACKGROUND

Despite the advances in robotic surgery and its benefits for the patient and surgeon, there are difficulties and challenges in reprocessing surgical instruments, including with regard to patient safety, such as the risk of infection. The aim of this article is to evaluate the effectiveness of manual plus ultrasonic cleaning of EndoWrist devices used in robotic surgery using the adenosine triphosphate bioluminescence quantitative test.

METHODS

A prospective cross-sectional study assessed the cleanliness of robotic instrumentals used in surgeries. Surgical instruments were collected immediately after the end of the surgery and sent for cleaning and disinfection following standard hospital procedures. The adenosine triphosphate test was done after visual evaluation. According to our hospital standard, instruments were classified as "approved" if the test found ≤50 relative light units.

FINDINGS

We evaluated 279 EndoWrist instruments from 65 robotic surgeries. The most frequently used instruments were needle drivers (102; 39%), followed by bipolar instruments (65; 25%). Median relative light units were 49 (range = 4-13,095); 54% of instruments were classified as approved according to the hospital's threshold (relative light units ≤50) and 78% when the manufacturer's threshold (relative light units ≤150) was used. Monopolar instruments presented the best rate of approval (94% considering relative light units ≤50 and 100% with relative light units ≤150). The average relative light units did not vary with the number of reuses. There were no surgical site infections.

CONCLUSION

Manual plus automated cleaning processes reduced bioburden in all situations evaluated. It seems that instruments can be safely reprocessed ≤9 times and that monopolar instruments are the easiest to clean.

Assessment of the Hawthorne effect during central venous catheter manipulation

OBJECTIVES

To describe the compliance to the practices of hand hygiene and hub disinfection before manipulation of the central venous catheter in two moments: before and after educational intervention. Adherence to hand hygiene was assessed with two methods: direct observation and video camera.

METHODS

Before and after study conducted with the nursing team in an adult intensive care unit, in São Paulo, Brazil, including 180 observations using video cameras and direct observation. Hand hygiene compliance before catheter manipulation and compliance with the correct technique and the hub disinfection for five seconds were observed.

RESULTS

When video cameras recording was observed, hand hygiene compliance increased from 46% to 66% and the use of the proper technique increased from 23% to 46% (p < 0.05). Regarding hub disinfection compliance, no difference was observed between the periods. Hand hygiene compliance in direct observation increased from 83% to 87% and in indirect observation, from 46% to 66% after the intervention.

CONCLUSION

After the educational intervention, hand hygiene compliance before CVC manipulation and the use of the correct technique improved. When observed indirectly, the adherence to these practices was lower, reinforcing the Hawthorne effect.

SARS-Cov-2 seroprevalence and risk factors among health care workers: Estimating the risk of COVID-19 dedicated units

We evaluated the seroprevalence of SARS-CoV-2 and risk factors among 1,996 oligo/asymptomatic health care workers. The seroprevalence was 5.5% and risk factors associated with being infected with SARS-CoV-2 was professional category of cleaning (adj odds ratio 2.22, 95% confidence interval: 1.12-4.44, P: .023) and male gender (adj odds ratio: 1.54, 95% confidence interval: 1.03-2.32, P: .035).Working at dedicated COVID-19 units (high-risk group) was not an independent risk factor for seropositivity.

Influenza A (H1N1): outbreak management in a dialysis unit and clinical outcomes of infection in chronic hemodialysis patients

INTRODUCTION

Chronic hemodialysis (HD) patients are considered to be at high risk for infection. Here, we describe the clinical outcomes of chronic HD patients with influenza A (H1N1) infection and the strategies adopted to control an outbreak of influenza A in a dialysis unit.

METHODS

Among a total of 62 chronic HD patients, H1N1 infection was identified in 12 (19.4%). Of the 32 staff members, four (12.5%) were found to be infected with the H1N1 virus. Outcomes included symptoms at presentation, comorbidities, occurrence of hypoxemia, hospital admission, and clinical evaluation. Infection was confirmed by real-time reverse transcriptase polymerase chain reaction.

RESULTS

The 12 patients who had H1N1 infection did not differ significantly from the other 50 non-infected patients with respect to age, sex, dialysis vintage, dialysis modality, or proportion of comorbidities. Obesity was higher in the H1N1-infected group (41.5 vs. 4%, p<0.002). The most common symptoms were fever (92%), cough (92%), and rhinorrhea (83%). Early empirical antiviral treatment with oseltamivir was started in symptomatic patients and infection control measures, including the intensification of contact-reduction measures by the staff members, antiviral chemoprophylaxis to asymptomatic patients undergoing HD in the same shift of infected patients, and dismiss of staff members suspected of being infected, were implemented to control the spread of infection in the dialysis unit.

CONCLUSION

The clinical course of infection with H1N1 in our patients was favorable. None of the patients developed severe disease and the strategies adopted to control the outbreak were successful.

Implementation of tailored interventions in a statewide programme to reduce central line-associated bloodstream infections

BACKGROUND

There have been few studies exploring implementation strategies to central line-associated bloodstream infections (CLABSIs) in low- or middle-income countries.

AIM

To implement tailored interventions to reduce CLABSI rates in adult intensive care units.

METHODS

The implementation strategy of the State Health Department was performed in São Paulo State, Brazil, over two cycles. Cycle 1 (56 hospitals) was exploratory and cycle 2 (77 hospitals) was designed to confirm the hypothesis generated by the first cycle, with three phases each (pre-intervention, intervention, post-intervention). Cycles included: evaluation of healthcare workers' knowledge, observation of practices, and CLABSI rates monthly report. In cycle 1, a log-normal mixed model was used to select variables significantly associated with the reduction of CLABSI. In cycle 2, CLABSI rates were evaluated.

FINDINGS

Healthcare workers' practices improved after intervention. In cycle 1, reduction of CLABSI rates was more pronounced in hospitals with initial CLABSI rates >7.4 per 1000 catheter-days (P < 0.001) and those that introduced the use of peripherally inserted central catheters (P = 0.01). For hospitals with high CLABSI initial rates, simulation demonstrated that the rates were expected to decrease by 36% (95% CI: 9-63), no matter the type of intervention. In cycle 2, there was an overall decrease in CLABSI rates during the intervention period; whereas the mean rate fell further post-intervention, rates at the 90^th percentile increased.

CONCLUSION

The implementation strategy may have had an effect on infection rates independently of the specific interventions implemented; however, the sustainability of reduction in the post-intervention period remains a challenge.

The Impact of Restricting Over-the-Counter Sales of Antimicrobial Drugs: Preliminary Analysis of National Data

To describe the nationwide impact of a restrictive law on over-the-counter sales of antimicrobial drugs, implemented in Brazil in November 2010. Approximately 75% of the population receives healthcare from the public health system and receives free-of-charge medication if prescribed. Total sales in private pharmacies as compared with other channels of sales of oral antibiotics were evaluated in this observational study before and after the law (2008-2012). Defined daily dose per 1000 inhabitants per day (DDD/TID) was used as standard unit. In private pharmacies the effect of the restrictive law was statistically significant (P < 0.001) with an estimated decrease in DDD/TID of 1.87 (s.e. =  0.18). In addition, the trend of DDD/TID before the restrictive law was greater than after the intervention (P < 0.001). Before November 2010, the slope for the trend line was estimated as 0.08 (s.e. = 0.01) whereas after the law, the estimated slope was 0.03 (s.e. = 0.01). As for the nonprivate channels, no difference in sales was observed (P = 0.643). The impact in the South and Southeast (more developed) regions was higher than in the North, Northeast, and Mid-West. The state capitals had a 19% decrease, compared with 0.8% increase in the rest of the states. Before the law, the sales of antimicrobial drugs were steadily increasing. From November 2010, with the restrictive law, there was an abrupt drop in sales followed by an increase albeit at a significantly lower rate. The impact was higher in regions with better socio-economic status.

Colonization pressure as a risk factor for colonization by multiresistant Acinetobacter spp and carbapenem-resistant Pseudomonas aeruginosa in an intensive care unit

OBJECTIVE

To determine factors associated with colonization by carbapenem-resistant Pseudomonas aeruginosa and multiresistant Acinetobacter spp.

METHODS

Surveillance cultures were collected from patients admitted to the intensive care unit at admission, on the third day after admission and weekly until discharge. The outcome was colonization by these pathogens. Two interventions were implemented: education and the introduction of alcohol rubs. Compliance with hand hygiene, colonization pressure, colonization at admission and risk factors for colonization were evaluated.

RESULTS

The probability of becoming colonized increased during the study. The incidence density of colonization by carbapenem-resistant P. aeruginosa and multiresistant Acinetobacter spp. and colonization pressure were different between periods, increasing gradually throughout the study. The increase in colonization pressure was due to patients already colonized at admission. The APACHE II score, colonization pressure in the week before the outcome and male gender were independent risk factors for colonization. Every 1% increase in colonization pressure led to a 2% increase in the risk of being colonized.

CONCLUSION

Colonization pressure is a risk factor for carbapenem-resistant P. aeruginosa and multiresistant Acinetobacter spp. colonization. When this pressure reaches critical levels, efforts primarily aimed at hand hygiene may not be sufficient to prevent transmission.

Candida colonisation as a source for candidaemia

Candida spp. are important healthcare-associated pathogens. Identifying the source of infection is important for prevention and control strategies. The objective of this study was to evaluate candida colonisation sites as potential sources for candidaemia. Sixty-three consecutive patients with a positive blood culture for candida were included. Surveillance cultures were collected from urine, rectum, oropharynx, skin, intravascular catheter tip and skin around catheter. Molecular typing was performed when the same species of candida was isolated from blood and surveillance sites of a patient. C. albicans was associated with 42% of candidaemias, C. parapsilosis 33%, C. tropicalis 16% and C. guilliermondii, C. krusei, C. glabrata, C. holmii and C. metapsilosis were all 2% each. Six of 10 C. parapsilosis catheter tip isolates were indistinguishable from corresponding blood isolates (all in neonates). C. albicans isolates from blood were indistinguishable from corresponding gastrointestinal tract isolates in 13 of 26 patients and from catheter tip isolates in two patients. In conclusion, the results suggest that gastrointestinal colonisation is the probable source of C. albicans candidaemia and C. parapsilosis is exogenous.

Disconnecting central hot water and using electric showers to avoid colonization of the water system by Legionella pneumophila: an 11-year study

Legionella spp. can be difficult to control in hospitals. The objective of this study was to describe an 11-year experience with the use of electric showers in the control of Legionella pneumophila. From June 1989 to March 1990 there was an outbreak of pneumonia caused by L. pneumophila in a 20-bed renal transplant unit in a university-associated tertiary-care hospital. Control measures included hyperchlorination, heating and flushing of the water system with limited results. In November 1993 the central hot water was disconnected and water for bathing was heated using electric showers. From January 1992 to June 1995 water was collected from showers and water faucets and cultured for L. pneumophila every two weeks. Surveillance cultures were then collected every month until May 1999. During this seven-year surveillance period, 1115 samples of water were cultured. Water cultures were positive on 24 of 429 occasions (without cases of legionellosis) during the pre-shower period (22 months). In the post-shower period (67 months) only one of 686 cultures was positive. Subsequently there have been no new cases of nosocomial pneumonia by L. pneumophila although surveillance continues. In conclusion, disconnecting the central hot water was effective in avoiding colonization of the water system by L. pneumophila. Heating was possible by using electric showers, which are effective, easy to maintain and cheap.