Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementation factors, activities and outcomes.

INTRODUCTION: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted. OBJECTIVE: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research. METHODS: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed. RESULTS: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement. Most studies reported activities from multiple categories. Implementation factors included: clinical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities. CONCLUSIONS: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.

Gentamicin should remain part of the empirical sepsis regimen for adults. / Gentamicin bør fortsatt inngå i empirisk sepsisregime hos voksne.

In the Norwegian guidelines, the combination of a narrow-spectrum beta-lactam antibiotic and aminoglycoside should remain the first choice for empirical antibiotic therapy for the majority of severe infections.

A Multifaceted Intervention and Its Effects on Antibiotic Usage in Norwegian Nursing Homes.

We explored the impact of an antibiotic quality improvement intervention across 33 nursing homes (NHs) in one Norwegian county, compared against four control counties. This 12-month multifaceted intervention consisted of three physical conferences, including educational sessions, workshops, antibiotic feedback reports, and academic detailing sessions. We provided clinical guiding checklists to participating NHs. Pharmacy sales data served as a measure of systemic antibiotic use. The primary outcome was a change in antibiotic use in DDD/100 BD from the baseline through the intervention, assessed using linear mixed models to identify changes in antibiotic use. Total antibiotic use decreased by 15.8%, from 8.68 to 7.31 DDD/100BD (model-based estimated change (MBEC): -1.37, 95% CI: -2.35 to -0.41) in the intervention group, albeit not a significantly greater reduction than in the control counties (model-based estimated difference in change (MBEDC): -0.75, 95% CI: -1.91 to 0.41). Oral antibiotic usage for urinary tract infections (UTI-AB) decreased 32.8%, from 4.08 to 2.74 DDD/100BD (MBEC: -1.34, 95% CI: -1.85 to -0.84), a significantly greater reduction than in the control counties (MBEDC: -0.9, 95% CI: -1.28 to -0.31). The multifaceted intervention may reduce UTI-AB use in NHs, whereas adjustments in the implementation strategy may be needed to reduce total antibiotic use.

A(H1N1)pdm09 vaccination of health care workers: improved immune responses in low responders following revaccination.

BACKGROUND: We conducted a clinical trial in October 2009 to evaluate the immunogenicity of the AS03-adjuvanted influenza vaccine (pH1N1 vaccine) in health care workers (HCWs). By 2 weeks after vaccination, 97% had protective hemagglutinin inhibition (HI) titers (≥ 40) however, 16% were low responders (LR) and failed to maintain a protective response 90 days after vaccination. METHODS: We analyzed the humoral responses (HI, antibody-secreting cell [ASC], and serum immunoglobulin G [IgG]) in 15 LRs and 25 control HCWs. Twelve LRs were revaccinated with the pH1N1 vaccine, and 7 were subsequently vaccinated with the 2010 seasonal trivalent influenza vaccine. We conducted a long-term analysis of the humoral and CD4(+) T-helper (Th) 1 responses. RESULTS: The LRs had a slower HI antibody response than the control HCWs, with protective antibody titers not reached until 2 weeks after vaccination in the majority of the participants. The LRs also had significantly lower IgG ASCs at day 7 and HA1-specific serum IgG responses at day 21, compared with the control HCWs. Revaccination with the pH1N1 vaccine elicited rapid HI antibody, ASC, memory B cell, and multifunctional CD4(+) Th1 cell responses. CONCLUSION: This study shows that revaccination of low-responding HCWs with the pH1N1 vaccine is required for maintaining long-term protection. CLINICAL TRIALS REGISTRATION: NCT01003288.

National surveillance of surgical site infections after coronary artery bypass grafting in Norway: incidence and risk factors.

OBJECTIVE: A mandatory national surveillance system for surgical site infections (SSIs) following certain surgical procedures, including coronary artery bypass grafting (CABG), was introduced in Norway in 2005. The objectives of this study were to measure national baseline incidence rates of SSIs after CABG, describe the characteristics of the patients and procedures, and identify possible risk factors for infection. METHODS: In 2005-2009, all hospitals that performed CABG were invited to assess all patients undergoing CABG surgery in 3-month periods for SSIs. The hospitals evaluated infection status at discharge and 30 days after surgery by sending post-discharge questionnaires to all patients. We calculated incidence proportions and risk ratios for different risk factors. We applied the National Nosocomial Infection Surveillance (NNIS) risk index to the data. RESULTS: In total, 2440 patients were included. Altogether, 124 sternal and 217 harvest site infections were registered, giving incidence proportions of 5.1% and 8.9%, respectively. Over 95% of infections occurred post-discharge from the hospital. No risk factors were identified. Incidence did not significantly increase with higher NNIS risk index; however, 93% of the patients fell into the same risk category. CONCLUSIONS: We have provided a baseline rate for SSIs after CABG procedures in Norway. The results show the importance of post-hospital discharge follow-up. The NNIS risk index did not adequately stratify CABG patients. We recommend that more potential risk variables should be included in the surveillance, such as the European System for Cardiac Operative Risk Evaluation (EuroSCORE), height, weight, and diabetes.

An adjuvanted pandemic influenza H1N1 vaccine provides early and long term protection in health care workers.

Mass vaccination was the most effective prophylaxis for protecting the population during the influenza H1N1 pandemic. We have evaluated the tolerability, immunogenicity and kinetics of the antibody response to a monovalent oil-in-water (AS03) adjuvanted human pandemic split influenza A/California/7/2009 H1N1 (3.75 µg haemagglutinin) vaccine in health care workers. Vaccination elicited a rapid and early protective level of haemagglutination inhibition antibody from 6 to 7 days post vaccination, and by 14 to 21 days post vaccination, up to 98% of vaccinees had protective antibody titres which persisted for at least 3 months in 84-92% of subjects. A rapid induction of protective antibody is important in reducing community spread of pandemic influenza and in helping maintain the integrity of the health care system during the pandemic.

[Needlestick injuries and reporting routines]. / Stikkskader og melderutiner.

BACKGROUND: Health care workers are at risk for transmission of blood-borne agents through percutaneous exposure. Reporting of sharps injuries is essential for instigation of adequate post-exposure prophylaxis and follow-up. We aimed at providing an account of number of sharps injuries reported by type of health care worker and the reporting systems used for injuries that have an inherent risk of transmitting blood-borne agents. MATERIAL AND METHODS: The section for HSE (health, safety and environment) at Haukeland University Hospital provided us with an overview of requests for analyses of hepatitis and HIV linked to 159 sharps injuries that had not been reported otherwise. Injury reports at Haukeland University Hospital from the period 2003 - 2007 (n = 8556) were systematically reviewed. RESULTS: On average, 210 sharps injuries are reported annually at Haukeland University Hospital. In addition analyses of hepatitis and HIV linked to 159 sharps injuries that had not been reported otherwise, were requested annually. 51 % of sharps injuries were reported by nurses, 10 % by laboratory workers, 6 % by doctors and 33 % by others. INTERPRETATION: Sharps injuries are often not reported, and especially doctors fail to report them. Of health care workers, nurses report most sharps injuries. Related to numbers employed, laboratory workers report most sharps injuries.

[Fighting antibiotic resistance]. / Tiltak mot antibiotikaresistens.

BACKGROUND: Due to the emergence and spread of antibiotic resistance, several infectious diseases are no longer treatable with standard drugs, and in many cases there are no adequate therapeutic options. Even though the situation in the Nordic countries is considerably better than in large parts of the world, we must also contribute to fight this development. In addition to continuing the prudent use of antibiotics, it is important to strengthen certain infection control strategies. WHO has stated that antibiotic resistance is a global health problem. MATERIAL AND METHODS: The article is based on personal experience from infection control and infectious diseases, and impressions from discussions in National and Nordic forums during the last years. We have also reviewed literature retrieved from non-systematic database searches. RESULTS AND INTERPRETATION: The introduction of pneumococcal vaccine in the Norwegian Childhood Vaccination Programme will probably contribute to both reducing the use of antibiotics, and preventing the spread of pneumococci that are resistant to antibiotics. Increased influenza vaccination uptake, standard barrier precautions (hand hygiene etc.) against infections in health care institutions, isolation and surveillance of resistant bacteria are among the most important infection control measures that should be strengthened if we are to succeed.

[Infection control in long-term care facilities for the elderly]. / Smittevern i helseinstitusjoner for eldre.

BACKGROUND: In Norway, around 20 % of the elderly live in long-term care facilities. The risk of acquiring a nosocomial infection increases by age and the consequences of infections become more severe. This article describes the epidemiology of nosocomial infections and the use of antibiotics in long-term care facilities. Infection control measures are recommended. MATERIAL AND METHODS: We used data from the national prevalence surveys of nosocomial infections and from the national surveillance system for communicable diseases. In addition we reviewed current literature. RESULTS: The prevalence of nosocomial infection is similar in hospitals and long-term care facilities in Norway, between 5 % and 10 %. Legal regulations require all health institutions in Norway to have an infection control programme, but little attention has been given to prevention of nosocomial infections in long-term care facilities. Less than 50 % of them have implemented the mandatory infection control programme. The vaccination coverage for influenza is only about 30 %. The coverage of pneumococcal vaccination is even lower. INTERPRETATION: The following actions are recommended for all long-term care facilities: improved hand hygiene by introducing hand disinfection, implementation of infection control programmes, and improved coverage of pneumococcal and influenza vaccination. Employing more health care personnel, nurses as well as doctors, should be a goal.