The use of real-time feedback via wireless technology to improve hand hygiene compliance.

BACKGROUND: Hand hygiene (HH) is widely regarded as the most effective preventive measure for health care-associated infection. However, there is little robust evidence on the best interventions to improve HH compliance or whether a sustained increase in compliance can reduce rates of health care-associated infection. METHODS: To evaluate the effectiveness of a real-time feedback to improve HH compliance in the inpatient setting, we used a quasiexperimental study comparing the effect of real-time feedback using wireless technology on compliance with HH. The study was conducted in two 20-bed step-down units at a private tertiary care hospital. Phase 1 was a 3-month baseline period in which HH counts were performed by electronic handwash counters. After a 1-month washout period, a 7-month intervention was performed in one step-down unit while the other unit served as a control. RESULTS: HH, as measured by dispensing episodes, was significantly higher in the intervention unit (90.1 vs 73.1 dispensing episodes/patient-day, respectively, P = .001). When the intervention unit was compared with itself before and after implementation of the wireless technology, there was also a significant increase in HH after implementation (74.5 vs 90.1 episodes/patient-day, respectively, P = .01). There was also an increase in mean alcohol-based handrub consumption between the 2 phases (68.9 vs 103.1 mL/patient-day, respectively, P = .04) in the intervention unit. CONCLUSION: We demonstrated an improvement in alcohol gel usage via implementation of real-time feedback via wireless technology.

Preventing catheter-associated urinary tract infection in the zero-tolerance era.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care‒associated infections in the critical care setting. METHODS: A quasi-experimental study involving multiple interventions to reduce the incidence of CAUTI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). Between June 2005 and December 2007 (phase 1), we implemented some Centers for Disease Control and Prevention‒recommended evidence-based practices. Between January 2008 and July 2010 (phase 2), we intervened to improve compliance with these practices at the same time that performance monitoring was being done at the bedside, and we implemented the Institute for Healthcare Improvement's bladder bundle for all ICU and SDU patients requiring urinary catheters. RESULTS: There was a statistically significant reduction in the rate of CAUTI in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], 6.6-8.6) before the intervention to 5.0 per 1,000 catheter-days (95% CI, 4.2-5.8; P < .001) after the intervention. There also was a statistically significant reduction in the rate of CAUTI in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, 13.9-16.6) before the intervention to 12.9 per 1,000 catheter-days (95% CI, 11.6-14.2) after the intervention (P = .014). CONCLUSION: Our findings suggest that reducing CAUTI rates in the ICU setting is a complex process that involves multiple performance measures and interventions that can be applied to SDU settings as well.

Positive deviance: a program for sustained improvement in hand hygiene compliance.

BACKGROUND: There is a paucity of data evaluating whether positive deviance (PD) can sustain improvement in hand hygiene compliance. METHODS: An observational study comparing the effect of PD on compliance with hand hygiene was conducted in two 20-bed step-down units (SDUs) at a private tertiary care hospital. In a 3-month baseline period (April-June 2008), hand hygiene counts were performed by electronic handwashing counters. Between July 1, 2008, and November 30, 2009, (East SDU) and between September 30, 2008, and December 2009 (West SDU), PD was applied in both units. RESULTS: There was more than a 2-fold difference in the number of alcohol gel aliquots dispensed per month from April 2008 (before PD) to November 2009 (last month in PD) in the East SDU. There was also a 2-fold difference in the number of alcohol gel aliquots dispensed per month from September 2008 (before PD) to December 2009 (last month in PD) in the West SDU. The difference in the rate of health care‒associated infections (HAIs) between the baseline period and 2009 was statistically significant in the East SDU (5.8 vs 2.8 per 1,000 device-days; P = .008) and in the West SDU (3.7 vs 1.7 per 1,000 device-days; P = .023). CONCLUSIONS: PD was responsible for a sustained improvement in hand hygiene in the inpatient setting and was associated with a decrease in the incidence of device-associated HAIs.

Alterações da pressão arterial e da frequência cardíaca devida a dor causada pela punção venosa periférica / Blood pressure and heart rate changes due to peripheral venous puncture pain

JUSTIFICATIVA E OBJETIVOS: Os pacientes submetidos a determinados procedimentos intra-hospitalares como a punção venosa periférica (PVP) sentem dor, que alem do sofrimento e medo podem alterar alguns sinais vitais. Os objetivos deste estudo foram avaliar a pressão arterial e a frequência cardíaca dos pacientes submetidos à PVP e comparar a variação destes parâmetros antes, durante e depois do procedimento, bem como identificar a intensidade da dor vivenciada e correlacionar com as alterações hemodinâmicas com a idade e o sexo.MÉTODO: Trata-se de estudo descritivo-exploratório, de nível I, com abordagem quantitativa, realizado com um questionário aplicado aos pacientes submetidos à punção venosa periférica. A amostra foi composta por 32 pacientes nos quais a pressão arterial e a frequência cardíaca foram avaliadas 15 min antes, durante e 15 min depois da punção venosa periférica. A avaliação da intensidade da dor causada pela PVP foi feita imediatamente após o termino do procedimento.RESULTADOS: De forma geral a intensidade da dor foi de baixa à moderada, mais de 88% dos pacientes não apresentaram variações hemodinâmicas maiores que 10% em relação às condições iniciais. Os pacientes mais idosos apresentaram incidência maior de dor de forte intensidade que os mais jovens, porém as alterações hemodinâmicas foram mais intensas nos mais jovens, apesar de terem apresentado menor intensidade da dor durante a PVP. CONCLUSÃO: A dor causada pela PVP foi de baixa ou moderada intensidade, sendo que os pacientes do sexo masculino e de faixa etária acima dos 64 anos foram os mais sensíveis à dor, porém as variações da pressão arterial sistólica e da frequência cardíaca foram mais intensas no sexo feminino, e nos pacientes da faixa etária entre 21 e 64 anos.

BACKGROUND AND OBJECTIVES: Patients submitted to some hospital procedures such as PVP feel pain, which in addition to distress and fear may change some vital signs. This study aimed at evaluating blood pressure and heart rate of patients submitted to PVP and comparing the variation of such parameters before, during and after the procedure, as well as at identifying the intensity of PVP pain and correlating pain and hemodynamic changes to age and gender. METHOD: Descriptive-exploratory, level II study, with quantitative approach, performed with a questionnaire applied to patients submitted to PVP. Sample was made of 32 patients in whom blood pressure and heart rate were evaluated 15 minutes before, during, and 15 minutes after PVP. Peripheral venous puncture pain intensity was evaluated immediately after procedure completion. RESULTS: In general, pain was mild to moderate. More than 80% of patients did not present hemodynamic changes higher than 10% as compared to baseline conditions. Elderly patients had a higher incidence of more severe pain as compared to younger patients; however hemodynamic changes were more significant in younger patients, in spite of them having presented lower intensity pain during PVP. CONCLUSION: Peripheral venous puncture pain was mild or moderate and male patients above 64 years of age were the most sensitive to pain. However, systolic blood pressure and heart rate variations were more significant in female patients and in patients between 21 and 64 years of age.

Impact of a program to prevent central line-associated bloodstream infection in the zero tolerance era.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) is one of the most important health care-associated infections in the critical care setting. METHODS: A quasiexperimental study involving multiple interventions to reduce the incidence of CLABSI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). From March 2005 to March 2007 (phase 1 [P1]), some Centers for Disease Control and Prevention evidence-based practices were implemented. From April 2007 to April 2009 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and we implemented the Institute for Healthcare Improvement central line bundle for all ICU and SDU patients requiring central venous lines. RESULTS: The mean incidence density of CLABSI per 1000 catheter-days in the ICU was 6.4 in phase 1 and 3.2 in phase 2, P < .001. The mean incidence density of CLABSI per 1000 catheter-days in the SDUs was 4.1 in phase 1 and 1.6 in phase 2, P = .005. CONCLUSION: These results suggest that reducing CLABSI rates in an ICU setting is a complex process that involves multiple performance measures and interventions that can also be applied to SDU settings.

Positive deviance: a new strategy for improving hand hygiene compliance.

OBJECTIVE: To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units. DESIGN: A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene. SETTING: Two 20-bed step-down units at a tertiary care private hospital. METHODS: The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units. RESULTS: During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01 ). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (p = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days. CONCLUSION: A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Controlled trial measuring the effect of a feedback intervention on hand hygiene compliance in a step-down unit.

OBJECTIVE: To evaluate hand hygiene compliance in 2 adult step-down units (SDUs). DESIGN: A 6-month (from March to September 2007), controlled trial comparing 2 SDUs, one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit). SETTING: Two 20-bed SDUs at a tertiary care private hospital. METHODS: Hand hygiene episodes were measured by electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures. RESULTS: A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit (P = .63). There was no significant difference in the amount of chlorhexidine used in the intervention and control units (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = .99); and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = .13). There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit). CONCLUSIONS: The feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.