Reducción del periodo de aislamiento de casos confirmados de COVID-19 / Reducción del período de aislamiento de casos confirmados de COVID-19

ANTECEDENTES: Este informe se efectúa en atención a la solicitud de la Jefatura del Instituto Nacional de Salud. El objetivo es brindar la evidencia disponible sobre el efecto de la reducción del periodo de aislamiento de los casos confirmados de COVID-19 sobre la transmisión del SARS-CoV-2. Pregunta PICO: ¿En los casos confirmados de COVID-19, cuál es el efecto de la reducción del periodo de aislamiento sobre la transmisión del SARS-CoV-2? Criterios de elegibilidad: Los criterios de selección de los estudios fueron los siguientes: Ensayos clínicos aleatorizados o revisiones sistemáticas que reporten resultados para al menos uno de los desenlaces en casos confirmados de SARS-CoV-2. En ausencia de resultados para alguno de los desenlaces, se considerará los resultados de estudios de modelos matemáticos o normas sanitarias de otros países. Estudios publicados en idioma inglés y español. Se excluyeron cartas al editor, revisiones narrativas, estudios preclínicos (estudios in vitro o en modelos animales), artículos de opinión y manuscritos no revisados por pares. Métodos para la búsqueda e identificación de la evidencia: Los estudios fueron identificados a partir de las siguientes fuentes: Plataforma Living Overview of the Evidence (L·OVE) de la Fundación Epistemonikos (https://www.epistemonikos.org/en/), búsqueda al 10 de enero de 2022. Bases de datos electrónicas: MEDLINE/Pubmed, Embase y Cochrane Library (búsqueda al 10 de enero de 2022). Páginas web institucionales de los ministerios de salud de otros países (búsqueda al 10 de enero de 2022). Este informe constituye un reporte breve, la selección y extracción de los datos fue realizada por un solo revisor y no se efectuó una evaluación de riesgo de sesgo de los estudios identificados. RESULTADOS: No se encontraron revisiones sistemáticas, ECA o estudios clínicos que evalúen el efecto de la reducción del tiempo de aislamiento de los casos confirmados de COVID-19 sobre la transmisión del SARS-CoV-2. En cambio, se encontró una publicación que evaluó el efecto de la reducción del aislamiento sobre la transmisión del SARS- CoV-2, a través de simulaciones estadísticas. La población consistió en datos simulados de personas infectadas por SARS-CoV-2; la intervención que se evaluó fue la evaluación diagnóstica con pruebas moleculares (RT-PCR) y antigénicas (ambas pruebas fueron analizadas con diferentes niveles de sensibilidad), así como la cuarentena (con escenarios de 14 días o menos). Los desenlaces fueron la transmisibilidad del SARS-CoV-2, medido a través del riesgo de transmisión residual postcuarentena (PQTR, por sus siglas en inglés). Uno de los supuestos asumidos en el modelo fue que el número reproductivo R0 tiene una distribución normal con media de 2.10. Los resultados de las simulaciones mostraron que la evaluación diagnóstica disminuye significativamente el PQTR. En el caso de personas que se realizan una prueba molecular con una sensibilidad de 95% antes de salir de la cuarentena de 14 días, el PQTR disminuye de 0.12% a 0.006%. En cambio, el PQTR disminuye a 0.09% con una cuarentena de 10 días y con prueba molecular antes de salida. El estudio menciona también que las cuarentenas deben prolongarse si las pruebas diagnósticas tienen menor sensibilidad; por ejemplo, con una prueba diagnóstica con una sensibilidad de 80%, se necesitará de una cuarentena de 11 días. Aunque se realizaron numerosas y repetidas simulaciones sistemáticas para evaluar la efectividad de las medidas sanitarias, una limitación del estudio consiste en la modelación estadística que no contempla interacciones sociales no aleatorias. CONCLUSIONES: El objetivo de la nota técnica fue sintetizar información sobre el efecto de la disminución del periodo de aislamiento en casos confirmados de COVID-19 sobre la transmisibilidad del SARS-CoV-2. No se encontraron estudios clínicos, ECA o revisiones sistemáticas que hayan evaluado el efecto de la disminución del periodo de aislamiento sobre la transmisibilidad del SARS-CoV-2. Se encontró un modelo estadístico que mostró que el riesgo de transmisión residual postcuarentena se reduce de 0.12% a 0.006% con una cuarentena de 14 días y se reduce a 0.09% con una cuarentena de 10 días, cuando se realiza una prueba diagnóstica (prueba molecular con sensibilidad mayor de 95%) antes de la salida de la cuarentena. Las cuarentenas se pueden prolongar cuando las pruebas diagnósticas tienen menor sensibilidad. El Sistema Nacional de Salud del Reino Unido recomienda un periodo de cuarentena por 10 días completos para los casos confirmados de COVID-19 y las personas que estuvieron en contacto cercano. Si hay inicio de síntomas durante la cuarentena, se cuentan 10 días adicionales desde el día de inicio de síntomas. El CDC de Estados Unidos establece el aislamiento para casos confirmados de COVID-19, independientemente de presencia de sintomatología o estado de vacunación. El aislamiento dura 5 días completos (día cero es el día de diagnóstico y el día 1 es el primer día de aislamiento), si no hay síntomas durante este periodo. Luego la persona debe usar una mascarilla bien ajustada por otros 5 días cuando esté cerca de otras personas, tanto dentro como fuera del domicilio. Si los síntomas no se resuelven, el aislamiento persiste hasta el día que la persona no tiene fiebre durante 24 horas sin usar antipiréticos. Los países de Europa como España, Portugal, Francia redujeron sus periodos de cuarentena a 7 días. En Alemania la cuarentena se reduce hasta 10 días y se puede disminuir hasta 7 días, si hay una prueba molecular o de antígenos negativa. Los países de América Latina como Argentina y Colombia disminuyeron el periodo de cuarentena a 7 días.

How to keep patients and staff safe from accidental SARS-CoV-2 exposure in the emergency room: Lessons from South Korea's explosive COVID-19 outbreak.

OBJECTIVES: We report our experience with an emergency room (ER) shutdown related to an accidental exposure to a patient with coronavirus disease 2019 (COVID-19) who had not been isolated. SETTING: A 635-bed, tertiary-care hospital in Daegu, South Korea. METHODS: To prevent nosocomial transmission of the disease, we subsequently isolated patients with suspected symptoms, relevant radiographic findings, or epidemiology. Severe acute respiratory coronavirus 2 (SARS-CoV-2) reverse-transcriptase polymerase chain reaction assays (RT-PCR) were performed for most patients requiring hospitalization. A universal mask policy and comprehensive use of personal protective equipment (PPE) were implemented. We analyzed effects of these interventions. RESULTS: From the pre-shutdown period (February 10-25, 2020) to the post-shutdown period (February 28 to March 16, 2020), the mean hourly turnaround time decreased from 23:31 ±6:43 hours to 9:27 ±3:41 hours (P < .001). As a result, the proportion of the patients tested increased from 5.8% (N=1,037) to 64.6% (N=690) (P < .001) and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (P < .001). All 23 patients with COVID-19 in the post-shutdown period were isolated in the ER without any problematic accidental exposure or nosocomial transmission. After the shutdown, several metrics increased. The median duration of stay in the ER among hospitalized patients increased from 4:30 hours (interquartile range [IQR], 2:17-9:48) to 14:33 hours (IQR, 6:55-24:50) (P < .001). Rates of intensive care unit admissions increased from 1.4% to 2.9% (P = .023), and mortality increased from 0.9% to 3.0% (P = .001). CONCLUSIONS: Problematic accidental exposure and nosocomial transmission of COVID-19 can be successfully prevented through active isolation and surveillance policies and comprehensive PPE use despite longer ER stays and the presence of more severely ill patients during a severe COVID-19 outbreak.

Epidemiological Investigation of the First 135 COVID-19 Cases in Brunei: Implications for Surveillance, Control, and Travel Restrictions.

Studies on the early introduction of SARS-CoV-2 in a naive population have important epidemic control implications. We report findings from the epidemiological investigation of the initial 135 COVID-19 cases in Brunei and describe the impact of control measures and travel restrictions. Epidemiological and clinical information was obtained for all confirmed COVID-19 cases, whose symptom onset was from March 9 to April 5, 2020. The basic reproduction number (R0), incubation period, and serial interval (SI) were calculated. Time-varying R was estimated to assess the effectiveness of control measures. Of the 135 cases detected, 53 (39.3%) were imported. The median age was 36 (range = 0.5-72) years. Forty-one (30.4%) and 13 (9.6%) were presymptomatic and asymptomatic cases, respectively. The median incubation period was 5 days (interquartile range [IQR] = 5, range = 1-11), and the mean SI was 5.4 days (SD = 4.5; 95% CI: 4.3, 6.5). The reproduction number was between 3.9 and 6.0, and the doubling time was 1.3 days. The time-varying reproduction number (Rt) was below one (Rt = 0.91; 95% credible interval: 0.62, 1.32) by the 13th day of the epidemic. Epidemic control was achieved through a combination of public health measures, with emphasis on a test-isolate-trace approach supplemented by travel restrictions and moderate physical distancing measures but no actual lockdown. Regular and ongoing testing of high-risk groups to supplement the existing surveillance program and a phased easing of physical distancing measures has helped maintain suppression of the COVID-19 outbreak in Brunei, as evidenced by the identification of only six additional cases from April 5 to August 5, 2020.

Older Adults' Intention to Socially Isolate Once COVID-19 Stay-at-Home Orders Are Replaced With "Safer-at-Home" Public Health Advisories: A Survey of Respondents in Maryland.

Background: The Theory of Planned Behavior (TPB) and the Health Belief Model (HBM) were used to examine the opinion and behaviors of older adults regarding Coronavirus Disease 2019 (COVID-19), social distancing practices, stay-at-home orders, and hypothetical public policy messaging strategies. Method: A convenience sample (N = 242) of adults 60 and older in the state of Maryland took part in an online survey. Respondents filled out questions regarding demographic information, political affiliation, current social distancing behaviors, and TPB and HBM constructs in our proposed model. Linear regression analysis and analysis of covariance (ANCOVA) were conducted to test the model. Results: Attitude toward social isolation was affected by perceived benefits and barriers to social distancing measures, perceived severity of COVID-19, and political affiliation. Behavior intention was influenced by attitude, subjective norms, political affiliation, and messaging strategies. Conclusion: The study provides support for the conceptual model and has public policy implications as authorities begin to lift stay-at-home orders.

The Spatial Allocation of Hospitals With Negative Pressure Isolation Rooms in Korea: Are We Prepared for New Outbreaks?

BACKGROUND: Allocation of adequate healthcare facilities is one of the most important factors that public health policymakers consider when preparing for infectious disease outbreaks. Negative pressure isolation rooms (NPIRs) are one of the critical resources for control of infectious respiratory diseases, such as the novel coronavirus disease 2019 (COVID-19) outbreak. However, there is insufficient attention to efficient allocation of NPIR-equipped hospitals. METHODS: We aim to explore any insufficiency and spatial disparity of NPIRs in South Korea in response to infectious disease outbreaks based on a simple analytic approach. We examined the history of installing NPIRs in South Korea between the severe acute respiratory syndrome (SARS) outbreak in 2003 and the Middle East respiratory syndrome coronavirus (MERS-Cov) in 2015 to evaluate the allocation process and spatial distribution of NPIRs across the country. Then, for two types of infectious diseases (a highly contagious disease like COVID-19 vs. a hospital-based transmission like MERS-Cov), we estimated the level of disparity between NPIR capacity and demand at the sub-regional level in South Korea by applying the two-step floating catchment area (2SFCA) method. RESULTS: Geospatial information system (GIS) mapping reveals a substantial shortage and misallocation of NPIRs, indicating that the Korean government should consider a simple but evidence-based spatial method to identify the areas that need NPIRs most and allocate funds wisely. The 2SFCA method suggests that, despite the recent addition of NPIRs across the country, there should still be more NPIRs regardless of the spread pattern of the disease. It also illustrates high levels of regional disparity in allocation of those facilities in preparation for an infectious disease, due to the lack of evidence-based approach. CONCLUSION: These findings highlight the importance of evidence-based decision-making processes in allocating public health facilities, as misallocation of facilities could impede the responsiveness of the public health system during an epidemic. This study provides some evidence to be used to allocate the resources for NPIRs, the urgency of which is heightened in the face of rapidly evolving threats from the novel COVID-19 outbreak.

Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset.

Importance: The dynamics of coronavirus disease 2019 (COVID-19) transmissibility are yet to be fully understood. Better understanding of the transmission dynamics is important for the development and evaluation of effective control policies. Objective: To delineate the transmission dynamics of COVID-19 and evaluate the transmission risk at different exposure window periods before and after symptom onset. Design, Setting, and Participants: This prospective case-ascertained study in Taiwan included laboratory-confirmed cases of COVID-19 and their contacts. The study period was from January 15 to March 18, 2020. All close contacts were quarantined at home for 14 days after their last exposure to the index case. During the quarantine period, any relevant symptoms (fever, cough, or other respiratory symptoms) of contacts triggered a COVID-19 test. The final follow-up date was April 2, 2020. Main Outcomes and Measures: Secondary clinical attack rate (considering symptomatic cases only) for different exposure time windows of the index cases and for different exposure settings (such as household, family, and health care). Results: We enrolled 100 confirmed patients, with a median age of 44 years (range, 11-88 years), including 44 men and 56 women. Among their 2761 close contacts, there were 22 paired index-secondary cases. The overall secondary clinical attack rate was 0.7% (95% CI, 0.4%-1.0%). The attack rate was higher among the 1818 contacts whose exposure to index cases started within 5 days of symptom onset (1.0% [95% CI, 0.6%-1.6%]) compared with those who were exposed later (0 cases from 852 contacts; 95% CI, 0%-0.4%). The 299 contacts with exclusive presymptomatic exposures were also at risk (attack rate, 0.7% [95% CI, 0.2%-2.4%]). The attack rate was higher among household (4.6% [95% CI, 2.3%-9.3%]) and nonhousehold (5.3% [95% CI, 2.1%-12.8%]) family contacts than that in health care or other settings. The attack rates were higher among those aged 40 to 59 years (1.1% [95% CI, 0.6%-2.1%]) and those aged 60 years and older (0.9% [95% CI, 0.3%-2.6%]). Conclusions and Relevance: In this study, high transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to contain the epidemic, and more generalized measures may be required, such as social distancing.

Flujogramas de Vigilancia Epidemiológica COVID-19: Investigación de casos sospechosos comunitarios de COVID-19 y en servicios de salud no habilitados para toma de muestra / Covid 19 epidemiological surveillance flow charts: Investigation of suspected community cases of COVID-19 and in health services not authorized for sampling

Describe graficamente el monitoreo de investigación de casos confirmados, sospechosos y comunitarios hasta el cierre de los casos.

Instructivo de la lista de verificación de alistamiento para la respuesta al COVID-19 en SEM Prehospitalarias / Instructions for the enlistment checklist for the response to COVID-19 in Pre-hospital SEM

Los servicios de emergencias médicas prehospitalarias (SEM) facilitan atención inicial de soporte vital básico y/o avanzado y traslado de heridos o enfermos desde el lugar donde ocurre la emergencia hasta el centro sanitario donde le van a prestar cuidados definitivos. Los SEM también pueden prestar traslado de pacientes desde una instalación de salud a otra de mayor nivel o complejidad, en lo que se conoce como traslado interhospitalario. Los servicios de ambulancia es el componente más conocido y puede ser prestado por diferentes proveedores que pueden ir desde departamentos de bomberos, organizaciones de voluntarios o servicios adscritos a universidades hasta hospitales que cuentan con su propio servicio de ambulancias para cubrir a sus usuarios. Los SEM prehospitalarios también incluyen otros componentes como los centros tipo 911 o los Centro Reguladores de Urgencia y Emergencias (CRUE) y los programas de primer respondiente. Todos ellos deben integrase de una forma coordinada con las redes integradas de servicios de salud para asegurar una continuidad de los cuidados de salud prestados a la persona herida o enferma. Durante emergencias de salud pública, los servicios de emergencia medicas prehospitalarias pueden verse superados por el número de llamadas o demanda de traslados médicos. Por ello es importante que las agencias y/o organizaciones que prestan atención prehospitalaria cuenten con las herramientas y mecanismos para asegurar no solo la actividad diaria sino también para adecuar su capacidad para la respuesta a escenarios específicos como el del COVID19 En este contexto, se insta a los SEM prehospitalarios a implementar las acciones de alistamiento para la respuesta y a trabajar de forma coordinada e integral con las autoridades de salud a cargo de la respuesta del COVID-19

Environmental considerations in the selection of isolation gowns: A life cycle assessment of reusable and disposable alternatives.

BACKGROUND: Isolation gowns serve a critical role in infection control by protecting healthcare workers, visitors, and patients from the transfer of microorganisms and body fluids. The decision of whether to use a reusable or disposable garment system is a selection process based on factors including sustainability, barrier effectiveness, cost, and comfort. Environmental sustainability is increasingly being used in the decision-making process. Life cycle assessment is the most comprehensive and widely used tool used to evaluate environmental performance. METHODS: The environmental impacts of market-representative reusable and disposable isolation gown systems were compared using standard life cycle assessment procedures. The basis of comparison was 1,000 isolation gown uses in a healthcare setting. The scope included the manufacture, use, and end-of-life stages of the gown systems. RESULTS: At the healthcare facility, compared to the disposable gown system, the reusable gown system showed a 28% reduction in energy consumption, a 30% reduction in greenhouse gas emissions, a 41% reduction in blue water consumption, and a 93% reduction in solid waste generation. CONCLUSIONS: Selecting reusable garment systems may result in significant environmental benefits compared to selecting disposable garment systems. By selecting reusable isolation gowns, healthcare facilities can add these quantitative benefits directly to their sustainability scorecards.

Infection control, genetic assessment of drug resistance and drug susceptibility testing in the current management of multidrug/extensively-resistant tuberculosis (M/XDR-TB) in Europe: A tuberculosis network European Trialsgroup (TBNET) study.

AIM: Europe has the highest documented caseload and greatest increase in multidrug and extensively drug-resistant tuberculosis (M/XDR-TB) of all World Health Organization (WHO) regions. This survey examines how recommendations for M/XDR-TB management are being implemented. METHODS: TBNET is a pan-European clinical research collaboration for tuberculosis. An email survey of TBNET members collected data in relation to infection control, access to molecular tests and basic microbiology with drug sensitivity testing. RESULTS: 68/105 responses gave valid information and were from countries within the WHO European Region. Inpatient beds matched demand, but single rooms with negative pressure were only available in low incidence countries; ultraviolet decontamination was used in 5 sites, all with >10 patients with M/XDR-TB per year. Molecular tests for mutations associated with rifampicin resistance were widely available (88%), even in lower income and especially in high incidence countries. Molecular tests for other first line and second line drugs were less accessible (76 and 52% respectively). A third of physicians considered that drug susceptibility results were delayed by > 2 months. CONCLUSION: Infection control for inpatients with M/XDR-TB remains a problem in high incidence countries. Rifampicin resistance is readily detected, but tests to plan regimens tailored to the drug susceptibilities of the strain of Mycobacterium tuberculosis are significantly delayed, allowing for further drug resistance to develop.

Effect of target-enriched multiplex polymerase chain reaction on patient outcomes and costs during the 2013-14 influenza season.

The US Centers for Disease Control and Prevention recommends the initial use of rapid antigen influenza diagnostic test (RIDT) for the detection of influenza A (H1N1-09). Nasopharyngeal samples were tested from 246 patients for H1N1-09 using target-enriched multiplex polymerase chain reaction (TEM-PCR), of which 163 were additionally tested via RIDT. RIDTs had a sensitivity of 18.7% compared with TEM-PCR as the reference standard. Patients with false-negative RIDTs were withheld from 111 days of oseltamivir and 65 days of isolation. Patients negative for H1N1 via TEM-PCR had antiviral therapy immediately stopped, thereby evading 408 days of oseltamivir and 315 days of unnecessary isolation. This cost avoidance saved US$208,982.

Hispanic Residential Isolation, ADHD Diagnosis and Stimulant Treatment among Medicaid-Insured Youth.

OBJECTIVE: This study aimed to evaluate a conceptual framework that assessed the effect of Hispanic residential isolation on Attention Deficit Hyperactivity Disorder (ADHD) health service utilization among 2.2 million publicly insured youth. DESIGN: Cross-sectional. SETTING: Medicaid administrative claims data for ambulatory care services from a US Pacific state linked with US census data. PARTICIPANTS: Youth, aged 2-17 years, continuously enrolled in 2009. MAIN OUTCOME MEASURES: The percent annual prevalence and odds of ADHD diagnosis and stimulant use according to two measures of racial/ethnic residential isolation: 1) the county-level Hispanic isolation index (HI) defined as the population density of Hispanic residents in relation to other racial/ethnic groups in a county (<.5; .5-.64; ≥.65); and 2) the proportion of Hispanic residents in a ZIP code tabulation area (<25%; 25%-50%; >50%). RESULTS: Among the 47,364 youth with a clinician-reported ADHD diagnosis, 60% received a stimulant treatment (N = 28,334). As the county level HI increased, Hispanic residents of ethnically isolated locales were significantly less likely to receive an ADHD diagnosis (adjusted odds ratio [AOR]=.92 [95% CI=.88-.96]) and stimulant use (AOR=.61 [95% CI=.59-.64]) compared with Hispanic youth in less isolated areas. At the ZIP code level, a similar pattern of reduced ADHD diagnosis (AOR=.81 [95% CI=.77-.86]) and reduced stimulant use (AOR=.65 [95% CI=.61-.69]) was observed as Hispanic residential isolation increased from the least isolated to the most isolated ZIP code areas. CONCLUSIONS: These findings highlight the opportunity for Big Data to advance mental health research on strategies to reduce racial/ethnic health disparities, particularly for poor and vulnerable youth. Further exploration of racial/ethnic residential isolation in other large data sources is needed to guide future policy development and to target culturally sensitive interventions.

A mathematical model of Clostridium difficile transmission in medical wards and a cost-effectiveness analysis comparing different strategies for laboratory diagnosis and patient isolation.

BACKGROUND: Clostridium difficile infection (CDI) is a common and potentially fatal healthcare-associated infection. Improving diagnostic tests and infection control measures may prevent transmission. We aimed to determine, in resource-limited settings, whether it is more effective and cost-effective to allocate resources to isolation or to diagnostics. METHODS: We constructed a mathematical model of CDI transmission based on hospital data (9 medical wards, 350 beds) between March 2010 and February 2013. The model consisted of three compartments: susceptible patients, asymptomatic carriers and CDI patients. We used our model results to perform a cost-effectiveness analysis, comparing four strategies that were different combinations of 2 test methods (the two-step test and uniform PCR) and 2 infection control measures (contact isolation in multiple-bed rooms or single-bed rooms/cohorting). For each strategy, we calculated the annual cost (of CDI diagnosis and isolation) for a decrease of 1 in the average daily number of CDI patients; the strategy of the two-step test and contact isolation in multiple-bed rooms was the reference strategy. RESULTS: Our model showed that the average number of CDI patients increased exponentially as the transmission rate increased. Improving diagnosis by adopting uniform PCR assay reduced the average number of CDI cases per day per 350 beds from 9.4 to 8.5, while improving isolation by using single-bed rooms reduced the number to about 1; the latter was cost saving. CONCLUSIONS: CDI can be decreased by better isolation and more sensitive laboratory methods. From the hospital perspective, improving isolation is more cost-effective than improving diagnostics.

Screening test recommendations for methicillin-resistant Staphylococcus aureus surveillance practices: A cost-minimization analysis.

BACKGROUND: To mitigate methicillin-resistant Staphylococcus aureus (MRSA) infections, intensive care units (ICUs) conduct surveillance through screening patients upon admission followed by adhering to isolation precautions. Two surveillance approaches commonly implemented are universal preemptive isolation and targeted isolation of only MRSA-positive patients. METHODS: Decision analysis was used to calculate the total cost of universal preemptive isolation and targeted isolation. The screening test used as part of the surveillance practice was varied to identify which screening test minimized inappropriate and total costs. A probabilistic sensitivity analysis was conducted to evaluate the range of total costs resulting from variation in inputs. RESULTS: The total cost of the universal preemptive isolation surveillance practice was minimized when a polymerase chain reaction screening test was used ($82.51 per patient). Costs were $207.60 more per patient when a conventional culture was used due to the longer turnaround time and thus higher isolation costs. The total cost of the targeted isolation surveillance practice was minimized when chromogenic agar 24-hour testing was used ($8.54 per patient). Costs were $22.41 more per patient when polymerase chain reaction was used. CONCLUSIONS: For ICUs that preemptively isolate all patients, the use of a polymerase chain reaction screening test is recommended because it can minimize total costs by reducing inappropriate isolation costs. For ICUs that only isolate MRSA-positive patients, the use of chromogenic agar 24-hour testing is recommended to minimize total costs.

Strategies to reduce the use of seclusion with tangata whai i te ora (Maori mental health service users).

Maori, the indigenous people of New Zealand, have the highest crude population-based rate of seclusion events reported internationally (McLeod et al. ). This qualitative study explored Maori clinical, cultural and consumer perspectives on potential strategies and initiatives considered likely to facilitate prevention of, and reduction in, the use of seclusion, with tangata whai i te ora (Maori mental health service users) in mental health inpatient services. A hui (gathering) over 2 days was held with 16 Maori participants with high levels of clinical, cultural and consumer expertise. The gathering was taped and the tapes transcribed. A thematic analysis of the hui data generated three key categories: Te Ao Maori (access to a Maori worldview); Te Ao Hurihuri (transforming practice); and Rangatiratanga (leadership, power, and control). The findings of this study align with the "six core strategies" for best practice to reduce the use of seclusion (Huckshorn ). A comprehensive approach to the reduction of the use of seclusion with tangata whai i te ora is required, which is clearly based on a Maori model of care and a vision for transformation of practice in mental health inpatient services, which involves Maori leadership.

Preventing healthcare-associated infections: Residents and attending physicians need better training in advanced isolation precautions.

OBJECTIVE: Compliance with advanced isolation precautions (IPs) is crucial to reduce healthcare-associated infections. Our aim was to evaluate physician's knowledge and attitudes related to IPs. METHODS: An online questionnaire was sent to our hospital's physicians (attending physicians and residents). RESULTS: A total of 111 physicians completed the questionnaire: 60 (54%) attending physicians and 51 (46%) residents. Overall, respondents had a poor knowledge of the three types of IPs, especially droplet precautions (13 correct answers, 11.7%) and airborne IP (17 correct answers, 16.3%). We observed a statistically significant difference between attending physicians and residents for the type of IP to prescribe to a patient presenting with multidrug-resistant urinary infection: 44 residents (86%) gave the correct answer vs 42 attending physicians (70%), P=0.04. Physicians (both residents and attending physicians) who were already familiar with the dedicated webpage available on the hospital's intranet (n=40) obtained a score of 4.75/10 (±2.0) compared with 4.03/10 (±1.7) for those who had never used that tool (n=71). The difference was statistically significant (P=0.04). The average score for both residents and attending physicians was 4.3/10 (±1.9, range: 1-10). Attending physicians' and residents' scores were 4/10 (±1.8) and 4.5/10 (±1.9), respectively, but the difference was not statistically significant (P=0.14). CONCLUSION: Physicians' knowledge of IPs was insufficient. Improvement in medical training is needed. The use of a dedicated webpage on hospitals' intranet could help physicians acquire better knowledge on that matter.