Cross-sectional study on emergency department management of sepsis.

INTRODUCTION: Emergency departments (EDs) play an important role in the early identification and management of sepsis. Little is known about local EDs' processes of care for sepsis, adoption of international recommendations, and the impact of the new Sepsis-3 definitions. METHODS: Structured telephone interviews based on the United Kingdom Sepsis Trust 'Exemplar Standards for the Emergency Management of Sepsis' were conducted from January to August 2017 with nominated representatives of all responding public hospital EDs in Hong Kong, followed by a review of hospital/departmental sepsis guidelines by the investigators. RESULTS: Sixteen of the 18 public EDs in Hong Kong participated in the study. Among various time-critical medical emergencies such as major trauma, sepsis was perceived by the interviewees to be the leading cause of in-hospital mortality and the second most important preventable cause of death. However, only seven EDs reported having departmental guidelines on sepsis care, with four adopting the Quick Sequential Organ Failure Assessment score or its modified versions. All responding EDs reported that antibiotics were stocked within their departments, and all EDs with sepsis guidelines mandated early intravenous antibiotic administration within 1 to 2 hours of detection. Reported major barriers to optimal sepsis care included lack of knowledge and experience, nursing human resources shortages, and difficulty identifying patients with sepsis in the ED setting. CONCLUSION: There are considerable variations in sepsis care among EDs in Hong Kong. More training, resources, and research efforts should be directed to early ED sepsis care, to improve patient outcomes.

Rationale for using single-use disposable air/water syringe tips.

The research discussed in this article was conducted to study the inaccessible lumen surfaces of used and unused metal tips of air/water syringes using a light and a scanning electron microscope. Factors affecting the selection of air/water syringe tips were enumerated and compared. Patient and dentist acceptance of reusable and single-use air/water syringe tips for use in the oral cavity was evaluated. Although heat sterilization may destroy microbial organisms, the internal surfaces of metal tips were found to be rough, making them the focus of mineral and bioburden deposits. With regard to cleaning and sterilization, disposable tips were found to be more acceptable in clinical use than metal tips.

Efficacy of cefepime in the treatment of infections due to multiply resistant Enterobacter species.

Cefepime is a new cephalosporin with an enhanced antibacterial potency and spectrum. More rapid penetration into many gram-negative bacilli, targeting of multiple penicillin-binding proteins, and resistance to inactivation by many beta-lactamases account for its activity against organisms that have developed resistance to agents such as ceftazidime, cefotaxime, or ceftriaxone. This study identified 16 patients with 17 infections due to Enterobacter species organisms with reduced susceptibility or resistance to ceftazidime. Most isolates were multiply resistant to other beta-lactam drugs as well, but all were susceptible to cefepime. All 17 infections, which included pneumonia, urinary tract infection, intraabdominal infection, and bacteremia, responded clinically to intravenous cefepime. In particular, cefepime was successfully used in the management of cases of chronic infection that had responded poorly to repeated therapy with imipenem, aminoglycosides, or ciprofloxacin. Eradication of Enterobacter species organisms occurred at 15 (88.2%) of the 17 sites of infection. No emergence of resistance to cefepime was noted.

Supervisor personal liability for ADA discrimination. Emerging issues for hospital administrators and physicians.

This article discusses emerging and conflicting trends in recent Americans with Disabilities Act discrimination legal decisions in which plaintiffs seek compensatory or punitive damages directly from supervisors and their employers, creating potential issues of personal liability for physicians or hospital administrators, for example. Also addressed in the article are potential problems employers face if supervisors are held personally liable for Americans with Disabilities Act discrimination.

"Eat for Health": a supermarket intervention for nutrition and cancer risk reduction.

OBJECTIVES: The results of an evaluation of "Eat for Health," a supermarket nutrition intervention, are presented. The study tested whether such a program could be successfully carried out and whether it could effect changes in knowledge, attitudes, and food purchasing behavior in line with nutrition and cancer risk reduction guidelines. METHODS: The evaluation consisted of an in-store monitoring element, an in-store and telephone consumer survey, and an analysis of sales data on selected foods. A matched-pair design, using a total of 40 stores in the intervention and comparison groups, was used. RESULTS: The intervention was successfully implemented and had limited success in changing some food purchasing behaviors. There appeared to be no effect on knowledge and attitudes except for increased awareness of a link between diet and cancer and of the program itself. CONCLUSIONS: Despite the intervention's success, limitations of the consumer survey and sales data analyses and the continuing diffusion of nutrition messages throughout society make it difficult to specify the impact of this program on consumer nutrition knowledge and behaviors.

Empowerment through rehabilitation nursing certification.

Certification empowers nurses by validating their clinical competency and continued professional growth. This article discusses the current state of certification in the nursing profession. The potential benefits to the certified nurse and the costs in both time and money needed to achieve and maintain certification are addressed. The article also describes how the nursing department of a 284-bed rehabilitation hospital developed a program to promote specialty certification among its nursing staff. The process and outcome of this program revealed several potential research topics.

Pharmacokinetics of cefepime after single and multiple intravenous administrations in healthy subjects.

The pharmacokinetics of cefepime in 31 young, healthy volunteers were assessed after the administration of single and multiple 250-, 500-, 1,000-, or 2,000-mg intravenous doses. Each subject received a single dose of cefepime via a 30-min intravenous infusion on day 1 of the study. Starting from day 2, subjects received multiple doses of cefepime every 8 h for 9 days, and on the morning of day 11, they received the last dose. Serial blood and urine samples were collected after administration of the first dose and on days 1, 6, and 11. Cefepime concentrations in plasma and urine were assayed by using reverse-phase high-performance liquid chromatography with UV detection. Data were evaluated by noncompartmental methods to determine pharmacokinetic parameters. The mean half-life of cefepime was approximately 2 h and did not vary with the dose or duration of dosing. The regression analyses of peak levels (Cmax) in plasma at the end of the 30-min intravenous infusion and the area under the plasma concentration-versus-time curve (AUCo-infinity) showed a dose-proportional response. The steady-state volume of distribution (Vss) was approximately 18 liters and was independent of the administered dose. The multiple-dose pharmacokinetic data are suggestive of a lack of accumulation or change in clearance of cefepime on repeated dosing. Cefepime was excreted primarily unchanged in urine. The recovery of intact cefepime in urine was invariant with respect to the dose and accounted for over 80% of the dose. The values for renal clearance ranged from 99 to 132 ml/min and were suggestive of glomerular filtration as the primary excretion mechanism. It is concluded that cefepime linear pharmacokinetics in healthy subjects.

Prevalence and characteristics of nursing home-acquired infections in the aged.

OBJECTIVES: This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out. METHODS: The records of 4,259 patients in a stratified random sample of 53 Maryland nursing homes were reviewed for diagnostic procedures, medical, functional, and behavioral status. Infections were identified by signs, symptoms, and laboratory findings. RESULTS: Study patients were characteristic of aged patients in US nursing homes. The prevalence of infections actually acquired in the nursing home (80% of all infections) was 4.4%. Multivariate analysis revealed that skin infections (35% of nursing home-acquired infections) were associated with skin ulcers and inversely with urine incontinence. Fevers of uncertain source (13%) were associated with bladder catheters. Symptomatic urinary infections (12%) and lower respiratory infections (12%) were associated with bedfast status, and the latter with tracheostomy and lung disease. Skin ulcers, urethral catheters, and bedfast status were markers for nursing home-acquired infection. The prevalence of infection in patients with all three markers was 32%; in patients with none, 2%. Fewer than a quarter of the four most common nursing home-acquired infections received an evaluation which met minimal diagnostic criteria established by a panel of infectious disease specialists and geriatricians. Patients with dementia, those in large homes (greater than 150 beds), and those in urban homes were less likely to be evaluated in a manner meeting these criteria. CONCLUSIONS: Use of three characteristics (ie skin ulcers, urethral catheters, bedfast status) to identify patients at risk for nursing home-acquired infections may allow targeted infection surveillance and prevention programs. In addition, nursing home-acquired infections are not evaluated uniformly across patients and facilities, suggesting the need to establish, through further study, guidelines for such evaluations.

Safety, tolerance, and pharmacokinetics of cefepime administered intramuscularly to healthy subjects.

Steady state pharmacokinetics, absolute bioavailability, and dose proportionality of cefepime were evaluated in healthy male subjects after single (250, 500, 1000, or 2000 mg) and multiple (1000 mg every 12 hours for 10 days) intramuscular injections. Safety and tolerance were also monitored. High performance liquid chromatography/UV methodology was used to determine cefepime concentrations in plasma and urine. Key pharmacokinetic parameters were determined using noncompartmental methods. Cefepime was absorbed rapidly; mean peak times were 1.0-1.6 hours. Pharmacokinetics were linear over the 250-mg to 2000-mg dose range, with mean total body clearance ranging from 125 to 141 mL/min. The peak plasma concentration and area under the curve increased in a dose-proportional manner. The apparent elimination half-life (2 hours) did not appear to be influenced by dose or by duration of dosing. No accumulation of cefepime was observed during the multiple-dose study. More than 80% of the administered dose was excreted in the urine as unchanged cefepime, and absolute bioavailability after intramuscular dose was 100%. Cefepime was well tolerated. Most subjects experienced none to mild pain and only minimum discomfort at the site of injection.

Eat for health: a nutrition and cancer control supermarket intervention.

The growing evidence linking dietary patterns to the incidence and prevention of chronic disease has prompted a number of prominent health and scientific agencies to publish dietary guidelines for the public. Some dietary guidelines address specific diseases, such as cancer or heart disease; others focus on overall health promotion. This situation has created a demand for nutrition education and information programs for the public. Increasingly, supermarkets are seen as potential sites for effective consumer education. Eat for Health is a joint research study by the National Cancer Institute (NCI) and Giant Food Inc., a regional supermarket chain in the Washington-Baltimore area. The study's goal was to test the feasibility of supermarkets as a site for consumer nutrition education. Eat for Health's educational focus was diet and cancer control issues in the context of dietary patterns that promote health. Particular attention was paid to reduction of fat intake and increases in consumption of dietary fiber from grains, vegetables, and fruits. Analysis of program results is currently underway; data should be available in early 1990.

The prevalence of urethral catheterization in Maryland nursing homes.

Urinary incontinence is common in the increasing numbers of aged people and is often the precipitating factor for nursing home admission. Recalcitrant incontinence may be managed by urethral catheters. In this study of a random stratified sample of Maryland nursing homes (4259 patients), we found that the daily prevalence of urethral catheter use in Maryland nursing homes was 7.5%. More than 80% of urethral catheter users were women. Among men, we found equal prevalences of urethral and condom catheter use. Previous studies have demonstrated long-term use of urethral catheters to be associated with almost universal bacteriuria of a polymicrobial and dynamic nature. Combining these data suggests that long-term catheter-associated bacteriuria is the most common infection in American health care facilities.

Nosocomial sepsis in the neonatal intensive care unit.

During a 12-month study of the causes of and risk factors for nosocomial sepsis in a neonatal intensive care unit (NICU), we detected 23 episodes of nosocomial sepsis in 20 of the 155 infants at risk who were hospitalized in the NICU for at least one week. The associated mortality was 20%. Gram-positive organisms accounted for 15 (65%) of the episodes. Low birth weight, multiple gestation, and prolonged hospitalization were significant risk factors for nosocomial sepsis by univariate analysis; together, these three factors correctly predicted 80% of the infants with sepsis and 82% of the control subjects. By logistic regression analysis, however, length of stay was not a significant risk factor, but rather a confounding variable that was highly associated with birth weight. Analysis of risk factors for nosocomial sepsis showed that previous antibiotic therapy placed an infant at risk for candidemia; assisted ventilation was a risk factor for sepsis caused by group D Streptococcus and Candida albicans. Sepsis was related to infected or malfunctioning intravascular catheters in nine of the 20 infants with sepsis. Further investigation to determine strategies for preventing nosocomial septicemia in the low birth weight infant is warranted.

Once-daily irrigation of long-term urethral catheters with normal saline. Lack of benefit.

Urinary incontinence is often managed with a long-term urethral catheter after other methods have failed. Such urethral catheterization is associated with polymicrobial bacteriuria, catheter obstruction, fever, bacteremia, urinary tract stones, and death. Periodic catheter irrigation is a common but untested management procedure intended to prevent catheter obstruction, fevers, and/or bacteremia. To evaluate this technique, we performed a randomized crossover trial comparing ten weeks of once-daily normal saline irrigation with ten weeks of no irrigation in 32 long-term catheterized women. The incidence of catheter obstructions and febrile episodes and the prevalence and species of bacteriuria were similar whether examined as completed crossover patients (N = 23) or as partially completed trials (N = 9). Once-daily irrigation with normal saline of long-term urethral catheters is a time-consuming and costly procedure that is unlikely to have an impact on the morbidity associated with such catheters.

Infection control in Maryland nursing homes.

We surveyed 53 randomly chosen Maryland nursing homes for infection control policies and practices. The majority had written infection control policies, an infection control committee, and a designated practitioner for infection control; in most facilities, however, the infection control practitioner had other major duties, spent little time on infection control, and had no specific training in the field. Thirty-four percent of homes in the survey performed routine environmental cultures, and more than half had insufficient or no isolation policies for infected decubiti and acute diarrhea. In general, the intensity of infection surveillance and the extent of infection control measures increased with the level of care provided, from domiciliary homes to homes providing chronic care. Employee health care fared generally well: 60% of homes offered influenza vaccine to employees and 66% had restriction policies for employees with upper respiratory infections. While the majority of homes offered the influenza vaccine to residents, acceptance of other vaccines recommended for the elderly was less widespread. We conclude that infection control efforts are made in most Maryland nursing homes; however, appropriate guidelines and more effort to educate nursing home personnel in proper infection control practices are badly needed.

Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery.

During a 30-month period, 20 median sternotomy wound infections or endocarditis occurred after 20 of 1204 (1.7%) cardiac surgery procedures in adults at the University of Maryland Hospital. We examined four risk factors related to the individual undergoing surgery: age, sex, and index of obesity (weight/height), and presence of diabetes mellitus. The odds ratio estimates of the relative risk of infection observed with use of a population control group were as follows: sex (female) 3.5 (p less than 0.05), obesity 2.0, and presence of diabetes mellitus 3.8. For a second control group matched for age, type of operative procedure, and date of operation, the estimated relative risks of infection were sex (female) 2.1, obesity 6.2 (p less than 0.05), and diabetes mellitus 2.0. More precise definition of the relative risk of sternotomy infection associated with obesity and diabetes is required to aid surgeons and patients in making judgments about the relative benefits of surgery and to alert nursing personnel to be particularly aware of early signs of infection in patients at high risk.

MR/K hemagglutination of Providencia stuartii correlates with adherence to catheters and with persistence in catheter-associated bacteriuria.

Providencia stuartii was the most prevalent bacterial species isolated, for one year, from weekly urine specimens from 51 long-term catheterized patients. Significantly more strains causing bacteriuric episodes of long duration expressed MR/K (mannose-resistant/Klebsiella-like) hemagglutination (74%) than did those causing episodes of short duration (26%; P = .004). Isolates expressing MR/K hemagglutinin bound in higher numbers to catheter material (P = .023) than did those not expressing this hemagglutinin. Significantly more strains causing bacteriuric episodes of short duration expressed the mannose-sensitive (MS) hemagglutinin (43%) than did those causing episodes of long duration (7%; P = .014). Isolates expressing MS hemagglutinin bound significantly more 125I-labeled Tamm-Horsfall protein (THP) than did isolates not expressing this hemagglutinin (P = .0001). Our results indicate that MR/K hemagglutinin plays an important role in the ability of P. stuartii to persist and suggest that MR/K adheres to the catheter. Conversely, MS hemagglutinin binds to THP and may prevent persistence of P. stuartii in the catheterized urinary tract.

From reporting system to MIS: getting there.

Human services agencies are closer than ever to fulfillment of their authoritative role. A critical step is transformation of the Reporting System to a Management Information System. This creates the information structure and mind set necessary to generate new, data-based ideas. There are too many obstacles to traditional MIS development approaches in agencies, however. New strategies such as selective use of end-user technology and prototyping can provide methods that overcome these obstacles.

Expression of type 1 fimbriae may be required for persistence of Escherichia coli in the catheterized urinary tract.

Long-term urinary catheterization results in polymicrobial bacteriuria and is complicated by fever, bacteremia, acute pyelonephritis, and death. Escherichia coli is a common urine isolate from catheterized patients and can persist for months. We hypothesized that fimbria-mediated adherence contributes to its persistence. For 1 year, urine specimens were collected from 51 patients greater than or equal to 65 years of age who were catheterized for greater than or equal to 30 days. E. coli was isolated at greater than or equal to 10(5) CFU/ml from 447 (36%) of 1,230 weekly urine specimens from 26 patients. Week 1 isolates from 52 definable episodes were tested for hemagglutination, hybridization with gene sequences from the pil and pap operons, in vitro adherence to catheter material, binding of 125I-labeled Tamm-Horsfall protein, hemolysin and colicin V production, and serum resistance. The proportions of isolates of short (1 week only), medium (2 to 11 weeks) and long (greater than or equal to 12 weeks) episodes of bacteriuria which expressed type 1 fimbriae as assayed by mannose-sensitive hemagglutination were 59, 65, and 92%, respectively. Isolates with the pil operon (the genome for type 1 fimbriae) from episodes lasting greater than 1 week expressed mannose-sensitive hemagglutination more frequently (P = 0.011) than pil-positive isolates from episodes of less than or equal to 1 week. Isolates from episodes of greater than 1 week also bound significantly more Tamm-Horsfall protein than isolates from episodes of less than or equal to 1 week (P = 0.044). Although nearly half of the isolates produced P fimbriae, an important virulence factor for the development of pyelonephritis, no correlation with persistence could be made. Overall, the E. coli isolates expressed traits similar to those of strains that caused cystitis. Type 1 fimbriae appear to be important for the persistence of E. coli in the long-term-catheterized urinary tract.