Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study.

OBJECTIVES: To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process. METHODS: A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities. RESULTS: Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis. CONCLUSION: Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Patient care experience with utilization of isolation precautions: systematic literature review and meta-analysis.

BACKGROUND: Use of isolation precautions (IP) may represent a trade-off between reduced transmission of infectious pathogens and reduced patient satisfaction with their care. OBJECTIVE: To perform a systematic literature review and meta-analysis to identify if and how IPs impact patients' care experiences. DATA SOURCES: Medline, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsychInfo, HSRProj and Cochrane Library databases. STUDY ELIGIBILITY CRITERIA: Interventional and observational studies published January 1990 to May 2019 were eligible for inclusion. PARTICIPANTS: Patients admitted to an acute-care facility. INTERVENTIONS: IPs versus no IPs. METHODS: Six reviewers screened titles, abstracts and full text. Experience of care reported by patients using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was assessed as the outcome for the meta-analysis. Pooled odds ratios were calculated using the random-effects model. Heterogeneity was assessed using the I2 value. RESULTS: After screening 7073 titles and abstracts, 15 independent studies were included in the review. Pooling of unadjusted estimates from the HCAHPS survey demonstrated that IP patients were less likely to give top scores on questions pertaining to respect, communication, receiving assistance and cleanliness compared to the no-IP patients. Patients under IP with longer length of stay appeared to have more negative experiences with the care received during their stay compared to no IP. CONCLUSIONS: Patients under IP were more likely to be dissatisfied with several aspects of patient care compared to patients not under IP. It is crucial to educate patients and healthcare workers in order to balance successful implementation of IP and patient care experiences, particularly in healthcare settings where it may be beneficial.

Stimulation of the ovaries in women with breast cancer undergoing fertility preservation: Alternative versus standard stimulation protocols; the study protocol of the STIM-trial.

BACKGROUND: Chemotherapy for breast cancer may have a negative impact on reproductive function due to gonadotoxicity. Fertility preservation via banking of oocytes or embryos after ovarian stimulation with FSH can increase the likelihood of a future live birth. It has been hypothesized that elevated serum estrogen levels during ovarian stimulation may induce breast tumour growth. This has led to the use of alternative stimulation protocols with addition of tamoxifen or letrozole. The effectiveness of these stimulation protocols in terms of oocyte yield is unknown. METHODS/DESIGN: Randomized open-label trial comparing ovarian stimulation plus tamoxifen and ovarian stimulation plus letrozole with standard ovarian stimulation in the course of fertility preservation. The study population consists of women with breast cancer who opt for banking of oocytes or embryos, aged 18-43years at randomisation. Primary outcome is the number of oocytes retrieved at follicle aspiration. Secondary outcomes are number of mature oocytes retrieved, number of oocytes or embryos banked and peak E2 levels during ovarian stimulation. DISCUSSION: Concerning the lack of evidence on which stimulation protocol should be used in women with breast cancer and the growing demand for fertility preservation, there is an urgent need to undertake this study. By performing this study, we will be able to closely monitor the effects of various stimulation protocols in women with breast cancer and pave the way for long term follow up on the safety of this procedure in terms of breast cancer prognosis. TRIAL REGISTRATION: NTR4108.

A mother's gift of life: exploring the concerns and ethical aspects of fertility preservation for mother-to-daughter oocyte donation.

With the introduction of oocyte vitrification, a special form of intergenerational intrafamilial medically assisted reproduction (IMAR) has now become feasible: fertility preservation for mother-to-daughter oocyte donation (FPMDD). For girls diagnosed with premature ovarian insufficiency (POI), banking of their mothers' oocytes can preserve the option of having genetically related offspring. Since policy documents on IMAR do not discuss specific concerns raised by FPMDD, clinicians can feel at a loss for guidance with regard to handling these requests. Through a comparison of FPMDD with reproductive practices in which similar concerns were raised, proportionality of cryopreservation for self-use and pressure to use the oocytes in fertility preservation in minors, we argue that FPMDD can be acceptable under conditions. The paper ends with recommendations for handling FPMDD-requests, including different options for the legal construction of this form of oocyte donation.

A prospective case series of women with estrogen receptor-positive breast cancer: levels of tamoxifen metabolites in controlled ovarian stimulation with high-dose tamoxifen.

Controlled ovarian stimulation (COS) in women with estrogen receptor (ER)-positive breast cancer is potentially harmful because of the increase in serum estrogen levels. During COS for cryopreservation of oocytes or embryos, these women may receive high doses of tamoxifen (60 mg) to modulate the ER and prevent extra growth of estrogen responsive tumours during COS. However, it is unknown whether adequate serum concentrations of endoxifen, the most important metabolite of tamoxifen, can be reached. The aim of this study is to evaluate whether the tamoxifen dose used in a tamoxifen-COS combined schedule for women with ER-positive breast cancer is high enough to reach endoxifen levels that are considered therapeutically effective to inhibit breast cancer growth. The four women with ER-positive breast cancer who underwent COS for cryopreservation of oocytes were prospectively studied at the Academic Medical Centre, Amsterdam, the Netherlands. Throughout COS, blood samples were collected and tamoxifen and endoxifen levels were determined by a validated high-performance liquid chromatography tandem mass spectrometry assay. The four women with ER-positive breast cancer underwent a total of five COS cycles, while additionally using tamoxifen 60 mg daily. The tamoxifen and endoxifen levels showed a large variability between the women, with endoxifen levels during the whole period of ovarian stimulation varying between 3.96 and 41.0 ng/ml. The average number of vitrified oocytes was 11 (5-14). Therapeutically effective endoxifen serum levels can be reached when tamoxifen is used to counteract estrogen levels during COS for fertility preservation, but not in all women. Large variations of tamoxifen and endoxifen levels between the women were observed.