Environmental challenges of identifying a patient zone and the healthcare zone in a crowded Vietnamese hospital.

BACKGROUND: The application of the World Health Organization (WHO) 'My five moments for hand hygiene' was designed for a healthcare environment with levels of bed spacing and occupancy normally present in developed countries. However, overcrowded healthcare facilities in Vietnam and other challenged settings require strategies to adapt 'My five moments for hand hygiene' in order to meet their situational needs. AIM: To identify the environmental challenges to compliance with the 'My five moments' indications. METHODS: Overt observation using the WHO hand hygiene audit tool was conducted in two clinical departments at a large teaching hospital in Vietnam. Clinical practice movements and the 'My five moments' indications were detailed diagrammatically. FINDINGS: Sharing a bed is widely practised outside the intensive care unit in this country, which makes visualizing a patient zone according to the WHO instructions difficult. In addition, decreased spacing between shared beds in overcrowded conditions results in the close proximity of patients to the shared healthcare zone. These two barriers prevent attempts to apply the 'My five moments' correctly. CONCLUSION: Undertaking hand hygiene and conducting audits in accordance with the 'My five moments for hand hygiene' assumes a separation of patients and individual healthcare zones. The barriers to applying 'My five moments' include the lack of distinct zones between patients and their shared healthcare zone, and amelioration requires resources beyond current chronic resource challenges. Until environmental resources can meet the western standards required for application of the 'Five moments' principle, healthcare workers urgently need detailed clarification of modifications that would empower them to comply.

The 'My five moments for hand hygiene' concept for the overcrowded setting in resource-limited healthcare systems.

Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the 'My five moments for hand hygiene' concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers' (HCWs) hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW's ability to visualize and delineate patient zones. The 'My five moments for hand hygiene' concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines--the reduction of infectious risks.

Facilitators for influenza vaccination uptake in nurses at the Shiraz University of Medical Sciences.

OBJECTIVE: Influenza is an important cause of morbidity and mortality. The aim of this study was to identify facilitators for vaccination in nursing staff at the Shiraz University of Medical Sciences. DESIGN: Cross-sectional study. METHOD: A self-administered questionnaire was distributed among nurses between November 2005 and February 2006. RESULTS: The response rate was 100%. Sixty-one percent (89/145) of nurses reported that they had continued working while sick with an influenza-like illness, and 21% (35/166) of nurses had been vaccinated for the current season. The most common reasons given for uptake of the current influenza vaccine were the belief that they were at risk of influenza due to the nature of their work (80%, 28/35), and concern about transmitting influenza to their patients (31%, 11/35). Vaccinated nurses were 3.4 times more likely [95% confidence interval (CI) 1.0-11.7; P = 0.05] to have the intention to be vaccinated next season than unvaccinated nurses. Respondents who intended to be vaccinated next season were 10.3 times more likely (95% CI 4.4-23.2; P = 0.000) to recommend the vaccine to their family and coworkers, and 4.6 times more likely (95% CI 1.9-11.0; P = 0.001) to recommend vaccination to their patients. CONCLUSION: Free of charge and widely available vaccination programmes, and the belief that nurses are at risk of influenza due to the nature of their work improve vaccination uptake among nurses, and thereby reduce the risk of healthcare-associated infection in susceptible patient populations.

Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks, hand rubs and in-service training.

Few attempts to increase healthcare workers' hand hygiene compliance have included an in-depth analysis of the social and behavioural context in which hand hygiene is not undertaken. We used a mixed method approach to explore hand hygiene barriers in rural Indonesian healthcare facilities to develop a resource-appropriate adoption of international guidelines. Two hospitals and eight clinics (private and public) in a rural Indonesian district were studied for three months each. Hand hygiene compliance was covertly observed for two shifts each in three adult wards at two hospitals. Qualitative data were collected from direct observation, focus group discussions and semistructured in-depth and informal interviews within healthcare facilities and the community. Major barriers to compliance included longstanding water scarcity, tolerance of dirtiness by the community and the healthcare organisational culture. Hand hygiene compliance was poor (20%; 57/281; 95% CI: 16-25%) and was more likely to be undertaken after patient contact (34% after-patient contact vs 5% before-patient contact, P<0.001) and 'inherent' opportunities associated with contacts perceived to be dirty (49% 'inherent' vs 11% 'elective' opportunities associated with clean contacts, P<0.001). Clinicians frequently touched patients without hand hygiene, and some clinicians avoided touching patients altogether. The provision of clean soap and water and in-service training will not overcome strong social and behavioural barriers unless interventions focus on long term community education and managerial commitment to the provision of supportive working conditions.

A survey of medical staff attitudes to an antibiotic approval and stewardship programme.

BACKGROUND: Antibiotic stewardship programmes (ASPs) are advocated to ensure appropriate antimicrobial use; with short-term evidence they may improve outcomes, limit adverse effects, encourage cost-effectiveness and reduce antibiotic resistance. At Concord Hospital, a 450-bed acute care hospital, we have used a telephone-based ASP for 15 years. There may be differences in attitudes to the ASP by prescribers, which may influence its long-term efficacy. METHOD: A 40-item self-administered questionnaire was sent to 190 junior and 250 specialist medical staff. We aimed to elicit medical staff attitudes to the ASP's utility, educational value, effect on patient care and ease of use. RESULTS: One hundred and sixty-four completed questionnaires were returned. Most (82%, 95% confidence interval (95%CI) 75-87%) clinicians had used the ASP, 98% of whom believed it to be a reasonable system. Most staff (85%, 95%CI 79-90%) believed that seeking approval made teams think carefully about antibiotic choice, agreed it provided helpful advice (91%, 95%CI 85-95%) and that the approval system provided useful advice and was educational (88%, 95%CI 81-92%). The ASP was felt time-consuming and detracting from clinical duties by 33% (95%CI 26-41%), while 10% (95%CI 5.8-15.7%) believed it undervalued intuition and experience. Few (19%, 95%CI 13-25%, P < 0.0001) clinicians believed it infringed their autonomy. The advice given through the ASP was believed by most (89%, 95%CI 81-92%) to improve patient outcomes. CONCLUSION: The ASP was surprisingly well supported by all levels of staff, and reinforced the benefits of maintaining an ASP policy.

Changing epidemiology of meticillin-resistant S. aureus in Queensland, Australia, 2000-2006: use of passive surveillance of susceptibility phenotypes.

The epidemiology of meticillin-resistant S. aureus (MRSA) infection has changed remarkably in recent years with the appearance of new MRSA strains causing infections in the community. These strains have now begun to cause healthcare-associated infections. The ability to track such changes is necessary to guide clinical and public health action. Here we report passive surveillance of all public laboratory susceptibility data in Queensland to track changes in MRSA phenotypes corresponding to the major epidemic strains from 2000 to 2006. The inpatient rate of MRSA isolation from pus, tissue and fluid (PTF) and blood culture (BC) specimens declined by 26% and 35%, respectively. The rate of isolation of the AUS-2/3-like phenotype (corresponding to ST239-MRSA-III) decreased from 651 to 242 isolates per million accrued patient days in inpatient PTF and BC, whereas that for non-multiresistant MRSA (nmMRSA, corresponding to community MRSA strains) increased from 71 to 315. The overall outpatient rate of MRSA isolation from PTF and BC increased by 224% and 31%, respectively. The rate of AUS-2/3-like isolates in outpatient PTF decreased from 131 to 60 per million outpatient occasions of service while the nmMRSA rate increased from 52 to 490. Surveillance of phenotypes derived from routine susceptibility data is a useful tool for tracking changes in the epidemiology of MRSA over large geographical regions.

Attitudes towards and evaluation of medical emergency teams: a survey of trainees in intensive care medicine.

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients. An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training. One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.

Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?

Post-discharge surgical infection surveillance by patients remains an integral part of many infection control programmes despite proven unreliability. We attempted to improve the validity of patient recognition of signs and symptoms of wound infection and post-discharge postal questionnaire responses through specific education prior to discharge. In total, 588 patients were studied after random assignment into two intervention groups, one of which received relevant education. Both groups were followed for four weeks post-operatively, with features of infection assessed weekly by experienced infection control nurses (ICNs) and by patient responses to routine postal questionnaires. Those patients who received education demonstrated a significantly poorer correlation with ICN diagnosis compared to the non-educated group (Kappa 0.69 and 0.81 respectively, P=0.05). Both patient groups achieved the same sensitivity for recall (83.3%), with high specificity demonstrated by both groups [educated (93.7%); non-educated (98.1%)]. The positive predictive value was 65.2% for the educated group and 83.3% for the non-educated patient group. When infected wounds identified by patients were examined for the proportion that were overdiagnosed, the excess of SSI identified by the educated patient group was 44.4% and by the non-educated group 16.7%. These results suggest that pre-discharge education causes patients to overdiagnose clinical features of wound infection and fails to improve the validity of diagnosis. This outcome further questions the value of post-discharge infection rates obtained by patient self-assessment as a measure of quality of performance.

Hindsight: a re-analysis of the severe acute respiratory syndrome outbreak in Beijing.

OBJECTIVE: To review the severe acute respiratory syndrome (SARS) epidemic in Beijing using basic epidemiological principles omitted from the original analysis. STUDY DESIGN: Analysis of Prospective surveillance data for Beijing collected during the outbreak. METHODS: Surveillance data were reclassified according to World Health Organization criteria. Cases previously excluded without date of onset of illness were included in the epidemic curve from estimates using the average time between date of onset and date of hospitalization for cases with both dates. Cases who failed to give a contact history were now included; 7% (n=5) of cases during the import phase and 61% (n=365) during the peak phase. Previously excluded cases were included for plotting on an epidemic curve, and basic spot mapping for distribution of cases was used from attack rates recalculated for age, gender, occupation, residential location, date of onset of illness and demographics. RESULTS: The spot map effectively illustrated clusters by residency, with the inner-city sustaining the highest attack rate (33.42 per 100,000), followed by an easterly distribution 5-30km away (21.62 per 10,000), and lowest in districts 60-160km away (9.21 per 100,000). The new epidemic curve shows the outbreak commencing 10 days earlier than initially reported, with a three-fold greater increase in cases during the escalation phase than previously estimated. CONCLUSION: In hindsight, the investigation of the Beijing SARS would have benefited from the use of spot maping as an essential outbreak tool for early identification of specific geographical area(s) for quarantining. If a spot map of incidence density rates was used during the early phase of the outbreak, the inner city might have been identified as a major risk factor requiring rapid quarantining. Contact history became uncommon as the outbreak progressed, suggesting that hospitals were over-burdened or pathogenesis and environment risk factors changed, strengthening the usefulness of early spot mapping and the need to modify risk factors included as contact history as the epidemic progresses.

Behavioural considerations for hand hygiene practices: the basic building blocks.

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

A tsunami related tetanus epidemic in Aceh, Indonesia.

In January 2005, a tetanus epidemic was discovered amongst survivors of the Boxing Day Tsunami in Aceh, Indonesia. Our aim was to describe the extent of the tetanus outbreak in tsunami survivors admitted and describe the case outcomes from one hospital. All clinicians were instructed to report suspected cases to a centralised organisation using a standardised data collection tool. Active case finding was carried out by a trained team that visited hospital wards in Aceh. Of the 106 cases, 79% was above 25 years old (the median age was 40 years) and 62% was male. The mortality rate in Aceh was 19% and that of in follow up cases was 17%. Fifteen of the follow-up cases were admitted with severe tetanus associated with superficial wounds, three of whom had a history of immersion. Supplies to treat the tetanus cases in this epidemic were initially limited as disaster relief agencies were not prepared for the resultant tetanus epidemic. The mortality rate of 17%, was significantly less than was usual for tetanus in adults (>50%) and children (80%) in underdeveloped countries. To reduce mortality and morbidity, rapid disaster relief organisations should include supplies for vaccination and treatment of tetanus cases and consider early tracheotomy for severe cases.

Handwashing in healthcare workers: accessibility of sink location does not improve compliance.

In spite of its importance, handwashing frequency in healthcare workers is generally low. The rebuilding and relocation of an 800-bed tertiary referral hospital on the same campus allowed assessment of the impact of easy accessibility to sinks on handwashing compliance. The new hospital design ensured that no clinical activity could occur more than 5 m (usually much less) from a sink. In the old hospital, clinical staff were often up to 30 m from a sink. Covert observation of nursing staff was undertaken in intensive care, infectious diseases, internal medicine and urology wards, over a total of 24 h during three consecutive days, two months before and one and 10 months after relocation to the new hospital. In all areas, handwashing compliance was greater before than after-patient contact. Initial increases (9-24%) in after-patient contact handwashing frequency following patient contact were demonstrated in units of both high and low clinical care activity one month after relocation. However, no sustained clinically significant improvement could be demonstrated nine months later. Glove use was shown to diminish compliance with handwashing protocols by as much as 25%. Improved accessibility to sinks does not lead to an improvement in healthcare workers' handwashing compliance.

The Hospital Infection Standardised Surveillance (HISS) programme: analysis of a two-year pilot.

In 1998 the New South Wales (NSW) Health Department funded the development and implementation of the State's first standardized methodology for the surveillance of healthcare-associated infection for public hospitals. Fifteen pilot hospitals targeted inpatient groups considered to represent their core patient groups to act as sentinel measurements of patient safety. The aggregated rates of surgical site infection for coronary artery bypass graft (CABG) (chest & leg) surgery was 1.7% (95%CI: 1.1-2.5), CABG (chest only) 2.1% (95%CI: 1.0-3.7), vascular 7.1% (95%CI: 4.6-10.3), hip prosthesis 1.3% (95%CI: 0.5-2.7), knee prosthesis 6.1% (95%CI: 2.8-11.2) and colorectal 12.5% (95%CI: 9.5-16.1). The development of a bloodstream infection (BSI) associated with a central venous catheter (CVC) was not significantly (P=0.6) different when examined by duration of exposure with 3.7 BSI per 1000 line-days for CVC in situ six or more days compared with 4.0 BSI per 1000 line-days for CVC in situ for five or less days. A significantly (P<0.0001) greater proportion of patients whose CVC was in situ six or more days (6.8 per 100 patients, 95%CI: 4.2-10.2) developed a BSI compared with the proportion of patients whose CVC was in situ for five or fewer days (0.6 per 100 patients, 95%CI: 0.3-1.3). Significantly (P<0.0001) different rates of patients acquiring a new methicillin-resistant Staphylococcus aureus infection were found when hospital type was examined with rates ranging from 0.2 to 5.0 per 10000 occupied acute-care bed-days. The pilot highlighted that the collection of data for aggregation of some procedures and intravascular catheters may take many years before a reliable benchmark can be identified and many hospitals may not achieve reliable local rates annually. For surveillance to provide timely measures of patient safety we should consider surveillance methods for many small to medium sized hospitals that includes active surveillance only for infections with concurrent passive surveillance of the relevant denominators.

Post-discharge surveillance: can patients reliably diagnose surgical wound infections?

Post-discharge surgical wound infection surveillance is an important part of many infection control programs. It is frequently undertaken by patient self-assessment, prompted either by a telephone or postal questionnaire. To assess the reliability of this method, 290 patients were followed for six weeks postoperatively. Their wounds were photographed and also covertly assessed for signs of infection by two experienced infection control nurses (ICNs). Patients also responded to a postal questionnaire seeking evidence of infection at both week four and week six post-surgery. Correlation between the patient's assessment of their wound and the ICNs diagnosis was poor (r = 0.37) with a low positive predictive value (28.7%), although negative predictive value was high (98.2%). Assessment of photos for signs of infection by two experienced clinicians also correlated poorly with the ICNs diagnosis of infection (r = 0.54). The patient's recall of prescription of an antibiotic by their general practitioner (GP) for wound infection during the postoperative period correlated best with the ICNs diagnosis (r = 0.76). This latter measure, particularly when confirmed by the GP in those patients reporting an infection, appears to provide the most valid and resource efficient marker of post-discharge surgical wound infection.

Estimation of the risk of bloodborne pathogens to health care workers after a needlestick injury in Taiwan.

OBJECTIVES: To estimate the number of health care workers (HCWs) in Taiwan at risk annually for contracting hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV after a needlestick and sharps injury (NSI) with a used hollow-bore needle. METHODS: All patients hospitalized in 1 tertiary hospital between September 1997 and June 1998 had routine pathological work-ups. On the first day of the months of September 1997, December 1997, March 1998, and June 1998, 1805 samples of deidentified residual sera randomly sampled from 18,474 inpatients older than 6 years were serologically tested for antigens to HBV (HBsAg and HBeAg) and antibodies to HCV (anti-HCV) and HIV (anti-HIV) with enzyme-linked immunosorbent assay reagents. The frequency of NSIs with contaminated devices in HCWs from 16 public teaching hospitals between July 1996 and June 1997 and the serologic results were used to extrapolate the estimated annual rate of seroconversion in HCWs after an NSI. RESULTS: Of the 1805 samples tested, 16.7% were seropositive for HBsAg (of which 1.7% were positive for HBeAg), 12.7% were positive for anti-HCV, and 0.8% were positive for anti-HIV. Of the 7550 NSIs reported by 8645 HCWs, 66.7% involved a contaminated hollow-bore needle. From these data, 308 to 924 HCWs were estimated to be at risk for contracting HBV; 334 to 836 were at risk for contracting HCV; and, at the most, 2 were at risk for contracting HIV. The estimated annual number of contaminated NSIs sustained by 4 categories of HCWs ranged from 0.3 to 0.7, resulting in 543 nurses, 113 technicians, 80 physicians, and 66 supporting staff to be at risk annually of acquiring HBV infection. The numbers of HCWs estimated to be at risk of acquiring HCV were 596 nurses, 90 physicians, 84 technicians, and 30 supporting staff. The risk of acquiring HIV was low, with 1 nurse and possibly 1 other staff potentially exposed annually. CONCLUSIONS: Our estimates of the risk for seroconversion after an NSI have demonstrated that an occult risk can be formulated into a quantifiable risk. The number of susceptible HCWs at risk for seroconversion is as many as 1762 annually. With the number of nurses employed and the frequency with which they use sharps and sustain an NSI, 64.7% of all possible seroconversions will be in the nursing staff. This is a salient reminder of the importance of the introduction of early training in safe-needle-handling techniques before nurses enter their internship in countries where safety equipment, safety instructions, and staff vaccination programs are absent.

Sharps injuries among hospital support personnel.

Sharps injuries (SIs) among support personnel in hospitals have received little attention in the scientific literature. A cross-sectional study was undertaken to measure the incidence of SIs in Taiwanese support personnel. All support personnel, including laundry workers, cleaners, porters and central supply workers, from 16 hospitals were surveyed for SIs, sustained between June 1996 and July 1997. Either a questionnaire or face-to-face interviews, for those staff with a literacy problem, were used. Of the 862 persons eligible for study, 79.4% (684) were evaluable. Few staff (30.4%) had attended a prevention programme and 61% had suffered an SI in the past year. Few (25.4%) reported their injury. Hollow-bore needles, of which 72.2% had been used, were associated with 42.2% of injuries. Cleaners sustained the majority (65.7%) of injuries, and inappropriate disposal was associated with 54.7% of all injuries. For those staff employed for more than four years, the risk of sustaining an injury increased significantly with length of employment (P<0.001). Most of the injuries were sustained by cleaners handling sharps inappropriately disposed of by clinical staff. A safer environment for support staff could be achieved with the co-operation of clinical staff to correctly dispose of sharps to ensure single handling of sharps. A formal orientation of support staff in the reporting of SIs would enable clinical assessment and management of injuries, as well as an evaluation of needle and sharps safety in the healthcare setting.

Risk of death from methicillin-resistant Staphylococcus aureus bacteraemia: a meta-analysis.

OBJECTIVE: To estimate the risk of death from healthcare-associated (nosocomial) bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA), and compare it with that of nosocomial bacteraemia caused by methicillin-sensitive S. aureus (MSSA), by meta-analysis of selected studies. DATA SOURCES: Medline, EMBASE, Current Contents and Cochrane Library were searched for the period January 1978 (or earliest date of the database, if later than 1978) to December 2000. STUDY SELECTION: Studies which compared mortality of nosocomial MRSA and MSSA bacteraemia. DATA SYNTHESIS: Nine studies were analysed. All but one found an increased relative risk (RR) of death from MRSA bacteraemia, with RR ranging from 0.89 to 4.94. Meta-analysis showed that patients with MRSA bacteraemia have an RR of death, compared with patients with MSSA bacteraemia, of 2.12 (95% CI, 1.76-2.57) using the fixed-effect method, and 2.03 (95% CI, 1.55-2.65) using the random-effect method. CONCLUSION: MRSA bacteraemia is associated with a real increase in risk of death, further justifying ongoing MRSA surveillance and control in healthcare facilities.