An opportunistic evaluation of a routine service improvement project to reduce falls in hospital.

BACKGROUND: Preventing falls in hospital is a perennial patient safety issue. The University Hospital Coventry and Warwickshire initiated a programme to train ward staff in accordance with guidelines. The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands was asked to expedite an independent evaluation of the initiative. We set out to describe the intervention to implement the guidelines and to evaluate it by means of a step-wedge cluster study using routinely collected data. METHODS: The evaluation was set up as a partially randomised, step-wedge cluster study, but roll-out across wards was more rapid than planned. The study was therefore analysed as a time-series. Primary outcome was rate of falls per 1000 Occupied Bed Days (OBDs) collected monthly using routine data. Data was analysed using a mixed-effects Poisson regression model, with a fixed effect for intervention, time and post-intervention time. We allowed for random variations across clusters in initial fall rate, pre-intervention slope and post-intervention slope. RESULTS: There was an average of 6.62 falls per 1000 OBDs in the control phase, decreasing to an average of 5.89 falls per 1000 OBDs in the period after implementation to the study end. Regression models showed no significant step change in fall rates (IRR: 1.02, 95% CI: 0.92-1.14). However, there was a gradual decrease, of approximately 3%, after the intervention was introduced (IRR: 0.97 per month, 95% CI: 0.95-0.99). CONCLUSION: The intervention was associated with a small but statistically significantly improvement in falls rates. Expedited roll-out of an intervention may vitiate a step-wedge cluster design, but the intervention can still be studied using a time-series analysis. Assuming that there is some value in time series analyses, this is better than no evaluation at all. However, care is needed in making causal inferences given the non-experimental nature of the design.

Molecular approach to evaluate biostimulation of 1,2-dibromoethane in contaminated groundwater.

This study investigated the effect of co-substrate amendments on EDB biodegradation under aerobic conditions. Microcosms were established using contaminated soil and groundwater samples and maintained under in situ conditions to determine EDB degradation rates, and the diversity and abundance of EDB degrading indigenous bacteria. After 100days of incubation, between 25% and 56% of the initial EDB was degraded in the microcosms, with added jet fuel providing highest degradation rates (2.97±0.49yr(-1)). In all microcosms, the quantity of dehalogenase genes did not change significantly, while the number of BTEX monooxygenase and phenol hydroxylase genes increased with jet fuel amendments. These results indicate that EDB was not degraded by prior dehalogenation, but rather by cometabolism with adapted indigenous microorganisms. This is also reflected in the history of the plume, which originated from an aviation gasoline pipeline leak. This study suggests that biostimulation of EDB is possible at aerobic groundwater sites.

Biodegradation of ethylene dibromide (1,2-dibromoethane [EDB]) in microcosms simulating in situ and biostimulated conditions.

Although 1,2-dibromoethane (EDB) is a common groundwater contaminant, there is the lack of knowledge surrounding EDB biodegradation, especially under aerobic conditions. We have performed an extensive microcosm study to investigate the biodegradation of EDB under simulated in situ and biostimulated conditions. The materials for soil microcosms were collected from an EDB-contaminated aquifer at the Massachusetts Military Reservation in Cape Cod, MA. This EDB plume has persisted for nearly 40 years in both aerobic and anaerobic EDB zones of the aquifer. Microcosms were constructed under environmentally relevant conditions (field EDB and DO concentrations; incubated at 12°C). The results showed that natural attenuation occurred under anaerobic conditions but not under aerobic conditions, explaining why aerobic EDB contamination is so persistent. EDB degradation rates were greater under biostimulated conditions for both the aerobic and anaerobic microcosms. Particularly for aerobic biostimulation, methane-amended microcosms degraded EDB, on average, at a first order rate eight times faster than unamended microcosms. The best performing replicate achieved an EDB degradation rate of 7.0 yr(-1) (half-life (t(1/2))=0.10 yr). Residual methane concentrations and the emergence of methanotrophic bacteria, measured by culture independent bacterial analysis, provided strong indications that EDB degradation in aerobic methane-amended microcosms occurred via cometabolic degradation. These results indicate the potential for enhanced natural attenuation of EDB and that methane could be considered co-substrate for EDB bioremediation for the EDB-contaminated groundwater in aerobic zone.