The Clean Care Contest: promoting hand hygiene among healthcare and medical students.

INTRODUCTION: Despite continuing efforts, compliance rates and knowledge of best practices in hand hygiene remain disappointing. Recognizing that conventional educational tools seem out of touch with young people and that the med and messages contents need refreshing, the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health devised a novel approach to promote the creation of innovative educational tools for improving knowledge of, and compliance with, hand hygiene rules among healthcare and medical students. METHODS: A contest in creating educational material on hand hygiene practices involved university students of nursing and medicine, and of other healthcare degrees. Students from the universities of the GISIO network were invited to create educational material (e.g., videos, posters, presentations, leaflets, and screensavers) to be presented by May 5th 2019 during the World Hand Hygiene Day / Save Lives: Clean Your Hands Global Annual Initiative of the World Health Organization). A local and a national winners were awarded. RESULTS: Three different local and national contests were performed during 2016, 2017 and 2018. During the three-year period, more than 270 educational tools have been developed: 130 (48%) were judged useful for hand hygiene promotion campaigns. The most frequent projects participating in the contests were videos (39%), posters (29%), leaflets (14%), and others (18%) submitted by more than 1,500 students of nursing (40%), medicine (31%), dentistry (7%), and of other healthcare courses in 14 universities. Products were evaluated by a local committee and, subsequently, local winners represented their University in a national contest. CONCLUSIONS: The contest provided a framework for the creation of innovative and potentially effective educational tools via an engaging approach that leveraged student creativity. Given the need to improve compliance rates, this study suggests that new ways can be advantageously explored to teach hand hygiene procedures and increase awareness of the importance of their consistent use among healthcare and medical students.

Do HCWs adequately know about meningitis and 4CMenB vaccine and recommend its use to parents? A cross sectional analysis in Campania Region, Italy.

Invasive meningococcal disease (IMD) is a severe disease caused by various Neisseria meningitidis serogroups that represents a serious public health problem worldwide. In Italy, serogroups B and C are the major causes of IMD. On 14 January 2013, the European Medicines Agency authorized the use of the first vaccine available to protect against meningococcal serogroup B (4CMenB). The aim of this study was to assess the IMD epidemiology knowledge and 4CMenB vaccine attitudes of healthcare workers (HCWs) with regard to recommending this vaccine for use, vaccine practices and infectious disease control in the Campania region in Italy. A cross-sectional study was conducted among 293 HCWs (49.5% physicians and 46.4% nurses)interviewed using a self-administered questionnaire. The majority of the HCWs had sufficient knowledge about the disease incidence and lethality, but they were less informed about the higher risk age categories and the serogroups most frequently involved. Additionally, their knowledge about the vaccine was poor with regard to the targeted categories and side effects. Approximately30.0% of the HCWs reported incidences of fever and pain and swelling at the injection site. Moreover,32.8% of the HCWs knew that the risk of developing adverse reactions increases when the 4CMenB vaccine is co-administered with other vaccines. Overall, all of the HCWs were convinced that vaccinations are an important instrument for preventing infectious diseases, and they were aware of their central role in promoting the 4CmenB vaccination and their need to be better informed.

Quality improvement of medical records in a teaching hospital.

INTRODUCTION: The aim of this study was to evaluate the quality of the MR compilation in some Operative Units of the "Azienda Ospedaliera Universitaria--II Università di Napoli" (AOU- SUN)-Italy, before and after an intervention of quality improvement, underlining the potential differences in the behaviour of different specialists (physicians vs. surgeons). METHODS: Two random samples of 660 MRs were reviewed. A four-step program was developed: (1) first assessment of the MR; (2) implementation of the MR quality, sending a letter with the purpose of the study, the results obtained in the first step from that ward, the guidelines to correctly fill out the MR; (3) follow-up step four months later; (4) comparison of the data before and after the distribution of the guidelines using indicators of completeness of all sections of MR, clarity of handwriting and presence and clarity of signature. RESULTS: The main concerns were related to the signature of the duty physician (present in 2.0% and legible in only 15.4%), the presence of the letter of discharge (18.0%) and the clarity of the days of hospital stay (32.0%). After the intervention the improvement of the quality of compilation was modest and regarded mainly medical rather than surgical wards. DISCUSSION AND CONCLUSIONS: The improvement was not satisfying since from a medical and a legal point of view the indicators should reach 100% of clarity and completeness. A further study is being carried out to improve the involvement of health care professional, so that such requirements will be perceived as a common goal, not as mere bureaucratic initiatives.

[Quality of medical records in Naples (Italy) 2nd University School of Medicine]. / Qualità di compilazione delle cartelle cliniche nell'Azienda Ospedaliera Universitaria di Napoli.

To evaluate and improve the quality of medical-record keeping, in clinics and surgery departments. The evaluation involved 66 Operative Units (O.U.) of the "2nd University Hospital" in Naples (Italy). 10 medical records for each O.U. were randomly selected, for a total of 660. The quality was evaluated in all sections of medical records using the criteria of completeness, clarity and traceability of the data. The most critical issues are: unclear handwriting in almost all sections, in the whole scarse presence of a discharge letter (17.0%) in surgery (1.4%), almost total absence of the physicians signature in the clinical diary (2.3%). The completeness of medical records (presence of patient's history, physical examination, informed consent) is significantly higher in the surgery departments. The medical records are significantly righter in the clinic departments. In general, a poor quality of medical-record keeping was detected. This indicates the need to improve the quality by involving the staff in the importance of correct compilation.

[Evaluation of the effectiveness of a nutrition education intervention performed by primary school teachers]. / Valutazione d'efficacia di un intervento di educazione alimentare condotto da insegnanti di scuola media inferiore.

This study values the effectiveness of nutrition education interventions carried out by teachers with active didactic methodologies. The research was carried out by administering a frequency of food intake questionnaire, before and after the intervention. To compare the answers given before and after the educational intervention the Wilcoxon-test was applied to dependent data. Our research confirmed that a substantial percentage of children do not show a correct nutrition and therefore nutrition education interventions are opportune and necessary. In the group with "insufficient execution" particular variations are not taken place. In the group with "sufficient execution" increase the number of subjects having breakfast, particularly with milk and biscuits, and decrease the snakes intake. Moreover there is a general decrease of intake food as meat, fish, vegetables, salami and legumes. So this educational intervention seems to have only partial effectiveness.

Investigating on a foodborne outbreak: analysis of the critical points.

The Authors describe an epidemiological survey performed after a cluster of cases of foodborne infection involving several participants at a wedding reception. The aim was to identify the food, the responsible pathogen and any shortcomings in the coordination between the various services and the territorial operating units involved in the outbreak investigation. The investigation involved 149 participants; fifty seven persons (38.3%) had a foodborne illness. The only food item that remained associated with illness after multiple regression analysis was the ricotta cheese (RR 3.58, I.C. 1.,72-7.48 ). The finding of B. cereus in samples of ricotta cheese collected at the dairy food supplier indicate its responsibility for the outbreak but diagnostic certainty could not be achieved as no leftovers were available. Thus, shortcomings in this epidemiological investigation are constituted by: delayed notification, which prevented the acquisition of food samples, lack of a reference laboratory and lack of a specific diagnostic protocols, which prevented the microbiological research for the rapid identification of new pathogens incriminated in foodborne diseases. Finally, environmental and sanitary inspections showed deficiencies in the hygienic measures of food storage, particularly regarding refrigeration and in the HACCP plan that was not properly implemented.

[Reasons for turning to healthcare services outside of own area of residence: a study among patients of the AV1 Local Health Unit in Italy]. / Questionario a pazienti della ASL AV1 in mobilità passiva.

In this study, 552 patients from the AV-1 Local Health Unit, who accessed healthcare services outside of their own area or region of residence ("intra- and extra-regional mobility") were interviewed by their general practitioner. The aim was to describe the healthcare "mobility" phenomenon and the reasons patient resort to it. Most cases involve patients who turn to healthcare services outside their local area but within their own region of residence (intraregional mobility). On the other hand cases that involved "extraregional mobility", that is involved patients who accessed healthcare services outside their own region of residence , occurred in Basilicata, Puglia, Emilia Romagna and Lombardia. Reasons given by patients for this choice are, in order of importance: prestige of a specific hospital or hospital department, trusted physician working in a given hospital, disease severity, specialist advice, reduced waiting times, friends' or relatives' suggestions, better hospital services, lack of trust in healthcare services provided locally, advice given by general practitioner.

[Biological risk in the operating room: microbiological monitoring of the environment and analysis of the associated variables]. / Rischio biologico in sala operatoria: monitoraggio micro- biologico ambientale ed analisi delle variabili associate.

The authors present an environmental microbiological monitoring programme carried out over a period of 15 months in 16 operating theatres performing specific types of surgery. The levels of microbial contamination of the air and of four of the most representative surfaces of the clean area were determined at 3 different times for each theatre, both before and during surgery. For the air assessment, the results obtained with three different samplers, Sed-3 Unit, SAS and RCS, were compared. The results were on the whole acceptable, but some poor conditions were detected during the theatres in use, especially in general surgery theatres; in some of these the floors showed levels of contamination consistently exceeding the reference limits. As the monitoring programme proceeded, the microbiological quality of the air and of the surfaces in the theatres notably improved. The three air samplers showed different conditions expressed with units of measure not always readily comparable. For active samplers, the bacterial load determined by RCS, although less variable, were always higher (even 2-3 fold) than those obtained with the SAS. Passive sampling takes longer but determines the real risk of infection for the patients; contemporary determination of the fall-out and the CFU/m3 helps to identify the occupational risks. Since the limit values established by the ISPESL guidelines for the operating theatres have been defined only for active samplers, there is urgent need for more exhaustive national guidelines to define similar values also for passive sampling. The Authors conclude stressing the importance of promoting continuing information-education programmes to heighten the awareness of all those involved in operating theatre activities.

[Epidemiology of Cesarean section and birth surveillance]. / Epidemiologia del taglio cesareo e sistema di sorveglianza sulla natalità.

The authors studied the incidence and the determinants of cesarean section in ASL Naples 4. In addition while they analysed the reliability and completeness of birth certificates in order to verify their accuracy for statistical and epidemiological purposes. The results show an increase of cesarean section higher than national mean (from 1997 to 2000: 44.5-54.9%), rarely justified by real risk conditions. 41.1% of vertex deliveries required cesarean section. The most frequent indications were repeated cesarean section (40.6%) and fetal problems (39.3%) in the multiparous; fetal dystocia (27.8%) and fetal distress (17.1%) in the primiparous. The quality of the compilation of the certificates was unsatisfactory for completeness and reliability. Indeed, 14.9% of 1997 birth certificates and more than 70% in the following years did not reach the epidemiological services of ASL; moreover, the comparison with clinical records proved that 46.9% of presentations resulted abnormal on clinical records were vertex on the birth certificates.

Appropriateness of admission and hospitalization days in a specialist hospital.

The assessment of hospital utilization is an important tool in the management of Hospital Health Care. The Authors examined the extent and the reasons of inappropriate hospital admission and stay in patients admitted to the Monaldi Hospital, Naples, Italy. Five hundred and thirty three medical records, were analysed. The survey was carried out in the period May-October 1999, using the italian version of the Appropriateness Evaluation Protocol (AEP) method. Of the admissions days, 15.8% were considered inappropriate; the most frequent cause of inappropriateness was waiting period for diagnostic test. The highest percentage of inappropriateness was found for females, for less serious pathologies and in the summer months. Compared to the admissions, the proportion of inappropriateness of the index days was higher (35.5%); the most frequent cause of an inappropriate day of stay was the persistence of mild symptoms which according to the attending physician justified prolonging the stay, while the same variables found for inappropriate admission (female sex, less serious pathologies and summer months) were related to inappropriateness of stay. This survey has allowed us to offer some useful suggestions with a view to making some of the activities of the "Monaldi Hospital" more efficient.

Evaluation of benzene exposure in children living in Campania (Italy) by urinary trans,trans-muconic acid assay.

The urinary benzene metabolite trans,trans-muconic acid (MA) was determined in 144 children living in Campania (Italy): 92 from Naples (1,300,000 inhabitants), designated as an urban source, and compared to 52 from Pollica (300 inhabitants), considered a rural, background exposure for benzene. The children participating in the study were tested by an anonymous questionnaire about the possible sources of exposure to benzene. Quantifiable levels of MA were found in 63% of the urine samples analyzed. Setting the value of nondetectable urinary samples at 7 microg/L MA, a value that is one-half of the instrument detection limit of 14 microg/L, the mean urinary concentration levels were 98.7+/-81.0 microg/L and 48.4+/-71.7 microg/L in Naples and Pollica, respectively; adjustment of these values to creatinine clearance resulted in MA levels of 141.2+/-145.4 microg/L in Naples and 109.8+/-133.2 microg/L in Pollica. Passive smoke exposure did not significantly affect urinary MA levels, but proximity of the home to traffic increased urine MA content. Data show that MA can be utilized as a biomarker for exposure; however, a clear-cut association to benzene requires personal monitoring and control of dietary sorbic acid.

Prevalence of asthma among young men in a military recruitment office of South Italy.

The prevalence of asthma was studied in 3065 male 18 year-olds, examined in a southern Italy (Basilicata) military recruitment office. The disease was evaluated by questionnaires, pulmonary function tests and specialist diagnosis. The point prevalence of asthma was 1.4%. The disturbance was more frequent in high versus a low level of maternal education (OR: 3.70; 95% CI: 2.00-6.88), in high versus a low level of paternal education (OR: 2.71; 95% CI: 1.48-4.98), in urban residence versus rural residence (OR: 3.04; 95% CI: 1.61-5.75), in first-borns versus nonfirst-borns (OR: 2.46; 95% CI: 1.33-4.53). Home environment (dampness, heating, crowding) was not significantly correlated to asthma. This reported prevalence of asthma is low, compared with overall European and Italian data. The higher risk in urban areas and high level of education has been confirmed. The association between asthma and first-borns is interesting and needs further investigation, focusing on maternal issues like the low maternal age and the mother-child interaction.

Ill-defined and multiple causes on death certificates--a study of misclassification in mortality statistics.

Biases can distort, limit or inhibit the value of mortality data as an epidemiological re source. From 9500 deaths occurring in Naples (Italy during 1994, a random sample of 372 death certificates reporting ill-defined causes and multiple causes of death was extracted. The code for the underlying cause on the death certificate (assigned code) was compared with the cause reattributed with the aid of interview of the certifying physician or clinical records (modified code). The aim was to investigate the extent of misclassification of 'underlying cause' in deaths attributed to ill-defined and/or multiple causes and the shortcomings in the ICD-IX. Ill-defined underlying causes of death (7.0% of death certificates) were cardiovascular diseases, tumours with no specified site or nature, symptoms, signs, ill-defined conditions and senility. There was disagreement between the initially assigned code and the modified code in 53.8% of ill-defined underlying causes; discordance was high for the certificates filled in by the family physician. Multiple causes of death were observed in 23.6% of certificates; of these 59.2% concerned subjects aged 75 years and over at death. Diabetes was always listed in association with other pathologies but neoplasms and traumas were generally listed alone. Disagreement between codes occurred in 48 (54.5%) certificates indicating multiple causes. In 10 of them, death was established as due to a concurrence of causes. As regards ill-defined causes of death, the authors concluded that specific training on certifying procedures would be insufficient on their own; the physician should be made aware that certification is a fundamental requirement for building up epidemiological data. Evidence-based educational interventions are needed. As regards multiple causes of death, multicausal analysis may be indicated for deaths due to a concurrence of causes.

[Endomyocardial biopsy in heart transplantation: the experience of the Naples Center]. / La biopsia endomiocardica nel trapianto cardiaco: esperienza del centro napoletano.

From January 1988 through August 1992, 38 cardiac transplants were performed. 385 endomyocardial biopsies (EMBs) from 32 cardiac allograft recipients were investigated. In 21 (5.45%) EMBs the specimens were inadequate for the diagnosis. In the remaining 364 EMBs the grades of acute rejection were: minimal in 213 (58.51%) EMBs, mild in 132 (36.26%), mild/moderate in 12 (3.3%) and moderate in 7 (1.93%). The most reliable histologic feature of acute rejection was the myocyte necrosis or damage in presence of pironinophilic mononuclear cell infiltrate, so our therapeutic protocol requires myocyte damage to perform an additional treatment, which was performed in 7 cases (1.93%). An intermediate grade mild/moderate, was introduced to classify the EMBs in which the myocyte necrosis was scant or not clear. In these patients another EMB was performed after 3 or 5 days. One patient died of chronic rejection 17 months after the transplant. Changes not related to acute rejection were: ischemic early or late necrosis; changes related to previous biopsy site; subendocardial infiltrate of mononuclear cells (Quilty's alteration); focal, diffuse or perimyocytic fibrosis and artefacts as contraction bands; nuclear or cytoplasmic vacuolar alterations. Some of these changes occasionally made the diagnosis hard or the specimens inadequate for the diagnosis. In spite of these diagnostic difficulties, the EMB is a safe and reliable invasive investigation which plays an important role in the management of rejection in cardiac allograft recipients.