"Call Me by My Name": Improving Communication with Family Members at the Bedside via the Caregiver Identification Badge.

BACKGROUND: Patient and family experience are integral to the care that we provide. In the pediatric hospital setting, multiple family members are directly involved in patient care. We identified the need for greater caregiver name recognition at The Hospital for Sick Children, Toronto, ON. OBJECTIVE: We aimed to improve communication between healthcare providers and families via the optimization of caregiver identification badges. METHODS: We used a qualitative, narrative study design to explore perceptions surrounding caregiver identification badges via unstructured interviews. RESULTS: We identified key hospital and family stakeholders. Unstructured interviews supported the theory that badge optimization could improve communication and patient care. Our initiative, however, was abruptly interrupted by the emergence of the COVID-19 pandemic. CONCLUSION: Communication with patients and families is crucial across medical disciplines. The optimization of caregiver identification badges to facilitate the use of preferred names and pronouns will ultimately lead to the more effective and safer delivery of high-quality care.

Physician Experience at the Leading Edge of the Digital Healthcare Transformation.

Physicians as a group have a highly variable love/hate relationship with digital technology: there is no doubt that digital technology has the potential to dramatically improve the care that we provide to our patients; however, it also has the potential to negatively disrupt how we work and interact with one another and may even cause harm, albeit rarely (Wachter 2015). One suspects that this trade-off is similar to what has been experienced by society as a whole as we have undergone the digital revolution over the past two decades. For example, although digital platforms have allowed us to stream more music than could ever be purchased by one individual, it comes at the cost of sound quality. Social media has allowed billions of people to connect across cultures but has opened up a whole new world of cyberbullying and "fake news."

The Efficacy of Computed Tomography-Guided Percutaneous Spine Biopsies in Determining a Causative Organism in Cases of Suspected Infection: A Systematic Review.

PURPOSE: In suspected spondylodiscitis and vertebral osteomyelitis, computed tomography (CT)-guided biopsies are often performed to determine a causative organism and guide antimicrobial therapy. The aim of this study is to determine the diagnostic culture yield of CT-guided biopsies performed in cases of suspected spinal infections. METHODS: A literature search of PubMed and MEDLINE up to April 2017 was performed for keywords "CT guided vertebral biopsy infection," "CT-guided spine biopsy infection," "CT guided spine biopsy yield," and "CT guided vertebral biopsy yield." Inclusion criteria primarily consisted of studies exclusively using CT-guided biopsies in cases of suspected infectious lesions only. After study selection, published articles were analysed to determine diagnostic culture yield. Descriptive statistics were applied. RESULTS: 220 search results were screened; 11 met our inclusion criteria and were reviewed. In total, 647 biopsies of suspected infectious spinal lesions were performed. Positive cultures were obtained in 241 cases. Upon excluding one paper's skewed results, the net pooled results culture yield was 33%. Several cultures grew multiple organisms, leading to a total of 244 species identified. Most common isolated organisms include Staphylococcus aureus (n = 83), coagulase-negative Staphylococcus (n = 45), and Mycobacteria (n = 38). CONCLUSIONS: The diagnostic culture yield of CT-guided biopsies in cases of suspected spinal infection is 33%. In the majority of cases, a causative organism is not identified. This suggests that improvements can be made in biopsy technique and specimen transfer to optimize culture yield and increase the clinical value of the procedure.

The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study.

BACKGROUND: Isolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes. OBJECTIVE: To examine the effect of isolation precautions on hospital-related outcomes and cost of care. DESIGN: Retrospective, propensity-score matched cohort study of inpatients admitted to general internal medicine (GIM) services at three academic hospitals in Toronto, Ontario, Canada between January 2010 and December 2012. PARTICIPANTS: Adult (≥18 years of age) patients on isolation precautions for respiratory illnesses and methicillin-resistant Staphylococcus aureus (MRSA) were matched to controls based on propensity scores derived from nine covariates: age, sex, Resource Intensity Weight, number of hospital readmissions within 90 days, total length of stay for hospital admissions within 90 days, site of admission, month of isolation, year of isolation, and Case Mix Group. MAIN MEASURES: Thirty-day readmission rates and emergency department visits, hospital length of stay, expected length of stay, adverse events, in-hospital mortality, patient complaints, and cost of care in Canadian doll ars (CAD). KEY RESULTS: A total of 17,649 non-isolated patients were admitted to the participating hospitals during the study period. We identified 1506 patients isolated for respiratory illnesses and 745 patients isolated for MRSA. Compared to non-isolated individuals, those on isolation precautions for respiratory illnesses stayed 17 % longer (95 % CI: 9 %, 25 %), stayed 9 % longer than expected (95 % CI: 3 %, 15 %), and had 23 % higher cost of care (95 % CI: 14 %, 32 %). Patients isolated for MRSA had similar outcomes, but they also had a 4.4 % higher (95 % CI: 1.4 %, 7.3 %) rate of readmission to hospital within 30 days. CONCLUSIONS: Isolation precautions are associated with adverse effects which may result in poorer hospital outcomes. Balancing the benefits for the many with the harms to the few will be a future challenge.

Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada.

BACKGROUND: All Canadian immigrants undergo screening for tuberculosis (TB) before immigration, and selected immigrants must undergo postimmigration surveillance for the disease. We sought to quantify the domestic health impact of screening for TB in all new immigrants and to identify mechanisms to enhance effectiveness and efficiency of this screening. METHODS: We linked preimmigration medical examination records from 944,375 immigrants who settled in Ontario between 2002 and 2011 to active TB reporting data in Ontario between 2002 and 2011. Using a retrospective cohort study design, we measured birth country-specific rates of active TB detected through preimmigration screening and postimmigration surveillance. We then quantified the proportion of active TB cases among residents of Ontario born abroad that were detected through postimmigration surveillance. Using Cox regression, we identified independent predictors of active TB postimmigration. RESULTS: Immigrants from 6 countries accounted for 87.3% of active TB cases detected through preimmigration screening, and 10 countries accounted for 80.4% of cases detected through postimmigration surveillance. Immigrants from countries with a TB (all-sites) incidence rate of less than 30 cases per 100 000 persons resulted in pre- and postimmigration detection of 2.4 and 0.9 cases per 100 000 immigrants, respectively. Postimmigration surveillance detected 2.6% of active TB cases in Ontario residents born abroad, and TB was detected a median of 18 days earlier in those undergoing surveillance than in those who were not referred to surveillance or who did not comply. Predictors of active TB postimmigration included radiographic markers of old TB, birth country, immigration category, location of application for residency, immune status and age. INTERPRETATION: Universal screening for TB in new immigrants has a modest impact on the domestic burden of active TB and is highly inefficient. Focusing preimmigration screening in countries with high incidence rates and revising criteria for postimmigration surveillance could increase the effectiveness and efficiency of screening.

Mild isoniazid-induced liver injury in humans is associated with an increase in Th17 cells and T cells producing IL-10.

Isoniazid (INH) remains a mainstay for the treatment of tuberculosis despite the fact that it can cause liver failure. The mechanism of INH-induced liver injury remains controversial. It had been proposed that the mechanism involves metabolic idiosyncrasy based on the observations that liver injury is not usually associated with fever, rash, or prompt increase in alanine aminotransferase (ALT) upon rechallenge. In the present study, we found that patients who were treated with INH because of a positive tuberculosis (TB) skin test and developed a small increase in ALT had an increase in Th17 cells as well as T cells that produce interleukin (IL)-10, which suggests stimulation of an adaptive immune response. Th17 cells are considered inflammatory and could be involved in causing the liver injury. IL-10 is considered anti-inflammatory and could be the reason that more serious liver injury did not occur. These changes were not observed in patients who did not have an increase in ALT. These are the first data to show a change in the T cell profile in patients with mild INH-induced liver injury; however, it is difficult to determine whether these changes were the cause or the result of the liver injury. Nevertheless, together with other studies, the data suggest that INH-induced liver injury is immune-mediated, with mild injury resulting in immune tolerance.

Integration and proliferation of Pseudomonas aeruginosa PA01 in multispecies biofilms.

Despite an increased awareness of biofilm formation by pathogens and the role of biofilms in human infections, the potential role of environmental biofilms as an intermediate stage in the host-to-host cycle is poorly described. To initiate infection, pathogens in biofilms on inanimate environmental surfaces must detach from the biofilm and be transmitted to a susceptible individual in numbers large enough to constitute an infectious dose. Additionally, while detachment has been recognized as a discrete event in the biofilm lifestyle, it has not been studied to the same extent as biofilm development or biofilm physiology. Successful integration of Pseudomonas aeruginosa strain PA01 expressing green fluorescent protein (PA01GFP), employed here as a surrogate pathogen, into multispecies biofilm communities isolated and enriched from sink drains in public washrooms and a hospital intensive care unit is described. Confocal laser scanning microscopy indicated that PA01GFP cells were most frequently located in the deeper layers of the biofilm, near the attachment surface, when introduced into continuous flow cells before or at the same time as the multispecies drain communities. A more random integration pattern was observed when PA01GFP was introduced into established multispecies biofilms. Significant numbers of single PA01GFP cells were continuously released from the biofilms to the bulk liquid environment, regardless of the order of introduction into the flow cell. Challenging the multispecies biofilms containing PA01GFP with sub-lethal concentrations of an antibiotic, chelating agent and shear forces that typically prevail at distances away from the point of treatment showed that environmental biofilms provide a suitable habitat where pathogens are maintained and protected, and from where they are continuously released.

Front-line ownership: generating a cure mindset for patient safety.

Great advances have been made in standardization and human factors engineering that have reduced variability and increased reliability in healthcare. As important as these advances are, the authors believe there is another important but largely ignored layer to the safety story in healthcare that has prevented us from progressing. In the field of infection prevention and control (IPAC), despite great attempts over several decades to improve compliance with hand hygiene, surveillance, environmental cleaning, isolation protocols and other control measures, very significant challenges remain. We believe this failure is in part due to the power gradients, often dysfunctional relationships and lack of safety mindfulness that exist in hospitals and healthcare more generally. Furthermore, safety culture requires different approaches and considerable ongoing attentiveness. If this is the case, and the authors contend in this paper that it is, then the role of the front line is much more important than many of our healthcare safety and IPAC approaches suggest.

Determining mortality rates attributable to Clostridium difficile infection.

To determine accuracy of measures of deaths attributable to Clostridium difficile infection, we compared 3 measures for 2007-2008 in Ontario, Canada: death certificate; death within 30 days of infection; and panel review. Data on death within 30 days were more feasible than panel review and more accurate than death certificate data.

Fifty years of infection control and healthcare design.

The examination of 1962 perspectives on healthcare provided by Ross Graham and Shannon Sibbald in their article "Looking Back 50 Years in Hospital Administration" provides an opportunity to see not only what happened 50 years ago, but how modern attitudes and concerns both match and differ from those of the past. Focusing on infection prevention and hospital design, this commentary explores the changes in procedure, policy and attitudes since 1962, and how they are affecting healthcare today.

Healthcare-associated infections: new initiatives and continuing challenges.

Healthcare-associated infections are a major cause of patient morbidity and mortality. Fortunately for patients and the healthcare system, there is increasing interest in this field and the growing realization that many of these infections are highly preventable. We explore some of the newer and more promising strategies for decreasing infections, including the use of practice bundles, behavioural change strategies, hand hygiene auditing, public reporting of infection rates and antimicrobial stewardship. We also identify several areas where improvement is needed, including empowering patients to prevent infections, building safer healthcare facilities and accepting the limitations of the evidence supporting some infection control interventions.

Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007.

While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998-2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998-2002 to 39% in 2003-2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating.

Clinical effectiveness of rapid tests for methicillin resistant Staphylococcus aureus (MRSA) in hospitalized patients: a systematic review.

BACKGROUND: Methicillin resistant Staphylococcus aureus (MRSA) are often resistant to multiple classes of antibiotics. The research objectives of this systematic review were to evaluate the clinical effectiveness of polymerase chain reaction (PCR) versus chromogenic agar for MRSA screening, and PCR versus no screening for several clinical outcomes, including MRSA colonization and infection rates. METHODS: An electronic literature search was conducted on studies evaluating polymerase chain reaction techniques and methicillin (also spelled meticillin) resistant Staphylococcus aureus that were published from 1993 onwards using Medline, Medline In-Process & Other Non-Indexed Citations, BIOSIS Previews, and EMBASE. Due to the presence of heterogeneity in the selected studies, the clinical findings of individual studies were described. RESULTS: Nine studies that compared screening for MRSA using PCR versus screening using chromogenic agar in a hospital setting, and two studies that compared screening using PCR with no or targeted screening were identified. Some studies found lower MRSA colonization and acquisition, infection, and transmission rates in screening with PCR versus screening with chromogenic agar, and the turnaround time for screening test results was lower for PCR. One study reported a lower number of unnecessary isolation days with screening using PCR versus screening with chromogenic agar, but the proportion of patients isolated was similar between both groups. The turnaround time for test results and number of isolation days were lower for PCR versus chromogenic agar for MRSA screening. CONCLUSIONS: The use of PCR for MRSA screening demonstrated a lower turnaround time and number of isolation days compared with chromogenic agar. Given the mixed quality and number of studies (11 studies), gaps remain in the published literature and the evidence remains insufficient. In addition to screening, factors such as the number of contacts between healthcare workers and patients, number of patients attended by one healthcare worker per day, probability of colonization among healthcare workers, and MRSA status of hospital shared equipment and hospital environment must be considered to control the transmission of MRSA in a hospital setting.

Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement.

Importance: The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. Objective: To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. Evidence Review: A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. Findings: The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. Conclusions and Relevance: Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Health care-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality.

BACKGROUND: C. difficile infection (CDI) has become an important and frequent nosocomial infection, often resulting in severe morbidity or death. Severe CDI is more frequently seen among individuals infected with the emerging NAP1/027/BI (NAP1) strain and in the elderly population, but the relative importance of these 2 factors remains unclear. We used a large Canadian database of patients with CDI to explore the interaction between these 2 variables. METHODS: The Canada-wide CDI study, performed in 2005 by the Canadian Nosocomial Infection Surveillance Program (CNISP), was used to analyze the role of infecting strain type and patient age on the severity of CDI. A severe outcome was defined as CDI requiring intensive care unit care, colectomy, or causing death (directly or indirectly) within 30 days after diagnosis. RESULTS: A total of 1008 patients in the CNISP database had both complete clinical data and infecting strain analysis documented. A total of 311 patients (31%) were infected with the NAP1 strain, 83 (28%) were infected with the NAP2/J strain, and the rest were infected with various other types. The proportion of NAP1 infections correlated with the incidence and the severity of CDI when analyzed by province. Thirty-nine (12.5%) of the infections due to the NAP1 strain resulted in a severe outcome, compared with only 41 (5.9%) of infections due to the other types (P < .001). The patient's age was strongly associated with a severe outcome, and patients 60-90 years of age were approximately twice as likely to experience a severe outcome if the infection was due to NAP1, compared with infections due to other types. CONCLUSIONS: Our study confirms the strong age association with infection due to the NAP1 strain and severe CDI. In addition, patients 60-90 years of age infected with NAP1 are approximately twice as likely to die or to experience a severe CDI-related outcome, compared with those with non-NAP1 infections. Patients >90 years of age experience high rates of severe CDI, regardless of strain type.

Healthcare culture and the challenge of preventing healthcare-associated infections.

Consider the following story: A patient in a teaching hospital is about to be examined by a resident physician. When asked by the patient to wash his hands, the resident refuses, saying he has done so recently. The staff physician then enters the room and the patient speaks of his disappointment regarding the actions of the resident. The staff physician is displeased and states that the patient should not be mistrusting his physicians. Later, when booking his follow-up appointment, the patient asks not to be seen by the resident. The staff physician overhears and, in front of other patients, angrily tells the patient not to return to his clinic because of his disruptive behaviour.

Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: a Canadian Nosocomial Infection Surveillance Program Study.

BACKGROUND: Clostridium difficile infection (CDI) is the most frequent cause of health care-associated infectious diarrhea in industrialized countries. The only previous report describing the incidence of health care-associated CDI (HA CDI) in Canada was conducted in 1997 by the Canadian Nosocomial Infection Surveillance Program. We re-examined the incidence of HA CDI with an emphasis on patient outcomes. METHODS: A prospective surveillance was conducted from 1 November 2004 through 30 April 2005. Basic demographic data were collected, including age, sex, type of patient ward where the patient was hospitalized on the day HA CDI was identified, and patient comorbidities. Data regarding severe outcome were collected 30 days after the diagnosis of HA CDI; severe outcome was defined as an admission to the intensive care unit because of complications of CDI, colectomy due to CDI, and/or death attributable to CDI. RESULTS: A total of 1430 adults with HA CDI were identified in 29 hospitals during the 6-month surveillance period. The overall incidence rate of HA CDI for adult patients admitted to these hospitals was 4.6 cases per 1000 patient admissions and 65 per 100,000 patient-days. At 30 days after onset of HA CDI, 233 patients (16.3%) had died from all causes; 31 deaths (2.2%) were a direct result of CDI, and 51 deaths (3.6%) were indirectly related to CDI, for a total attributable mortality rate of 5.7%. CONCLUSIONS: The rates are remarkably similar to those found in our previous study; although we found wide variations in HA CDI among the participating hospitals. However, the attributable mortality increased almost 4-fold (5.7% vs. 1.5%; P<.001).

A population-based study of tuberculosis in children and adolescents in Ontario.

BACKGROUND: There are few population-based data on presentation and treatment of tuberculosis (TB) in children and adolescents in Ontario. METHODS: We analyzed data from 121 patients less than 17 years of age with TB disease reported to the Province of Ontario between 1999 and 2002. Physician provider data were obtained from the College of Physicians and Surgeons of Ontario. RESULTS: Of the 121 patients, 84 (69.4%) patients were foreign born. The median time of residence in Canada before diagnosis was 2.7 years (range, 7 days-16 years). Diagnosis was made by symptoms in 78 (64.5%), by contact investigation in 25 (20.7%), and by immigration screening in 5 (4.1%) patients. Pulmonary TB occurred in 94 (77.7%) patients. When cases detected by contact tracing and screening were excluded, isolated extrapulmonary TB was present in 4 (23.5%), 6 (35.0%), and 19 (37.0%) of young children (0-4 years), older children (5-12 years), and adolescents (13-17 years), respectively. Eleven patients (9.1%) had drug-resistant strains. Eighty (66.1%) patients received directly observed therapy (DOT). Prescribed treatment was completed in 105 (86.8%) patients with a trend toward higher completion rates in those receiving DOT (P = 0.07). Of 57 physician providers, 50 (87.7%) had treated less than 1 pediatric TB patient/year during the study period. CONCLUSIONS: Extrapulmonary disease accounted for a high proportion of TB in older children and adolescents who presented with symptoms. One-third of patients did not receive DOT and most were cared for by physicians with limited experience in managing TB. Further studies are needed to determine whether these factors influence outcome in pediatric TB.

Tuberculosis infection in the United States: national trends over three decades.

RATIONALE: In 1989, the United States embarked upon an ambitious path to eliminate tuberculosis (TB) nationwide. Although incidence rates of TB disease in the United States are declining, these cases represent only a tiny fraction of all TB infections. Understanding national trends in TB infection may be important in anticipating future trends in TB disease. OBJECTIVES: Describe the epidemiology of Mycobacterium tuberculosis infection in the United States in 1971-1972 and 1999-2000. METHODS: We studied nationally representative cohorts of the U.S. noninstitutionalized civilian population participating in the 1971-1972 and 1999-2000 National Health and Nutrition Examination Surveys. Participants were tuberculin skin tested and the epidemiology of TB infection was compared across surveys. Logistic regression was used to identify associations between participant and household characteristics and TB infection. MEASUREMENTS AND MAIN RESULTS: In 1999-2000, 4.2% (95% confidence interval [CI], 3.3-5.2%) of the U.S. population aged 1 year or older displayed evidence of TB infection. Among persons aged 25-74, the prevalence of infection decreased from 14.4% in 1971-1972 (95% CI, 11.6-17.7%) to 5.6% in 1999-2000 (95% CI, 4.4-7.1%). Declines in the relative burden of infection among persons aged 25-74 were greater in the United States-born population (12.6 to 2.5%) compared with the nation's foreign-born population (35.9 to 21.3%). CONCLUSIONS: The United States has experienced a substantial decline in the burden of TB infection since the early 1970s. Despite this, the prevalence of infection among the nation's foreign-born population is over eight times greater than that observed in the United States-born population.