Alan P. Gibb

Increasing Clinical Presence of Mobile Communication Technology: Avoiding the Pitfalls

Mobile communication technologies are employed in many diverse areas of healthcare delivery to provide improved quality and efficiency of communication and facilitate increased rapidity of data or information transfer. Mobile phones enable healthcare professionals to possess a portable platform from which to provide many healthcare-related applications and are a popular means to directly communicate with colleagues and patients. As involvement of mobile communication technology in healthcare delivery continues to rapidly expand, there are also important considerations of relevance to patient safety and security as a result. Here, we review the previous evidence of reported clinical risks associated with mobile communication technology, such as electromagnetic interference, confidentiality and data security, distraction/noise, infection control, and cross contamination. In conclusion, although mobile phones provide much putative potential improvement to healthcare delivery, further evaluation and research are required to both inform and protect health professionals and users of such technology in the healthcare environment and provide the evidence base to support the provision of clear and comprehensive guidelines.

Clostridium difficile infection in general surgery patients; identification of high-risk populations

BACKGROUND Risk factors associated with Clostridium difficile infection (CDI) in general surgical patients are poorly characterised. This study aimed to characterise the incidence and associations of C. difficile positivity (CDP) in general surgical inpatients to aid in the design of future policies regarding focused screening and risk-stratification mechanisms in this patient subpopulation. MATERIALS AND METHODS Discharge, laboratory and coding data from all general surgery inpatients admitted to a large tertiary referral general surgical unit, between March 2005 and May 2007, were examined. RESULTS 21,371 patient records were interrogated. 101 (0.47%) CDP cases were identified from laboratory records and compared with non-CDP controls for age, gender, length of stay (LOS), admission to intensive care unit or high dependency unit (ICU/HDU), co-morbidities and surgical procedures. Univariate analysis identified a range of risk factors associated with positivity. Multivariate analysis identified malignancy, gastrointestinal disease, anaemia, respiratory disease, circulatory disease, diabetes mellitus, those undergoing gastrointestinal surgery and increasing age to be independently associated with CDP status. CONCLUSIONS This study identifies incidence and risk factor associations of those who tested CDP in a large contemporary general surgery inpatient population. Focused screening programmes based on high-risk populations may provide information on further risk factors and allow risk-stratification. Further healthcare worker education regarding risk factors may reduce the clinical impact of CDI by encouraging increased vigilance and therefore earlier detection.

Methicillin-resistant Staphylococcus aureus in surgical patients: identification of high-risk populations for the development of targeted screening programmes.

INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA)-related hospital-acquired infection (HAI) in surgical patients is associated with high morbidity, mortality and financial cost. The identification and characterisation of populations of patients who are at high risk of developing MRSA infection or colonisation could inform the design of more effective strategies to prevent HAIs and reduce transmission of MRSA. PATIENTS AND METHODS An analysis of historical discharge data for the whole of 2005 (7145 surgical in-patients) was performed, for all patients admitted to general surgery at the Royal Infirmary of Edinburgh. Analysis specifically focused on MRSA laboratory data and coding data for patient demographics, medical co-morbidities, and progress of in-patient stay. RESULTS A total of 134 (1.88%) individual patients with colonisation or infection by MRSA were identified from indicated laboratory testing. Univariate analysis identified a significant association of concurrent MRSA-positive status with patients aged over 60 years (P < 0.01), a duration of inpatient stay > 7 days (P < 0.01), presence of a malignant neoplasm (P < 0.01), circulatory disease (P < 0.01), respiratory disease (P < 0.01), central nervous system disease (P < 0.01), renal failure (P < 0.01), and concurrent admission to ITU/HDU (P < 0.01). Multivariate analysis suggested MRSA colonisation or infection was strongest in those with co-morbid malignancy (P < 0.0001) or admission to ITU/HDU (P < 0.0001). CONCLUSIONS This large observational study has identified cancer patients as a UK surgical patient subpopulation which is at significantly higher risk of colonisation by MRSA. These data could inform the development of focused hospital in-patient screening protocols and provide a means to stratify patient risk.

Mobile phone usage in the clinical setting: Evidence-based guidelines for all users is urgently required

1. Carling P, Parry M, Bruno-Murtha L, Dick B. Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission. Crit Care Med 2010;38:1054-9. 2. Carling P, Bartley J. Evaluating hygienic cleaning in health care settings: what you do not know may harm your patients. Am J Infect Control 2010; 38:S41-50. 3. Victorian government cleaning standards. Cleaning standards for health facilities. 2009. Available from: http://www.health.vic.gov.au/cleaningstandards/ standards.htm. Accessed June 30, 2011. 4. NHMRC. Australian Guidelines for the prevention and control of infection in health care. 2010. Available from: http://www.nhmrc.gov.au/guidelines/ publications/cd33. Accessed June 30, 2011.

Knowledge of Clostridium difficile infection among UK health-care workers: development of a knowledge assessment tool.

Doctors’ knowledge provides the basis to support good practice in infection prevention and control. However, there exists a paucity of validated knowledge assessment tools that can be reliably employed to identify poor knowledge levels of Clostridium difficile infection (CDI) within populations of doctors, preventing the effective identification of knowledge deficiencies and focused targeting of educational interventions. Here, we describe a development process to validate a novel CDI knowledge assessment tool for doctors. Two previously published CDI knowledge questionnaires were amalgamated to produce a combined questionnaire. Content was further evaluated by a panel of CDI experts, producing the ‘Lothian’ questionnaire. These questionnaires were tested in control populations comprising either infection control nurse (ICN) specialists or non-clinically trained individuals, and a cohort of medical staff. We compared the efficacy of the ‘Lothian’ questionnaire against that of previous questionnaire reports. We found that all of the questionnaires studied significantly discriminated between non-clinical and clinical populations (ICNs and medical staff) (P < 0.001) and had similar levels of sensitivity and specificity in discrimination between these targeted populations. This study describes the development of a robust CDI knowledge assessment tool that can be used to evaluate knowledge levels among doctors, compare populations and assist the targeting of educational interventions and plot trends following such interventions.

Infectious communication: Smart phones for clinical communication

We read with interest the recent study evaluating utilization of smart phones for clinical communication. While debate remains over efficiency and quality of care benefits, an additional concern is the implication of such technology for infection control. More than 20 studies have demonstrated that mobile communication devices in the clinical environment provide a reservoir of bacteria known to cause nosocomial infections. As observed, the median use of smart phones is 27.5 times per day. Such utilization frequency, in the absence of strict hand hygiene and regular device decolonization, provides obvious potential for cross-contamination within clinical environments. Additionally, a majority of doctors routinely carry a personal mobile phone at work. The ‘‘team blackberry’’ approach requires yet another device to be hosted. While questions surround the need for such additional devices, as an alternative to directing calls to a particular personal phone or email address (which would negate costs), the proposed approach acts to compound the risk of cross-contamination. Doctors could potentially be required to carry multiple mobile devices/reservoirs through diverse clinical environments, including sensitive areas such as intensive care or operating theatre environments. Therefore, consideration of specific actions to mitigate cross-contamination risk is also required.

Clostridium difficile knowledge in healthcare workers: conclusions in the absence of broader evaluation

A validated, knowledge-based questionnaire tool could provide the means for identification of risk factors associated with poor levels of knowledge, assist in targeting educational interventions, and provide measurable data on the impact of educational interventions. Unfortunately, Aroori et al. failed to examine if data resulting from the questionnaire could discriminate populations with known differing levels of knowledge or if conclusions were valid in repeated sampling of healthcare worker populations elsewhere. Additionally, the questionnaire provides no clear conclusion/definition of what is an adequate level of knowledge, i.e. does anything less than 100% correct response deem a healthcare worker as possessing a lack of knowledge? Previously, we assessed methicillin resistant Staphylococcus aureus knowledge in healthcare workers, both in a surgical trainee1 and wider healthcare worker population in repeated sampling. We found questionnaire statements on policy could be UK-region specific and that knowledge levels needed to be judged against a broader healthcare worker population context. In addition, even populations with assumed high levels of knowledge (infection control nurses) did not achieve 100% correct answers.2 Until further validation, it is difficult to support the conclusions that the study findings are indeed ‘valid’ in reference to a presumed ‘significant lack of knowledge’ in wider consultant and nursing staff populations.3 This questionnaire can only ultimately comment on a local population, sampled at a specific time, and does not adequately define an appropriate level of knowledge.