Caspar W. N. Looman

The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison

BACKGROUND Nosocomial bloodstream infections are a major cause of morbidity and mortality in neonatal intensive care units. Appropriate hand hygiene is singled out as the most important measure in preventing these infections. However, hand hygiene compliance among healthcare professionals remains low despite the well-known effect on infection reduction. OBJECTIVES We studied the effectiveness of a hand hygiene education program on the incidence of nosocomial bloodstream infections. DESIGN Observational study with two pretests and two posttest measurements and interrupted time series analysis. SETTING A 27 bed level IIID neonatal intensive care unit in a teaching hospital in the Netherlands. PARTICIPANTS Healthcare professionals who had physical contact with very low birth weight (VLBW) infants. METHODS The study was conducted during a period of 4 years. Medical and nursing staff followed a problem-based education program on hand hygiene. Hand hygiene practices before and after the education program were compared by guided observations. The incidence of nosocomial infections in VLBW infants was compared. In addition, numbers of nosocomial bloodstream infections per day-at-risk in very low birth weight infants were analyzed by a segmented loglinear regression analysis. RESULTS During 1201 observations hand hygiene compliance before patient contact increased from 65% to 88% (p<0.001). Median (interquartile range) drying time increased from 4s (4-10) to 10s (7-14) (p<0.001). The proportion of very low birth weight infants with one or more bloodstream infections and the infection rate per 1000 patient days (relative risk reduction) before and after the education program on hand hygiene intervention decreased from 44.5% to 36.1% (18.9%, p=0.03) and from 17.3% to 13.5% (22.0%, p=0.03), respectively. At the baseline the nosocomial bloodstream infections per day-at-risk decreased by +0.07% (95% CI -1.41 to +1.60) per month and decreased with -1.25% (95% CI -4.67 to +2.44) after the intervention (p=0.51). The level of instant change was -14.8% (p=0.48). CONCLUSIONS The results are consistent with relevant improvement of hand hygiene practices among healthcare professionals due to an education program. Improved hand hygiene resulted in a reduction in nosocomial bloodstream infections.

Trends in Wrist Fractures in Children and Adolescents, 1997–2009

PURPOSE Distal radius and carpal fractures in children and adolescents represent approximately 25% of all pediatric fractures. Incidence rates and causes of these fractures change over time owing to changes in activities and risk factors. The purpose of this study was to examine recent population-based trends in incidence and causes of wrist fractures in children and adolescents. METHODS We obtained data from the Dutch Injury Surveillance System of emergency department visits of 15 geographically distributed hospitals, and from the National Hospital Discharge Registry. This included a representative sample of outpatients and inpatients, respectively. We calculated incidence rates of wrist fractures per 100,000 person-years for each year between 1997 and 2009. Using Poissons regression, we analyzed trends for children and adolescents 5 to 9, 10 to 14, and 15 to 19 years of age separately for boys and girls. RESULTS During the study period, incidence rates increased significantly in boys and girls 5 to 9 and 10 to 14 years of age, with the strongest increase in the age group 10 to 14 years. The observed increases were mainly due to increased incidence rates during soccer and gymnastics at school. CONCLUSIONS This population-based study revealed a substantial sports-related increase in the incidence rate of wrist fractures in boys and girls aged 5 to 9 and 10 to 14 years in the period 1997 to 2009. CLINICAL RELEVANCE With knowledge of the epidemiology of wrist fractures, prevention programs can be improved. From this study, we know that the incidence rate of wrist fractures in childhood is increasing, mainly as a result of soccer and gymnastics at school. Future sport injury research and surveillance data are necessary to develop new prevention programs based on identifying and addressing specific risk factors, especially in young athletes.

New Insights: Dose‐Response Relationship Between Psychotropic Drugs and Falls: A Study in Nursing Home Residents With Dementia

The contribution of specific psychotropic drugs to fall risk in patients with dementia has not been quantified precisely until now. The authors evaluated the dose‐response relationship between psychotropic drugs and falls in nursing home residents with dementia. Daily drug use and daily falls were recorded in 248 nursing home residents with dementia from January 1, 2006, to January 1, 2008. For each day of the study period, data on drug use were abstracted from the prescription database, and falls were retrieved from a standardized incident report system, resulting in a data set of 85 074 person‐days. The authors found significant dose‐response relationships for the use of antipsychotics (hazard ratio [HR], 2.78; 95% confidence interval [CI], 1.49–5.17), anxiolytics (1.60; 1.20–2.14), hypnotics and sedatives (2.58; 1.42–4.68), and antidepressants (2.84; 1.93–4.16). Fall risk increased significantly with 28% at 0.25 of the defined daily dose (DDD) of an antipsychotic or antidepressant, with 8% at 0.2 of the DDD of an anxiolytic, and with 56% at 0.5 of the DDD of a hypnotic or sedative; it increased further with dose increments and with combinations of psychotropics. Even at low dosages, psychotropic drugs are associated with increased fall risk in nursing home residents with dementia.

Dose–response relationship between selective serotonin re-uptake inhibitors and injurious falls: a study in nursing home residents with dementia

AIM The contribution of selective serotonin re-uptake inhibitors (SSRIs) to injurious fall risk in patients with dementia has not been quantified precisely until now. Our objective was to determine whether a dose-response relationship exists for the use of SSRIs and injurious falls in a population of nursing home residents with dementia. METHODS Daily drug use and daily falls were recorded in 248 nursing home residents with dementia from 1 January 2006 until 1 January 2008. For each resident and for each day of the study period, data on drug use were abstracted from the prescription database, and information on falls and subsequent injuries was retrieved from a standardized incident report system, resulting in a dataset of 85,074 person-days. RESULTS We found a significant dose-response relationship between injurious falls and the use of SSRIs. The risk of an injurious fall increased significantly with 31% at 0.25 of the Defined Daily Dose (DDD) of a SSRI, 73% at 0.50 DDD, and 198% at 1.00 DDD (Hazard ratio = 2.98; 95% confidence interval 1.94, 4.57). The risk increased further in combination with a hypnotic or sedative. CONCLUSIONS Even at low doses, SSRIs are associated with increased risk of an injurious fall in nursing home residents with dementia. Higher doses increase the risk further with a three-fold risk at 1.00 DDD. New treatment protocols might be needed that take into account the dose-response relationship between SSRIs and injurious falls.

Inequalities in Alcohol-Related Mortality in 17 European Countries : A Retrospective Analysis of Mortality Registers.

Background Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time. Methods and Findings We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3–4.0) and the slope index of inequality is 112.5 (95% CI 106.2–118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem. Conclusions Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Sharp upturn of life expectancy in the Netherlands: effect of more health care for the elderly?

During the 1980s and 1990s life expectancy at birth has risen only slowly in the Netherlands. In 2002, however, the rise in life expectancy suddenly accelerated. We studied the possible causes of this remarkable development. Mortality data by age, gender and cause of death were analyzed using life table methods and age-period-cohort modeling. Trends in determinants of mortality (including health care delivery) were compared with trends in mortality. Two-thirds of the increase in life expectancy at birth since 2002 were due to declines in mortality among those aged 65 and over. Declines in mortality reflected a period rather than a cohort effect, and were seen for a wide range of causes of death. Favorable changes in mortality determinants coinciding with the acceleration of mortality decline were mainly seen within the health care system. Health care expenditure rose rapidly after 2001, and was accompanied by a sharp rise of specialist visits, drug prescriptions, hospital admissions and surgical procedures among the elderly. A decline of deaths following non-treatment decisions suggests a change towards more active treatment of elderly patients. Our findings are consistent with the idea that the sharp upturn of life expectancy in the Netherlands was at least partly due to a sharp increase in health care for the elderly, and has been facilitated by a relaxation of budgetary constraints in the health care system.

The impact of a national mass media campaign in The Netherlands on the prevention of weight gain

OBJECTIVE A 5-year nationwide mass media campaign aimed at prevention of overweight was organised from 2002 onwards. The present study evaluates the first campaign, which was aimed primarily at increasing awareness of weight gain. DESIGN AND SUBJECTS Data were collected by telephone interview in four independent cross-sectional surveys among non-obese Dutch adults aged 25-35 years (total n = 1,949) for statistical analyses. Awareness of personal body-weight status, overweight-related risk perceptions, attitudes towards weight-gain prevention, motivation to prevent weight gain and self-reported body mass index (BMI) were measured in each survey. Campaign exposure was assessed in the post-intervention surveys. To identify intervention effects over time multiple linear and logistic regression analyses were used, adjusted for secular time effects and age. RESULTS After the campaign about 65% of the respondents knew about the campaign. The campaign was associated with more positive attitudes towards the prevention of weight gain (beta = 0.16; P < 0.01) and higher self-reported BMI (beta = 0.14; P < 0.01). CONCLUSIONS The results suggest that the first campaign reached a large proportion of the population and initiated some positive change in attitudes, but did not achieve significant improvements in other determinants of weight-gain prevention among non-obese young adults.

Is the Tinetti Performance Oriented Mobility Assessment (POMA) a feasible and valid predictor of short-term fall risk in nursing home residents with dementia?

BACKGROUND The feasibility and predictive validity of balance and gait measures in more severe stages of dementia have been understudied. We evaluated the clinimetric properties of the Tinetti Performance Oriented Mobility Assessment (POMA) in nursing home residents with dementia with a specific objective of predicting falls in the short term. METHODS Seventy-five ambulatory nursing home residents with dementia, mean age 81 +/- 8 years, participated in a prospective cohort study. All participants underwent the full POMA-test. Fall statistics were retrieved from incident reports during a three-months follow-up period. The predictive validity was expressed in terms of sensitivity and specificity. Loglinear regression analysis was used to examine the relationship between POMA scores and the occurrence of a fall. RESULTS The POMA showed several feasibility problems, with 41% of patients having problems in understanding one or more instructions. The inter-rater reliability of the instrument was good. The predictive validity was acceptable, with a sensitivity of 70-85% and a specificity of 51-61% for the POMA and its subtests, and an area under the curve (AUC) of 0.70 for POMA-Total (95% CI: 0.53-0.81), 0.67 for POMA-Balance (95% CI: 0.52-0.81), and 0.67 for POMA-Gait (95% CI: 0.53-0.81). After loglinear regression analysis, only POMA-T was significant in predicting a fall (adjusted HR = 1.08 per point lower; 95% CI 1.00-1.17). CONCLUSIONS Application of the POMA in populations with moderate to severe dementia is hampered by feasibility problems. Its implementation in clinical practice cannot therefore be recommended, despite an acceptable predictive validity. To refine our findings, large prospective studies on the predictive validity of the POMA in populations with mild, moderate and severe dementia are needed. In addition, the performance of mobility assessment methods that are less dependent on cognition should be evaluated.

An electronic walkway can predict short-term fall risk in nursing home residents with dementia

OBJECTIVES To evaluate the feasibility and validity of gait parameters measured with an electronic walkway system in predicting short-term fall risk in nursing home residents with dementia. METHODS 57 ambulatory nursing home residents with moderate to severe dementia participated in this prospective cohort study. We used the GAITRite(®) 732 walkway system to assess gait parameters. Measurements were collected every 3 months over a 15 month period, with each measurement being a baseline for the subsequent measurement. Falls were retrieved from incident reports. The predictive validity of the GAITRite(®) parameters was expressed in terms of sensitivity and specificity. Logistic regression analysis was conducted to examine the association between these parameters and falls occurrence within three months. RESULTS Reduced velocity (OR=1.22; 95% CI 1.04-1.43) and reduced mean stride length (OR=1.19; 95% CI 1.03-1.40) were the best significant gait predictors of a fall within three months, with a sensitivity of 82% for velocity and 86% for mean stride length, and a specificity of 52% for velocity and for mean stride length. The test procedure took an average of 5 min per participant. Some verbal persuasion or physical cueing was necessary in 142 measurements (80.7%). CONCLUSION Gait parameters as measured with an electronic walkway system can be used for the prediction of short-term fall risk in nursing home residents with moderate to severe dementia. However some form of persuasion might be needed to perform the task. To refine our findings, large prospective studies on the predictive validity of gait parameters in this type of population are needed.

Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior

BACKGROUND Appropriate hand hygiene among health care workers is the most important infection prevention measure; however, compliance is generally low. Gain-framed messages (ie, messages that emphasize the benefits of hand hygiene rather than the risks of noncompliance) may be most effective, but have not been tested. METHODS The study was conducted in a 27-bed neonatal intensive care unit. We performed an interrupted time series analysis of objectively measured hand disinfection events. We used electronic devices in hand alcohol dispensers, which continuously documented the frequency of hand disinfection events. In addition, hand hygiene compliance before and after the intervention period were directly observed. RESULTS The negative trend in hand hygiene events per patient-day before the intervention (decrease by 2.3 [standard error, 0.5] per week) changed to a significant positive trend (increase of 1.5 [0.5] per week) after the intervention (P < .001). The direct observations confirmed these results, showing a significant improvement in hand hygiene compliance from 193 of 303 (63.6%) observed hand hygiene events at pretest to 201 of 281 (71.5%) at posttest. CONCLUSIONS We conclude that gain-framed messages concerning hand hygiene presented on screen savers may improve hand hygiene compliance.