Joshua D. Lenchus

The efficacy of visual cues to improve hand hygiene compliance

Background: Guidelines governing healthcare workers (HCW) hand hygiene (HH) behavior are well established. Despite known hazards of healthcare-associated infection to both HCW and patients, hand hygiene compliance (HHC) rates remain dismally low. To evaluate a potential solution to this ongoing challenge, we used a simulated patient encounter in an actual hospital room to test the efficacy of individual HH triggers. Methods: One hundred fifty HCW (75 physicians and 75 nurses) participated in this study and were randomly assigned to one of five equal-size groups. Each participant performed a focused physical examination on a standardized patient and was expected to maintain HH before and after the examination. Using two rooms on a medical-surgical unit in a tertiary care teaching hospital, various cues were employed, and the impact on pre- and postexamination HHC was recorded. In the control group, the hand sanitizer dispenser was in its usual location (Baseline). In one group, the dispenser was relocated to direct line of sight (Line-of-Sight) on entering the room; in another, flashing lights were affixed to the dispenser in its usual location (Baseline & Flicker); and in a third group, the dispenser was relocated to the line of sight, and flashing lights were attached (Line-of-Sight & Flicker). In the last group, a large warning sign (Warning Sign) was affixed to the door, informing the healthcare provider that the room was under electronic surveillance, and failure to perform HHC would trigger an alarm. Data were analyzed using a generalized linear model to perform a repeated measures logistic regression; P < 0.05 was considered statistically significant. Results: In the control group (Baseline), pre- and postexamination HHC rates were 36.7% and 33.3%, respectively. All interventions improved HHC preintervention compared with baseline (Line-of-Sight = 53.3%, Baseline & Flicker = 60%, Line-of-Sight & Flicker = 66%, Warning Sign = 93.3%), but only the Line-of-Sight & Flicker and the Warning Sign produced statistically significant increased pre-examination HHC (P = 0.022 and P < 0.001, respectively). Only the Warning Sign produced statistically significant increased HHC postexamination (P < 0.001). Conclusions: Visual cues can improve HHC, but their efficacy varies. A warning sign informing of a surveillance system with subsequent reporting of noncompliance resulted in the most significant improvement in HHC. Using a standardized patient in an actual hospital room was a helpful tool in assessing the impact of various interventions designed to improve HHC and patient safety.

effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections*

Objective: Determine the impact of three stepwise interventions on the rate of central catheter-associated bloodstream infections. Design: Quasi-experimental study. Setting: Three surgical intensive care units (general surgery, trauma, and neurosurgery) at a 1500-bed county teaching hospital in the Miami metro area. Patients: All consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department. Interventions: Three interventions aimed at catheter maintenance were implemented at different times in the units: chlorhexidine “scrub-the-hub,” chlorhexidine daily baths, and daily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist. Measurements and Main Results: The primary outcome was the monthly intensive care unit rate of central catheter-associated bloodstream infections (infections per 1000 central catheter days). Over 33 months of follow-up (July 2008 to March 2011), we found decreased rates in each of the three intensive care units evaluated during the interventions, especially after implementation of chlorhexidine daily baths. Rates in unit A decreased from a rate of 8.6 to 0.5, unit B from 6.9 to 1.6, and unit C from 7.8 to 0.6. Secondary bloodstream infection rates remained unchanged throughout the observation period in units A and B; however, unit C had a decrease in its rates over time. Conclusions: We report the progressive reduction of central catheter-associated bloodstream infection rates after the stepwise implementation of chlorhexidine “scrub-the-hub” and daily baths in surgical intensive care units, suggesting effectiveness of these interventions.

Filling the Void: Defining Invasive Bedside Procedural Competency for Internal Medicine Residents

BACKGROUNDnResidents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care.nnnOBJECTIVEnWe developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine-pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes.nnnMETHODSnWe conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a residents self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the residents confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores.nnnRESULTSnA total of 148 internal medicine and medicine-pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4xa0weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent.nnnCONCLUSIONSnOur multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.

Sexual assault forensic examiners' training and assessment using simulation technology

INTRODUCTIONnMore than 190,000 sexual assaults involving persons aged 12 years or older occur annually in the United States. For these victims, a forensic examination is the first step in the process to justice. Assessment and treatment of victims, as well as the meticulous collection and documentation of evidence, are vital for a strong case. Providing timely services 24/7 by qualified professionals can be taxing on schedules and budgets. Using in-house resources to cross-train ED personnel, we developed a program that introduced novice forensic examiners to common clinical scenarios encountered in the treatment of victims and provided a framework for the evaluation and management of each case.nnnMETHODSnSeventeen ED personnel attended statewide sexual assault nurse examination training and participated in four simulation scenarios and debriefings. Pre-tests and post-tests were administered, and a checklist was used to assess competence in performing examinations independently.nnnRESULTSnThe majority of participants achieved competence (≥85% on the checklist) with their first case and had statistically significant gains in knowledge between pre-test and post-test (pre-test mean score [±SE] of 69.1 ± 1.7 vs. post-test mean score of 84.4 ± 2.6, P < .001). Course evaluations were favorable, with a mean score of 91.3%.nnnDISCUSSIONnOur results validated the use of simulation technology and in-house resources for cross-training in a sexual assault forensic examination program, together with a checklist to assess competence in performing examinations independently. Benefits of having a sexual assault forensic examination program in the emergency department are standardized and timely care for victims, as well as enhanced evidence collection and increased reporting and prosecution of crimes.

Factors impacting hand hygiene compliance among new interns: findings from a mandatory patient safety course.

BACKGROUNDnResidency is a critical transition during which individuals acquire lifelong behaviors important for professionalism and optimal patient care. One behavior is proper hand hygiene (HH), yet poor compliance with accepted HH practices remains a critical issue in many settings. This study explored the factors affecting hand hygiene compliance (HHC) in a diverse group of interns at the beginning of graduate training.nnnMETHODSnDuring a required patient safety course, we observed HH behaviors using a standardized patient encounter. Interns were instructed to perform a focused exam in a simulated inpatient environment with HH products available and clearly visible. Participants were blinded to the HH component of the study. An auditory alert was triggered if participants failed to perform prepatient encounter HH. Compliance rates and the number of alerts were recorded. All encounters were videotaped.nnnRESULTSnThe HHC among the 169 participants was 37.9% pre-encounter and was higher among female interns than males, although this difference was not statistically significant (41.6% versus 31.5%, P u200a=u200a .176). International medical graduates had significantly lower HHC compared with US graduates (23.2% versus 45.1%, P u200a=u200a .006). Most initially noncompliant participants performed HH after 1 alert (87.6%).nnnDISCUSSIONnThe initial low rate of HHC in our sample is comparable to other studies. Using direct video surveillance and auditory alarms, we improved our success rates for prepatient encounter HHC. Our study identified medical school origin as an important factor for HHC, and the significantly lower compliance for international medical graduates compared with US graduates has not been previously reported. These findings should be considered in designing interventions such as intern orientation and clinical education programs to improve HH behaviors.

Strategies for Venous Thromboembolism Prophylaxis Programs

Abstract Prevention of venous thromboembolism (VTE) is often overlooked in clinical practice, despite being a frequent and serious complication of various medical conditions and surgical procedures. The need to reduce hospital-acquired VTE is becoming increasingly recognized in the United States, and various quality-improvement initiatives have been developed. Prevention of VTE through evidence-based, practice-informed pathways includes assessing the patients risk of VTE and provision of VTE at different stages: at admission, during hospitalization, and after hospital discharge. A multidisciplinary approach, involving physicians working with pharmacists, nurses, and other staff, can ensure that VTE prevention is routinely addressed. Patients admitted to hospitals should undergo VTE risk assessment, and the appropriate dose, type, and duration of medication should be administered with regular monitoring for VTE events and bleeding complications. Venous thromboembolism risk assessment should continue throughout hospitalization with appropriate prophylaxis when necessary. Patients may need to continue anticoagulation into the outpatient setting to achieve adequate prophylaxis duration. Useful approaches to ensure successful transition of care include patient education and support, with the accurate and timely transfer of information from the hospital to the primary care physician. Various strategies and tools are available to help physicians establish good VTE practices at each stage, including risk assessment models, reminders, clinical decision support systems, educational programs, and online resources, such as those from the Society of Hospital Medicine. Effective use of these strategies by physicians, with the engagement and support of nurses and pharmacists, should help to improve current practices and to reduce the considerable burden of VTE.

A novel cognitive assessment paradigm to detect Pre-mild cognitive impairment (PreMCI) and the relationship to biological markers of Alzheimer's disease

OBJECTIVEnA number of older adults obtain normal scores on formal cognitive tests, but present clinical concerns that raise suspicion of cognitive decline. Despite not meeting full criteria for Mild Cognitive Impairment (MCI), these PreMCI states confer risk for progression to Alzheimers disease (AD). This investigation addressed a pressing need to identify cognitive measures that are sensitive to PreMCI and are associated with brain biomarkers of neurodegeneration.nnnMETHODnParticipants included 49 older adults with a clinical history suggestive of cognitive decline but normal scores on an array of neuropsychological measures, thus not meeting formal criteria for MCI. The performance of these PreMCI participants were compared to 117 cognitively normal (CN) elders on the LASSI-L, a cognitive stress test that uniquely assesses the failure to recover from proactive semantic interference effects (frPSI). Finally, a subset of these individuals had volumetric analyses based on MRI scans.nnnRESULTSnPreMCI participants evidenced greater LASSI- L deficits, particularly with regards to frPSI and delayed recall, relative to the CN group. No differences on MRI measures were observed. Controlling for false discovery rate (FDR), frPSI was uniquely related to increased dilatation of the inferior lateral ventricle and decreased MRI volumes in the hippocampus, precuneus, superior parietal region, and other AD prone areas. In contrast, other LASSI-L indices and standard memory tests were not related to volumetric findings.nnnCONCLUSIONSnDespite equivalent performance on traditional memory measures, the frPSI distinguished between PreMCI and CN elders and was associated with reductions in brain volume in numerous AD-relevant brain regions.

In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Effectiveness of a Perioperative Transthoracic Ultrasound Training Program for Students and Residents

OBJECTIVEnFocused ultrasound (US) is being incorporated across all levels of medical education. Although many comprehensive US courses exist, their scope is broad, requiring expert instructors, access to simulation, and extensive time commitment by the learner. We aim to compare learning across levels of training and specialties using a goal-directed, web-based course without live skills training.nnnDESIGNnA prospective observational study of students and residents from medicine, surgery, and anesthesiology. Analysis compared pretests and posttests assessing 3 competencies. Individual mean score improvement (MSI) was compared by paired-sample t-tests and MSI among cohorts by analysis of variance, with significance set at p ≤ 0.05. McNemar test compared those who agreed or strongly agreed with survey items with those who did not before and after intervention.nnnSETTINGnJackson Memorial Hospital, Miami, FL residency training programs in Medicine, Surgery, and Anesthesiology.nnnRESULTSnA total of 180 trainees participated. A significant MSI was noted in each of 3 competencies in all 3 cohorts. Students (S) MSI was significantly higher than residents (R) and interns (I) in US knobology and window recognition [S = 2.28 ± 1.29/5 vs R = 1.63 ± 1.21/5 (p = 0.014); vs I = 1.59 ± 1.12/5 (p = 0.032)]; students total score MSI was significantly higher than residents [7.60 ± 3.43/20 vs 5.78 ± 3.08/20 (p < 0.008)]. All cohorts reported improved comfort in using transthoracic US and improved ability to recognize indications for use. More than 81% of all participants reported improved confidence in performing transthoracic US; more than 91% reported interest in additional training; and more than 88% believed course length was appropriate.nnnCONCLUSIONSnLearners across levels of medical training and specialties can benefit from a brief, goal-directed, web-based training with early incorporation producing maximal yield.

The Right to Health Care

distress and had significant functional impairment. This brief transdiagnostic intervention improved both outcomes compared with enhanced usual care, and improvements were sustained over time. Importantly, the intervention was delivered by lay workers with no prior experience of delivering mental health interventions, and it was feasible and acceptable to participants as well as to the primary care centers. We recognize the positive effects of social and family support on mental health and agree that some of the improvements seen in the control group could have been a result of an increase in family support following consultation with and psychoeducation by the physician. However, the intervention itself also addresses this directly by actively encouraging patients to reactivate their social networks. Although we did not measure this, we would not be surprised if participants in the intervention group felt more socially supported at follow-up. In studies of this nature, although it is not feasible to measure every variable of interest, robust randomization procedures ensure that intervention and control participants are as similar as possible on recruitment, and any differences in outcomes should be related to the intervention or control conditions. Our intervention was primary care facility based and represents one, albeit an important, aspect of care for this population. Community-based interventions that rebuild and strengthen families and communities affected by violence and conflict will also be required, as will specialist-focused interventions for patients who are more severely affected. Furthermore, this intervention targeted the adult population, and similar interventions are needed in children and adolescents. Our study demonstrated that relatively sophisticated applied health research is possible in such challenging settings and paves the way for further research.