K. Chami

Reluctance of caregivers to perform oral care in long-stay elderly patients: the three interlocking gears grounded theory of the impediments.

To the Editor: A clustered randomized controlled trial was previously carried out in long-stay facilities to assess the impact of oral care in the prevention of pneumonia and oral candidosis.1 However, despite an education program focusing on optimal oral care delivery practices2 and oral health knowledge improvement in the interventional arm,3e5 oral care seemed to be often underperformed or inadequately performed in both groups. Consequently, reluctance of caregivers to perform oral care emphasized the need for an analytical monitoring of the process of oral health care performed by registered nurses (RNs) and certified nursing assistants (CNAs). Therefore, we sought to develop a multivariate conceptual framework of the implicit impediments hampering the process of oral care by caregivers in the elderly. We undertook a 2-cycle study in 2006e2007 using grounded theory, a research method that aims to develop theoretical explanations of social phenomena.6e10 Three volunteer geriatric wards from 3 countries were included: France (long term care facility), Belgium (acute care and rehabilitative), and Switzerland (rehabilitative). The participants, blinded to the real focus of the study, were primary dayshift RNs and CNAs. We selected a purposive sampling, a nonrandom method of sampling wherein the researcher selects information-rich cases for in-depth study until saturation (the point at which no additional data are being found by further sampling)6e8 to ensure diversification in observations and responses. A research assistant, with a background in ethnology, collected all the data, which were analyzed with the principal investigator. Cycle 1 involved nonparticipant observation of daily oral care for patients requiring assistance with oral care. Caregivers were observed primarily in the early morning during routine care activities (7 oral care observations out of 112 basic care [7/112] observed in France, 38/95 in Belgium, 24/ 49 in Switzerland), and they subsequently completed shortened informal individual or group interviews. During Cycle 2, we recorded in-depth semistructured interviews, each lasting between 30 and 45 minutes. Thus, based on Cycle 1, we developed a series of vignette recordings (10 sets in France, 16 in Belgium, and 17 in Switzerland) according to real-life situations. The 43 participants included were 42 caregivers (23 nurses [1 student nurse] and 19 CNAs) and 1 physician. According to nonparticipant observations and caregivers’ declarations, impediments to performing oral care in the elderly include the following: organizational attributes, caregivers’ oral health knowledge and education, and caregivers’ behavior and oral care perceptions and misconceptions.

A short-term, multicomponent infection control program in nursing homes: a cluster randomized controlled trial.

OBJECTIVES To assess the impact of a hygiene-encouragement program on reducing infection rates (primary end point) by 5%. DESIGN A cluster randomized study was carried out over a 5-month period. SETTINGS AND PARTICIPANTS Fifty nursing homes (NHs) with 4345 beds in France were randomly assigned by stratified-block randomization to either a multicomponent intervention (25 NHs) or an assessment only (25 NHs). INTERVENTION The multicomponent intervention was targeted to caregivers and consisted of implementing a bundle of infection prevention consensual measures. Interactive educational meetings using a slideshow were organized at the intervention NHs. The NHs were also provided with color posters emphasizing hand hygiene and a kit that included hygienic products such as alcoholic-based hand sanitizers. Knowledge surveys were performed periodically and served as reminders. MEASUREMENTS The primary end point was the total infection rate (urinary, respiratory, and gastrointestinal infections) in those infection cases classified either as definite or probable. Analyses corresponded to the underlying design and were performed according to the intention-to-treat principle. This study was registered (#NCT01069497). RESULTS Forty-seven NHs (4515 residents) were included and followed. The incidence rate of the first episode of infection was 2.11 per 1000 resident-days in the interventional group and 2.15 per 1000 resident-days in the control group; however, the difference between the groups did not reach statistical significance in either the unadjusted (Hazard Ratio [HR] = 1.00 [95% confidence interval (CI) 0.89-1.13]; P = .93]) or the adjusted (HR = 0.99 [95% CI 0.87-1.12]; P = .86]) analysis. CONCLUSION Disentangling the impact of this type of intervention involving behavioral change in routine practice in caregivers from the prevailing environmental and contextual determinants is often complicated and confusing to interpret the results.

COL5-05 Enquête PRIAM : prévalence nationale des infections en Établissements d’Hébergement pour Personnes Âgées Dépendantes (EHPAD)

Introduction et objectifs En France, on compte 6460 EHPAD, soit 443 765 lits. Ces structures particulieres situees entre le domicile prive et l’hopital, hebergent des residents polypathologiques et polymedicamentes, susceptibles aux infections. Une enquete regionale de prevalence des infections organisee en 2005 a montre un taux de 14,5 %. Un programme de surveillance et de prevention des infections a donc ete mis en place ; la premiere etape a consiste en une enquete de prevalence. Materiels et methodes Il s’agissait d’une enquete nationale, transversale, periodique (cinq periodes saisonnieres), sur un mois donne, descriptive. Tout resident de 65 ans et plus present dans l’etablissement au moment de l’enquete etait inclus. Ont ete prises en compte toutes les infections avec distinction entre les cas certains (definitions de McGeer) et les cas probables (definitions de l’ORIG). Resultats Ces resultats ont concerne 44 870 residents et 577 etablissements. L’âge moyen etait de 86 ans, le sexe feminin predominait (75,6 %), la moitie des residents (49 %) etaient tres dependants (GIR 1 ou 2), 4,6 % etaient porteurs d’escarres, 2,2 % etaient sondes, 93,4 % etaient vaccines contre la grippe et 13 % contre le pneumocoque. Le taux de prevalence des infections etait de 11,2 %. Les infections respiratoires basses et hautes representaient le premier site infectieux (41 %), suivies des infections urinaires (24 %) et des infections cutanees (10 %). Conclusion Le risque infectieux parait important dans les EHPAD. Une etude type essai randomise en clusters est en preparation, dans le but d’evaluer l’efficacite d’un programme interventionnel sur la diminution de l’incidence des infections dans ces structures.