Lennox K. Archibald

The effect of increased mobility on morbidity in the neurointensive care unit.

OBJECTnThe detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive care unit patients.nnnMETHODSnAll patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period (April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preintervention observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus.nnnRESULTSnImplementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections.nnnCONCLUSIONSnAmong neurointensive care unit patients, increased mobility can be achieved quickly and safely with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.

Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success

OBJECTnTo date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate.nnnMETHODSnAll patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted.nnnRESULTSnThe urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r(2) = 0.79, p < 0.0001).nnnCONCLUSIONSnThis single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Reduction in Surgical Site Infections in Neurosurgical Patients Associated With a Bedside Hand Hygiene Program in Vietnam

OBJECTIVEnWe conducted an intervention study to assess the impact of the use of an alcohol-chlorhexidine-based hand sanitizer on surgical site infection (SSI) rates among neurosurgical patients in Ho Chi Minh City, Vietnam.nnnDESIGNnA quasi-experimental study with an untreated control group and assessment of neurosurgical patients admitted to 2 neurosurgical wards at Cho Ray Hospital between July 11 and August 15, 2000 (before the intervention), and July 14 and August 18, 2001 (after the intervention). A hand sanitizer with 70% isopropyl alcohol and 0.5% chlorhexidine gluconate was introduced, and healthcare workers were trained in its use on ward A in September 2000. No intervention was made in ward B. Centers for Disease Control and Prevention definitions of SSI were used. Patient SSI data were collected on standardized forms and were analyzed using Stata software (Stata).nnnRESULTSnA total of 786 patients were enrolled: 377 in the period before intervention (156 in ward A and 221 in ward B) and 409 in the period after intervention (159 in ward A and 250 in ward B). On ward A after the intervention, the SSI rate was reduced by 54% (from 8.3% to 3.8%; P=.09), and more than half of superficial SSIs were eliminated (7 of 13 vs 0 of 6 in ward B; P=.007). On ward B, the SSI rate increased by 22% (from 7.2% to 9.2%; P=.8). In patients without SSI, the median postoperative length of stay and the duration of antimicrobial use were reduced on ward A (both from 8 to 6 days; P<.001) but not on ward B.nnnCONCLUSIONSnOur study demonstrates that introduction of a hand sanitizer can both reduce SSI rates in neurosurgical patients, with particular impact on superficial SSIs, and reduce the overall postoperative length of stay and the duration of antimicrobial use. Hand hygiene programs in developing countries are likely to reduce SSI rates and improve patient outcomes.

Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution

OBJECTnVentricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated.nnnMETHODSnA best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period.nnnRESULTSnAt the authors institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation.nnnCONCLUSIONSnBundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

Challenges for management of the diabetic foot in Africa: doing more with less.

Diabetes mellitus reached epidemic proportions in much of the less‐developed world over a decade ago. In Africa, incidence and prevalence rates of diabetes are increasing and foot complications are rising in parallel. The predominant risk factor for foot complications is underlying peripheral neuropathy, although there is a body of evidence that confirm the increasing role of peripheral vascular disease. Gangrene and infections are two of the more serious sequelae of diabetic foot ulcer disease that cause long‐standing disability, loss of income, amputation or death. Unfortunately, diabetes imposes a heavy burden on the health services in many African countries, where resources are already scarce or cut back. Reasons for poor outcomes of foot complications in various less‐developed countries include the following: lack of awareness of foot care issues among patients and health care providers alike; very few professionals with an interest in the diabetic foot or trained to provide specialist treatment; non existent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking timely medical care, or among untrained health care providers in referring patients with serious complications for specialist opinion; lack of the concept of a team approach; absence of training programs for health care professionals; and finally lack of surveillance activities. There are ways of improving diabetic foot disease outcomes that do not require an exorbitant outlay of financial resources. These include implementation of sustainable training programmes for health care professionals, focusing on the management of the complicated diabetic foot and educational programmes that include dissemination of information to other health care professionals and patients; sustenance of working environments that inculcate commitment by individual physicians and nurses through self growth; rational optimal use of existing microbiology facilities and prescribing through epidemiologically directed empiricism, where appropriate; and using sentinel hospitals for surveillance activities. Allied with the golden rules of prevention (i.e. maintenance of glycaemic control to prevent peripheral neuropathy, regular feet inspection, making an effort not to walk barefooted or cut foot callosities with razors or knives at home and avoidance of delays in presenting to hospital at the earliest onset of a foot lesion), reductions in the occurrence of adverse events associated with the diabetic foot is feasible in less‐developed settings.

Prevalence of surgical-site infections and patterns of antimicrobial use in a large tertiary-care hospital in Ho Chi Minh City, Vietnam.

BACKGROUNDnFew studies have been conducted in Vietnam on the epidemiology of healthcare-associated infections or antimicrobial use. Thus, we sought to determine the prevalence of and risk factors for surgical-site infections (SSIs) and to document antimicrobial use in surgical patients in a large healthcare facility in Vietnam.nnnMETHODSnWe conducted a point-prevalence survey of SSIs and antimicrobial use at Cho Ray Hospital, Ho Chi Minh City, a 1,250-bed inpatient facility. All patients on the 11 surgical wards and 2 intensive care units who had surgery within 30 days before the survey date were included.nnnRESULTSnOf 391 surgical patients, 56 (14.3%) had an SSI. When we compared patients with and without SSIs, factors associated with infection included trauma (relative risk [RR], 2.65; 95% confidence interval [CI95], 1.60 to 4.37; P < .001), emergency surgery (RR, 2.74; CI95, 1.65 to 4.55; P < .001), and dirty wounds (RR, 3.77; CI95, 2.39 to 5.96; P < .001). Overall, 198 (51%) of the patients received antimicrobials more than 8 hours before surgery and 390 (99.7%) received them after surgery. Commonly used antimicrobials included third-generation cephalosporins and aminoglycosides. Thirty isolates were identified from 26 SSI patient cultures; of the 25 isolates undergoing antimicrobial susceptibility testing, 22 (88%) were resistant to ceftriaxone and 24 (92%) to gentamicin.nnnCONCLUSIONSnOur data show that (1) SSIs are prevalent at Cho Ray Hospital; (2) antimicrobial use among surgical patients is widespread and inconsistent with published guidelines; and (3) pathogens often are resistant to commonly used antimicrobials. SSI prevention interventions, including appropriate use of antimicrobials, are needed in this population.

The 'Step by Step' Diabetic Foot Project in Tanzania: a model for improving patient outcomes in less-developed countries.

Foot complications cause substantial morbidity in Tanzania, where 70% of leg amputations occur in diabetic patients. The Step by Step Foot Project was initiated to train healthcare personnel in diabetic foot management, facilitate transfer of knowledge and expertise, and improve patient education. The project comprised a 3‐day basic course with an interim period 1‐year of for screening, followed by an advanced course and evaluation of activities. Fifteen centres from across Tanzania participated during 2004–2006 and 12 during 2004–2007. Of 11 714 patients screened in 2005, 4335 (37%) had high‐risk feet. Of 461 (11%) with ulcers, 45 (9·8%) underwent major amputation. Of 3860 patients screened during 2006–2007, there was a significant increase in the proportion with ulcers and amputations compared with 2005 (P < 0·001), likely a result of enhanced case finding. During 2005–2008, there was a fall in the incidence of foot ulcers in patient referrals to the main tertiary care centre in Dar es Salaam and a parallel fall in amputation among these referrals. In conclusion, the Step by Step Foot Project in Tanzania improved foot ulcer management for persons with diabetes and resulted in permanent, operational foot clinics across the country. This programme is an effective model for improving outcomes in other less‐developed countries.

Methicillin‐Resistant Staphylococcus aureus Infection in a College Football Team: Risk Factors Outside the Locker Room and Playing Field

We investigated a cluster of methicillin-resistant Staphylococcus aureus infections in college football players. Risk factors included a history of recurrent skin infections and contact with the skin lesions of persons outside college. The infections were controlled through treatment of carriers with topical mupirocin, chlorhexidine body washes, and enhancement of personal hygiene practices. Varsity and professional teams need to consider similar preventive measures.

Tropical Diabetic Hand Syndrome

The tropical diabetic hand syndrome (TDHS) is a complication affecting patients with diabetes mellitus in the tropics. The syndrome encompasses a localized cellulitis with variable swelling and ulceration of the hands, to progressive, fulminant hand sepsis, and gangrene affecting the entire limb. TDHS is less well recognized than foot infections and not generally classified as a specific diabetes complication. Hand infection was first described in Nigeria in 1984. Since then, the majority of cases have been reported in the African continent and more recently in India. There is often a history of antecedent minor hand trauma (e.g. scratches or insect bites). Presentation to hospital is often delayed due to the patients’ unawareness of the potential risks, lack of concern because the initiating trauma might have been trivial, or decision to seek initial help from traditional healers. The first analytic study was done in Dar es Salaam, Tanzania, to characterize the epidemiology, clinical characteristics and risk factors of TDHS.Independent risk factors for TDHS include poorly controlled diabetes, neuropathy, insulin treatment or malnutrition. Clinicians should be aware of these complications and be prepared to immediately admit TDHS patients to hospital for aggressive surgical intervention (i.e. debridement, pus drainage or amputation) and high-dose, intravenous, broad-spectrum antibacterial therapy that includes anti-anaerobic activity. Without prompt, aggressive treatment TDHS can lead to permanent disability, limb amputation (13% of TDHS patients require major upper limb amputation), or death. Prevention strategies include patient and staff education that focuses on proper hand care, nutrition, and the importance of seeking medical attention immediately following hand trauma regardless of the severity of the injury, or at the earliest onset of hand-related symptoms, such as redness or swelling. Prevention of permanent disability and death due to TDHS will require improved management of glycemic levels in resource-limited countries, and surgical intervention during less severe stages of the condition.

Health Care–Associated Infection Outbreak Investigations by the Centers for Disease Control and Prevention, 1946–2005

Since 1946, Centers for Disease Control and Prevention (CDC) personnel have investigated outbreaks of infections and adverse events associated with delivery of health care. CDC Epidemic Intelligence Service officers have led onsite investigations of these outbreaks by systematically applying epidemiology, statistics, and laboratory science. During 1946-2005, CDC Epidemic Intelligence Service officers conducted 531 outbreak investigations in facilities across the United States and abroad. Initially, the majority of outbreaks involved gastrointestinal tract infections; however, in later years, bloodstream, respiratory tract, and surgical wound infections predominated. Among pathogens implicated in CDC outbreak investigations, Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, nonfermentative Gram-negative bacteria, or yeasts predominated, but unusual organisms (e.g., the atypical mycobacteria) were often included. Outbreak types varied and often were linked to transfer of colonized patients or health care personnel between facilities (multihospital outbreaks), national distribution of contaminated products, use of invasive medical devices, or variances in practices and procedures in health care environments (e.g., intensive care units, water reservoirs, or hemodialysis units). Through partnerships with health care facilities and local and state health departments, outbreaks were terminated and lives saved. Data from investigations invariably contributed to CDC-generated guidelines for prevention and control of health care-associated infections.