Marta Nobile

Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: Results of the GISIO-ISChIA study

BACKGROUND Recent studies have shown a higher rate of surgical site infections in hip prosthesis implantation using unidirectional airflow ventilation compared with turbulent ventilation. However, these studies did not measure the air microbial quality of operating theatres (OTs), and assumed it to be compliant with the recommended standards for this ventilation technique. AIM To evaluate airborne microbial contamination in OTs during hip and knee replacement surgery, and compare the findings with values recommended for joint replacement surgery. METHODS Air samplings were performed in 28 OTs supplied with unidirectional, turbulent and mixed airflow ventilation. Samples were collected using passive sampling to determine the index of microbial air contamination (IMA). Active sampling was also performed in some of the OTs. The average number of people in the OT and the number of door openings during the sampling period were recorded. FINDINGS In total, 1228 elective prosthesis procedures (60.1% hip and 39.9% knee) were included in this study. Of passive samplings performed during surgical activity in unidirectional airflow ventilation OTs (U-OTs) and mixed airflow OTs (M-OTs), 58.9% and 87.6% had IMA values >2, respectively. Of samplings performed during surgical activity in turbulent airflow OTs (T-OTs) and in turbulent airflow OTs with the surgical team wearing Steri-Shield Turbo Helmets (TH-OTs), 8.6% and 60% had IMA values ≤ 2, respectively. Positive correlation was found between IMA values and the number of people in the OT and the number of door openings (P < 0.001). In addition, correlation was found between active and passive sampling (P < 0.001). CONCLUSION These findings challenge the belief that unidirectional systems always provide acceptable airborne bacterial counts.

Reinforcing good practice: Implementation of guidelines at hospital G. Pini

INTRODUCTION Surgical site infections (SSIs) in orthopaedic surgery are a demanding complication for the patient and in terms of economics. Many guidelines (GLs) are available on antibiotic prophylaxis as an effective preventive measure; however, these GLs are often ignored in practice. A surveillance study of SSIs in arthroplasty, promoted by the Italian Study Group of Hospital Hygiene of the Italian Society of Public Health (SitI), showed a high percentage of non-adherence to GLs on antibiotic prophylaxis. OBJECTIVES The purpose of this study was to review the existing GLs, share them within the hospital and then monitor their implementation. MATERIALS AND METHODS Information and training are considered to be great tools for implementation and sharing of GLs, which leads to significant improvements in clinical practice. A multidisciplinary team comprising infectious disease specialists, orthopaedic surgeons, nurse epidemiologists and public health specialists was established at the G. Pini Hospital in Milan to revise GLs, and to organise educational events for their implementation, sharing and dissemination. A checklist was devised for monitoring purposes. RESULTS GLs were presented to orthopaedic surgeons and nurse coordinators during two educational events. Meetings were organised in each unit to present the results of the surveillance of SSIs in arthroplasty and to discuss the reasons why the prophylaxis regimens adopted were not consistent with GLs. It was emphasised that the most important issue, on which there is consensus in the scientific literature, was related to the duration of prophylaxis beyond 24h. The review process for GLs was presented and pocket-sized GLs were given to surgeons. The importance of documenting on medical record any deviations from the GLs was emphasised. CONCLUSIONS Any changes in behaviour in clinical practice must be monitored and evaluated regularly. The monitoring of GLs in terms of correct choice of drug, timing of administration and duration of prophylaxis is made using a special checklist on a representative sample of medical records.

Comparative evaluation of MicroDTTect device and flocked swabs in the diagnosis of prosthetic and orthopaedic infections

The evolution of new prosthetic and osteosynthetic devices has led to more surgical indications, and this is accompanied by an increased incidence of septic complications in orthopaedic and trauma surgery in the general population. The strategy for choosing surgical or therapeutic (conservative) treatment is based on the identification of the pathogen: knowledge of the aetiological agents is an essential element in the decision-making process to ensure the most effective treatment is administered. The pathogen also needs to be considered in the challenging case of doubtful infection, where perhaps the only sign is inflammation, for a more accurate prediction of progression to either sepsis or healing. Biofilm-related infections and low-grade infections may fall into this category. Biofilm slows the metabolism of microorganisms and prolongs their survival, which renders them resistant to antibiotics. Moreover, when microorganisms are embedded in the biofilm they are poorly recognised by the immune system and the infection becomes chronic. As recently demonstrated, isolation and identification of bacteria in biofilm is difficult as the bacteria are concealed. The development of an effective means of sample collection and laboratory methods that can dislodge bacteria from prosthetic surfaces has therefore become necessary. The primary aim of the study was to evaluate the reliability of an innovative technology (MicroDTTect), specifically applied to collect and transport explanted samples (prostheses, osteosynthetic devices, biological tissues), and compare with flocked swabs. The MicroDTTect system is quick and simple to use and, most importantly, is a closed system that is totally sterile and safe for the patient being treated. It contains a specific concentration of dithiotreitol (DTT) that can dislodge bacteria from the biofilm adhering to prosthetic surfaces. The numbers of positive and negative samples were measured to compare the MicroDTTect methodology with swab collection in 30 procedures. The results showed that MicroDTTect had a higher sensitivity compared to swabs (77% and 46%, respectively), and was associated with more positive results than swabs (35% and 20%, respectively). These preliminary results show that MicroDTTect is superior to swab collection for bacterial identification in orthopaedic surgery. The early identification of microorganisms that cause sepsis may help improve treatment strategies and the efficacy of therapy, which will lead to an increased healing rate, reduced severity of sequelae and improved quality of life.

Developing a model for analysis the extra costs associated with surgical site infections (SSIs): an orthopaedic and traumatological study run by the Gaetano Pini Orthopaedic Institute

Over the years, the Gaetano Pini Orthopaedic Institute has implemented several projects in the hope of preventing healthcare-associated infections (HAIs). In particular, the institute participated in a long-term project monitoring arthroplasty-associated SSIs in 2010 (the ISChIA study), funded by the Italian Society of Hygiene’s GISIO (the Italian Study Group of Hospital Hygiene) which involved several different hospitals and enabled it to assess the frequency of SSIs in this kind of operation and identify potential risk factors.

Survey on professional training in three Italian. Post-Graduate Schools of Public Health.

BACKGROUND In 2005 the European Union (EU) recognized the equivalence within its member states of qualifications conferred by post-graduate schools (PGS) in public health. In Italy, ministerial decree no. 176 of 1st August 2005 defined the training goals and the related training programmes (Training Activities) leading to conferral of the qualification of specialist in Public Health and Preventive Medicine (PHPM). This study aimed to develop and validate an assessment tool for professional training programmes. The purpose has been to identify and evaluate their typical features and, at the same time, to enable comparison between Italian PGSs in PHPMs. METHODS In the first phase, a multiple-choice questionnaire was created, using a Likert scale with scores from 1 to 6. This was prepared by post-graduates attending the Milan PGS. This tool was validated by applying it to a pilot sample of post-graduates attending the Milan PGS in PHPM. Following this, a second round of discussion and validation of the model took place, involving 61 post-graduates attending PGSs in PHPM at the Universities of Palermo, Pisa and Turin. A web platform was used that enabled the survey to be created and managed by defining and managing pre-set interview templates. RESULTS The questionnaire consisted of three sections: Section A - Twenty-eight percent of post-graduates attended their training programme in a university or research centre, 29.8% in a hospital and 35.1% in a Local Health Unit. This training program lasted more than 12 months in 37% of the cases. Section B - The answers were all above pass-level (3 to 4 = satisfactory) except as regards the level of empowerment and the workload, which was judged to be unsatisfactory overall.The skills of the staff present in the facility attended were judged favourably (3.5). Section C - Section C investigates the duration and autonomy of the activities performed during the training programmes aimed at meeting the training requirements set out in ministerial decree no. 176/2005. Among respondents, 87% had taken part in ongoing statistical public health analyses, 81% had given presentations and contributed posters in public health congresses and 79% had planned or implemented an epidemiological survey. CONCLUSIONS A pre-set form for the assessment of training programmes by the post-graduates themselves is a useful tool with which to obtain their feedback. Public health providers must be able to view their training programme as a means of developing the numerous skills the profession requires. Eventually, they must be capable of acting autonomously, and to this end they need to interact with the numerous tutors with whom they come into contact. These latter were judged very favourably by the survey.

Definizione di un modello di analisi degli extra-costi legati alle infezioni del sito chirurgico (ISC): uno studio in ambito ortopedico e traumatologico Azienda Ospedaliera Istituto Ortopedico "Gaetano Pini"

Il presente progetto ha l’obiettivo di definire un modello di valutazione dei costi diretti delle ISC sostenuti dall’Azienda e dal Servizio Sanitario Regionale (SSR). Lo studio e stato condotto dall’Azienda Ospedaliera Istituto Ortopedico G. Pini in collaborazione con il team Healthcare AGCR Italy (Aon Global Risk Consulting) di Aon Hewitt Risk & Consulting e l’Universita degli Studi di Milano. Per lo studio sono stati selezionati i sette pazienti che nell’ambito del progetto di sorveglianza attiva prospettica ISChIA hanno presentato una ISC. E stato messo a punto un modello di analisi degli extra-costi di una ISC a partire dalla considerazione di due situazioni distinte: ricoveri con modifica del DRG, imputabile alla ISC e casi in cui gli extra-costi erano riferibili a episodi di ricovero successivi ovvero a prestazioni ambulatoriali. Inoltre e stata effettuata un’analisi finalizzata a definire i costi sostenuti dall’Azienda e quelli a carico del SSR.

REXIC project: retrospective cross-sectional study of documentation of informed consent for research biobanking in a public research and teaching hospital

Background The Center for Transfusion Medicine, Cell Therapy and Cryobiology, Milan, Northern Italy, is the headquarter of the POLI-MI biobank. It co-ordinates the biobank activities of the Fondazione Ca’ Granda Ospedale Maggiore Policlinico of Milan. Such activities require specific safeguarding of donors’ rights and protection of sensitive and genetic data. The Fondazione Ca’ Granda Ospedale Maggiore Policlinico has set up a project on informed consent with the aim of developing awareness and understanding of this issue. Within this project, it has been decided to evaluate how consent for biobanking material is expressed. Design and methods The aim of the study was to evaluate the quality and completeness of consent to biobanking in the POLI-MI biobank. This was a retrospective study carried out in 2012 on samples of consent declarations collected by biobank units in 2011. Some units used a single, standard consent model available from a previous POLI-MI biobank workgroup. Other units used models which had been previouly formulated. Evaluation was made using a form that indicated the essential elements of consent. Results A total of 48 consent declarations were collected using the single, standard model and 84 were collected using other models. The consent declarations that used the single, standard model were found to be the most complete and were filled in better than other models. Conclusions Progressive adoption of a simple, standard consent model is expected to improve the quality of consent acquisition. Regular audit of the compliance of consent practices with ethical and legal requirements is mandatory to improve the quality of research biobanking.