Sandra M. Swoboda

Double-Blind Placebo-Controlled Trial of Fluconazole to Prevent Candidal Infections in Critically Ill Surgical Patients

ObjectiveTo evaluate the prophylactic use of enteral fluconazole to prevent invasive candidal infections in critically ill surgical patients. Summary Background DataInvasive fungal infections are increasingly common in the critically ill, especially in surgical patients. Although fungal prophylaxis has been proven effective in certain high-risk patients such as bone marrow transplant patients, few studies have focused on surgical patients and prevention of fungal infection. MethodsThe authors conducted a prospective, randomized, placebo-controlled trial in a single-center, tertiary care surgical intensive care unit (ICU). A total of 260 critically ill surgical patients with a length of ICU stay of at least 3 days were randomly assigned to receive either enteral fluconazole 400 mg or placebo per day during their stay in the surgical ICU at Johns Hopkins Hospital. ResultsThe primary end point was the time to occurrence of fungal infection during the surgical ICU stay, with planned secondary analysis of patients “on-therapy” and alternate definitions of fungal infections. In a time-to-event analysis, the risk of candidal infection in patients receiving fluconazole was significantly less than the risk in patients receiving placebo. After adjusting for potentially confounding effects of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, days to first dose, and fungal colonization at enrollment, the risk of fungal infection was reduced by 55% in the fluconazole group. No difference in death rate was observed between patients receiving fluconazole and those receiving placebo. ConclusionsEnteral fluconazole safely and effectively decreased the incidence of fungal infections in high-risk, critically ill surgical patients.

Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit

ObjectiveTo determine whether electronic monitoring of hand hygiene and voice prompts can improve hand hygiene and decrease nosocomial infection rates in a surgical intermediate care unit. DesignThree-phase quasi-experimental design. Phase I was electronic monitoring and direct observation; phase II was electronic monitoring and computerized voice prompts for failure to perform hand hygiene on room exit; and phase III was electronic monitoring only. SettingNine-room, 14-bed intermediate care unit in a university, tertiary-care institution. All patient rooms, utility room, and staff lavatory were monitored electronically. ParticipantsAll healthcare personnel including physicians, nurses, nursing support personnel, ancillary staff, all visitors and family members, and any other personnel interacting with patients on the intermediate care unit. All patients with an intermediate care unit length of stay >48 hrs were followed for nosocomial infection. InterventionsElectronic monitoring during all phases, computerized voice prompts during phase II only. Measurements and Main ResultsWe evaluated a total of 283,488 electronically monitored entries into a patient room with 251,526 exits for 420 days (10,080 hrs and 3,549 patient days). Compared with phase I, hand hygiene compliance in patient rooms improved 37% during phase II (odds ratio, 1.38; 95% confidence interval, 1.04–1.83) and 41% in phase III (odds ratio, 1.41; 95% confidence interval, 1.07–1.84). When adjusting for patient admissions during each phase, point estimates of nosocomial infections decreased by 22% during phase II and 48% during phase III; when adjusting for patient days, the number of infections decreased by 10% during phase II and 40% during phase III. Although the overall rate of nosocomial infections significantly decreased when combining phases II and III, the association between nosocomial infection and individual phase was not significant. ConclusionsElectronic monitoring provided effective ongoing feedback about hand hygiene compliance. During both the voice prompt phase and postintervention phase, hand hygiene compliance and nosocomial infection rates improved suggesting that ongoing monitoring and feedback had both a short-term and, perhaps, a longer-term effect.

Survival and functional outcome after prolonged intensive care unit stay.

OBJECTIVE To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was

Guidelines for intensive care unit design.

85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

282,618 (1996). CONCLUSIONS An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

Candidemia: the impact of antifungal prophylaxis in a surgical intensive care unit.

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit. Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit. Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment. Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations. Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace. (Crit Care Med 2012; 40:–16)

Handwashing Compliance Depends on Professional Status

Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Surveillance strategies and impact of vancomycin-resistant enterococcal colonization and infection in critically ill patients

BACKGROUND Candidemia is fourfold more common in 1990 compared to 1980. In addition, a shift to non-albicans species has occurred in some institutions. Antifungal prophylaxis (AP) is effective in high-risk patients including critically ill surgical patients, but its use has been attributed to a resultant shift to non-albicans candida species. We hypothesized that the use of fluconazole prophylaxis would lead to a decreased incidence of candidemia but a possible increased incidence of resistant species of Candida, especially Candida glabrata (CG). METHODS From 1990 to 2002, all patients with candidemia (C) in the surgical intensive care unit (SICU) of a large tertiary care hospital were identified and reviewed retrospectively. Antifungal prophylaxis began in 2000 for high-risk patients. The periods were separated into PRE (1990-2000), and POST prophylaxis (2000-2002). RESULTS Excluding the year of the trial studying prophylaxis, (1998; five cases of C) a total of 83 patients developed candidemia: 69 PRE (83%) (1.94/1000 patient days) and 14 POST (17%) (0.76/1000 patient days) (OR 0.44; 95% CI 0.25, 0.78; p = 0.004). In the PRE period C. albicans (45%) and CG (30%) were predominant, whereas in the POST period, CG (9/14, 64%) (p = 0.05), and C. albicans (3/14, 21%) were common. Non-albicans species were 38/69 (55%) PRE and 11/14 (79%) POST, p = 0.14. Mortality in the group was 43/83 (52%) and did not differ PRE/POST or based on treatment. Predictors of SICU mortality (model r2 = 0.61) included hospital length of stay (LOS) (OR 1.14, CI 1.04, 1.25), fever (OR 51.2, CI 2.46, 1064), and broad-spectrum antibiotics (OR 69.7, CI 2.08, 2351), whereas post-transplantation status (OR 0.005, CI 0.00, 0.56), blood sugar <180 mg/dL (OR 0.03, CI 0.01, 0.81), and fungal prophylaxis (OR 0.03, CI 0.01, 0.58) were associated with a decreased risk of mortality. CONCLUSIONS Unfortunately, the mortality of candidemia remains high in SICU patients (52%). In the SICU, risk factors for candidemia and mortality are common. However, antifungal prophylaxis has significantly decreased the annual incidence of candidemia without a statistically significant shift to non-albicans pathogens.

Unconscious race and class bias: Its association with decision making by trauma and acute care surgeons

BACKGROUND Nosocomial infections can be transmitted from microorganisms on the hands of health care workers to patients. Handwashing (HW) has a proven benefit in preventing transmission of infection, yet compliance with handwashing, especially in intensive care units, ranges between 28% and 74%. METHODS To determine if HW behavior varies as a function of health care professional status and patient interaction, we conducted an observational study of a surgical intermediate care unit in a large university teaching hospital. HW compliance was observed among all health care workers (HCW): physicians (MD; N = 46), nurses (RN; N = 295), and nursing support personnel (NSP; N = 93). Over an 8-week period, unidentified, trained observers documented all HCW interactions in 1-h random blocks. HW opportunities were classified into low and high risk of pathogen acquisition and transmission. RESULTS A total of 493 HW opportunities were observed, of which 434 involved MD, RN, and NSP. Two hundred and sixty-one low-risk (MD 35, RN 171, NSP 55) and 173 (MD 11, RN 124, NSP 38) high-risk interactions were observed. Overall HW rates were low (44%). Significant differences existed among HCW, with MDs being the least likely to wash (15% versus RN 50%, NSP 37%, p < 0.01). In adjusting for high-risk situations, MDs (odds ratio [OR] 5.58, 95% CI 2.49-12.54; NSP, OR 1.73, 95% CI 1.13-2.64; RN, OR 0.98, 95% CI 0.77-1.23) were significantly less likely to perform HW when compared to RNs. Nursing groups were significantly less likely to wash in low-risk versus high-risk situations (MD 9.2% versus 17.1%; RN 69.4% versus 39.6%; NSP 85% versus 23.3%), suggesting individual discrimination of the importance of HW. Although nurses were less likely to wash in high-risk situations compared to NSP, the overall number of opportunities was greater, suggesting that improvement in HW to the level of NSP could have a major impact on infection transmission. CONCLUSION Significant opportunities exist for quality improvement, novel educational strategies, and assessment of reasons why MDs and, to a lesser extent, RNs fail to follow simple HW practices.

Meeting standards of high-quality intensive care unit palliative care: Clinical performance and predictors

ObjectiveTo determine the optimal site and frequency for vancomycin-resistant enterococci (VRE) surveillance to minimize the number of days of VRE colonization before identification and subsequent isolation. Summary Background DataThe increasing prevalence of VRE and the limited therapeutic options for its treatment demand early identification of colonization to prevent transmission. MethodsThe authors conducted a 3-month prospective observational study in medical and surgical intensive care unit (ICU) patients with a stay of 3 days or more. Oropharyngeal and rectal swabs, tracheal and gastric aspirates, and urine specimens were cultured for VRE on admission to the ICU and twice weekly until discharge. ResultsOf 117 evaluable patients, 23 (20%) were colonized by VRE. Twelve patients (10%) had VRE infection. Of nine patients who developed infections after ICU admission, eight were colonized before infection. The rectum was the first site of colonization in 92% of patients, and positive rectal cultures preceded 89% of infections acquired in the ICU. This was supported by strain delineations using pulsed-field gel electrophoresis. Twice-weekly rectal surveillance alone identified 93% of the maximal estimated VRE-related patient-days; weekly or admission-only surveillance was less effective. As a test for future VRE infection, rectal surveillance culture twice weekly had a negative predictive value of 99%, a positive predictive value of 44%, and a relative risk for infection of 34. ConclusionsTwice-weekly rectal VRE surveillance of critically ill patients is an effective strategy for early identification of colonized patients at increased risk for VRE transmission, infection, and death.