scholarly journals 3. Stopping Hospital Infections with Environmental Services (SHINE): A Cluster-Randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-Resistant Organisms (MDROs) in the Intensive Care Unit (ICU)

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S2-S3
Author(s):  
Matthew J Ziegler ◽  
Hilary Babcock ◽  
Hilary Babcock ◽  
Sharon F Welbel ◽  
David K Warren ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Random Effect ◽  
Multidrug Resistant ◽  
Primary Study ◽  
Environmental Services ◽  
Relative Reduction ◽  
Intervention Period ◽  
Monitoring Methods ◽  
Intensive Monitoring ◽  
Cluster Randomized

Abstract Background MDROs frequently contaminate hospital environments. We performed a multicenter cluster-randomized, crossover trial of two methods for intensive monitoring of terminal cleaning effectiveness at reducing infection and colonization with MDROs within ICUs. Methods Six medical and surgical ICUs at three medical centers received both intensive monitoring interventions sequentially, in a randomized order. The intervention included surveying a minimum of 10 surfaces each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services (EVS) staff in real-time, with failing surfaces recleaned. The primary study outcome was the monthly rate of infection or colonization with MDROs, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MDR-GNB), assessed during a 12-month baseline comparison period and sequential 6-month intervention periods, separated by a 2-month washout. Outcomes during each intervention period were compared to the combined baseline period plus the alternative intervention period using mixed-effects Poisson regression, with study hospital as a random effect. Results The primary outcome rate varied by hospital and ICU (Figure 1). The ATP method was associated with a relative reduction in the incidence rate of infection or colonization with MDROs (incidence rate ratio (IRR) 0.887, 95% confidence-interval (CI) 0.811–0.969, P=0.008) (Table 1), infection with MDROs (IRR 0.924, 95% CI 0.855–0.998, P=0.04), and infection or colonization limited to multidrug-resistant MDR-GNB (IRR 0.856, 95% CI 0.825–0.887, P< 0.001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turn-around time was increased by a median of one minute with the ATP intervention and 4.5 minutes with the UV/F intervention compared to baseline. Conclusion Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a relative reduction of infection and colonization with MDROs with a negligible impact on TAT. Disclosures Hilary Babcock, MD, MPH, FIDSA, FSHEA (nothing to disclose), David K. Warren, MD, MPH, Homburg & Partner (consultant), Ebbing Lautenbach, MD, MPH, MSCE (nothing to disclose), Jennifer Han, MD, MSCE, GlaxoSmithKline (employee, shareholder).

scholarly journals Meta Salud Diabetes for cardiovascular disease prevention in Mexico: a cluster-randomized behavioural clinical trial

2021 ◽  
Author(s):  
Cecilia B Rosales ◽  
Catalina A Denman ◽  
Melanie L Bell ◽  
Elsa Cornejo ◽  
Maia Ingram ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Clinical Trial ◽  
Support Groups ◽  
Diabetes Distress ◽  
Primary Study ◽  
Positive Trend ◽  
Cvd Risk ◽  
Low Resource ◽  
Resource Setting ◽  
Cluster Randomized

Abstract Background Healthy lifestyle interventions offered at points of care, including support groups, may improve chronic disease management, especially in low-resource populations. We assessed the effectiveness of an educational intervention in type 2 diabetes (T2D) support groups to reduce cardiovascular disease (CVD) risk. Methods We recruited 518 participants to a parallel, two-arm, cluster-randomized, behavioural clinical trial across 22 clinics in Sonora, Mexico, between August 2016 and October 2018. We delivered a 13-week secondary prevention intervention, Meta Salud Diabetes (MSD), within the structure of a support group (GAM: Grupo de Ayuda Mutua) in government-run (community) Health Centres (Centros de Salud). The primary study outcomes were difference in Framingham CVD risk scores and hypertension between intervention (GAM+MSD) and control (GAM usual care) arms at 3 and 12 months. Results CVD risk was 3.17% age-points lower in the MSD arm versus control at 3 months [95% confidence interval (CI): −5.60, −0.75, P = 0.013); at 12 months the difference was 2.13% age-points (95% CI: −4.60, 0.34, P = 0.088). There was no evidence of a difference in hypertension rates between arms. Diabetes distress was also lower at 3 and 12 months in the MSD arm. Post-hoc analyses showed greater CVD risk reduction among men than women and among participants with HbA1c < 8. Conclusions MSD contributed to a positive trend in reducing CVD risk in a low-resource setting. This study introduced an evidence-based curriculum that provides T2D self-management strategies for those with controlled T2D (i.e. HbA1c < 8.0) and may improve quality of life.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults

2021 ◽  
pp. ASN.2020101511
Author(s):  
Rebecca Thorsness ◽  
Shailender Swaminathan ◽  
Yoojin Lee ◽  
Benjamin D. Sommers ◽  
Rajnish Mehrotra ◽  
...  
Keyword(s):  
United States ◽  
Incidence Rate ◽  
Kidney Failure ◽  
The United States ◽  
Early Years ◽  
Relative Reduction ◽  
Medicaid Expansion ◽  
Expansion Time ◽  
Incident Cases ◽  
Medicaid Expansions

BackgroundLow-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care.MethodsUsing a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19–64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion).ResultsThe unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, −3.89 to −0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, −5.43% to −0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (−0.56 cases per million per quarter; 95% CI, −2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period.ConclusionsThe ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Quality of life of children treated for unilateral hearing loss: a systematic review and meta-analysis

2021 ◽  
pp. archdischild-2020-320389
Author(s):  
Sarah Nicolas ◽  
Yohan Gallois ◽  
Marie-Noëlle Calmels ◽  
Olivier Deguine ◽  
Bernard Fraysse ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Systematic Review ◽  
Hearing Loss ◽  
Meta Analysis ◽  
Random Effect ◽  
Risk Of Bias ◽  
Primary Study ◽  
Unilateral Hearing Loss ◽  
Design Selection

ObjectiveTo evaluate the treatments’ consequences for unilateral hearing loss in children.DesignSystematic review and meta-analysis (CRD42018109417). The MEDLINE, CENTRAL, ISRCTN and ClinicalTrials databases were searched between September 2018 and May 2019. Articles were screened and data were collected independently by two authors following the Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. The risk of bias was evaluated using the Cochrane tool, the Newcastle-Ottawa Scale, the National Institute of Health, USA tool and considering the risk of confounding. In the studies with the lowest risk of bias, a meta-analysis was conducted.InterventionsValidated hearing rehabilitation devices.Patients6–15 years old children with moderate to profound unilateral hearing loss.Main outcome measuresThe primary study outcome was children’s quality of life. Academic performances were studied as an additional outcome.Results731 unique articles were identified from the primary search. Of these, 18 articles met the Population, Intervention, Control, Outcomes and Study design selection criteria. In the eight studies with the lowest risk of bias, two meta-analysis were conducted. There was not enough data on academic results to conduct a meta-analysis. In 73 children included in a fixed effect meta-analysis (two studies), no effect of treatment could be shown (g=−0.20, p=0.39). In 61 children included in a random-effect meta-analysis (six studies), a strong positive effect of hearing treatment on quality of life was demonstrated (g=1.32, p<0.05).ConclusionsThe treatment of unilateral hearing loss seems to improve children’s quality of life. Further research is needed to identify the most effective treatment and its corresponding indications.

Azithromycin distribution and childhood mortality in compliance-related subgroups in Niger: complier average causal effect and spillovers in a cluster-randomized, placebo-controlled trial

2021 ◽  
Author(s):  
Kieran S O’Brien ◽  
Ahmed M Arzika ◽  
Ramatou Maliki ◽  
Abdou Amza ◽  
Farouk Manzo ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Causal Effect ◽  
Controlled Trial ◽  
Effect Analysis ◽  
Intention To Treat ◽  
Average Causal Effect ◽  
Cluster Randomized ◽  
Complier Average Causal Effect

Abstract Background Biannual azithromycin distribution to children 1–59 months old reduced all-cause mortality by 18% [incidence rate ratio (IRR) 0.82, 95% confidence interval (CI): 0.74, 0.90] in an intention-to-treat analysis of a randomized controlled trial in Niger. Estimation of the effect in compliance-related subgroups can support decision making around implementation of this intervention in programmatic settings. Methods The cluster-randomized, placebo-controlled design of the original trial enabled unbiased estimation of the effect of azithromycin on mortality rates in two subgroups: (i) treated children (complier average causal effect analysis); and (ii) untreated children (spillover effect analysis), using negative binomial regression. Results In Niger, 594 eligible communities were randomized to biannual azithromycin or placebo distribution and were followed from December 2014 to August 2017, with a mean treatment coverage of 90% [standard deviation (SD) 10%] in both arms. Subgroup analyses included 2581 deaths among treated children and 245 deaths among untreated children. Among treated children, the incidence rate ratio comparing mortality in azithromycin communities to placebo communities was 0.80 (95% CI: 0.72, 0.88), with mortality rates (deaths per 1000 person-years at risk) of 16.6 in azithromycin communities and 20.9 in placebo communities. Among untreated children, the incidence rate ratio was 0.91 (95% CI: 0.69, 1.21), with rates of 33.6 in azithromycin communities and 34.4 in placebo communities. Conclusions As expected, this analysis suggested similar efficacy among treated children compared with the intention-to-treat analysis. Though the results were consistent with a small spillover benefit to untreated children, this trial was underpowered to detect spillovers.

The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities

2018 ◽  
Vol 39 (12) ◽  
pp. 1400-1405 ◽  
Author(s):  
Erika M. C. D’Agata ◽  
Curt C. Lindberg ◽  
Claire M. Lindberg ◽  
Gemma Downham ◽  
Brandi Esposito ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Interrupted Time Series ◽  
Multidrug Resistant ◽  
Prescribing Patterns ◽  
Antimicrobial Stewardship Program ◽  
Intervention Period ◽  
Positive Effects ◽  
Antimicrobial Prescribing ◽  
Stewardship Program ◽  
Dialysis Facilities

AbstractBackgroundAntimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%–35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed.ObjectiveTo quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.Study design and settingAn interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period.ResultsImplementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met.ConclusionsWithin 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.

scholarly journals Multimodal Surveillance of HAI in an Intensive Care Unit of a Large Teaching Hospital

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
G Migliara ◽  
C Di Paolo ◽  
D Barbato ◽  
V Baccolini ◽  
C Salerno ◽  
...  
Keyword(s):  
Intensive Care ◽  
Incidence Rate ◽  
Teaching Hospital ◽  
Surveillance System ◽  
Multidrug Resistant ◽  
Surveillance Systems ◽  
Bacterial Isolates ◽  
Environmental Isolates ◽  
Infectious Risk ◽  
Large Teaching Hospital

Abstract Background Healthcare associated Infections (HAIs) represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients in intensive care units (ICU). Surveillance systems are recommended to gather data in order to elaborate and evaluate intervention to reduce HAIs risk. Here we describe results of the multimodal surveillance system implemented in the ICU of a large teaching hospital in Rome from April 2016 to October 2018. Methods The surveillance system integrated four different approaches: i) active surveillance focused on inpatients; ii) environmental microbiological surveillance; iii) surveillance focused on isolated microorganisms; iv) behavioral surveillance of the healthcare personnel. The system included the molecular genotyping of bacterial isolates through the pulsed field gel electrophoresis (PFGE). Moreover, an intervention to improve personnel adherence to hand hygiene (HH) guidelines was conducted. Results Overall, 773 patients were included in the surveillance. The global incidence rate of the device related HAIs was 14.1 (95%CI: 12.2-16.3) per 1000 patient day. Monthly device related HAIs incidence rate showed a decreasing, from 26.9 per 1000 patient day in October 2016, to 4.9 in September 2018. The most common bacterial isolate was K. pneumoniae (20.7%), the 94.0% of which were multidrug-resistant. A total of 305 environmental bacterial isolates were retrieved and the most frequent was A. baumannii (27.2%), that was always multidrug-resistant. Genotyping showed a limited number of major PFGE patters in clinical and environmental isolates. Behavioral compliance to HH guidelines improved after the educational intervention. Conclusions The data showed an overall slight decrease over time of the adjusted risk HAIs rates. Through the integration of information gathered from the four approaches, the application of this model returns a precise and detailed view of the infectious risk and of the microbial ecology of the ICU. Key messages Multimodal surveillance systems are effective to monitor HAI incidence and to determine the infectious risk. Genotyping techniques allows to characterize and link the clinical and environmental isolates.

Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals

2008 ◽  
Vol 29 (11) ◽  
pp. 1035-1041 ◽  
Author(s):  
Philip C. Carling ◽  
Michael M. Parry ◽  
Mark E. Rupp ◽  
John L. Po ◽  
Brian Dick ◽  
...  
Keyword(s):  
Acute Care ◽  
Performance Feedback ◽  
Hospital Setting ◽  
Acute Care Hospitals ◽  
The United States ◽  
Multidrug Resistant ◽  
Environmental Services ◽  
Environmental Surfaces ◽  
Before And After ◽  
Quasi Experimental

Objective.The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices.Design.Prospective quasi-experimental, before-after, study.Setting.Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds.Methods.We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions.Results.Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4-51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel (P = .02). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it was determined that 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P < .001). Improvement was unrelated to any demographic, fiscal, or staffing parameter but was related to the degree to which cleaning was suboptimal at baseline (P < .001).Conclusions.Significant improvements in disinfection cleaning can be achieved in most hospitals, without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.

Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi

2015 ◽  
Vol 12 (4) ◽  
pp. 248-256
Author(s):  
Manoj Kumar ◽  
Sanjay Jain ◽  
Neetu Shree ◽  
Mukesh Sharma
Keyword(s):  
Incidence Rate ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Multidrug Resistant ◽  
Care Hospital ◽  
Multidrug Resistant Organisms

scholarly journals Early and comprehensive care bundle in elderly for acute heart failure in the emergency department: study protocol of The ELISABETH stepped wedge cluster randomized trial

2018 ◽  
Author(s):  
Yonathan Freund ◽  
Judith Gorlick ◽  
Marine Cachanado ◽  
Sarah Salhi ◽  
Vanessa Lemaitre ◽  
...  
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Elderly Patients ◽  
Acute Heart Failure ◽  
Control Period ◽  
Care Bundle ◽  
Stepped Wedge ◽  
Precipitating Factors ◽  
Intervention Period ◽  
Cluster Randomized

Abstract Background: Acute heart failure (AHF) is one of the most common diagnoses for elderly patients in the emergency department (ED), with an admission rate higher than 80% and 1-month mortality around 10%. The European guidelines for the management of AHF are based on moderate levels of evidence, due to the lack of randomized controlled trials and the scarce evidence of any clinical added value of a specific treatment to improve outcomes. Recent reports suggest that the very early administration of full recommended therapy may decrease mortality. However, several studies highlighted that elderly patients often received suboptimal treatment. Our hypothesis is that an early care bundle that comprises early and comprehensive management of symptoms, along with prompt detection and treatment of precipitating factors should improve AHF outcome in elderly patients. Method/design: ELISABETH is a stepped-wedge, controlled cluster randomized, clinical trial in 15 emergency departments in France recruiting all patients aged 75 years and older with a diagnosis of AHF. The tested intervention is a care bundle with a checklist that mandates detection and early treatment of AHF precipitating factors, early and intensive treatment of congestion with intravenous nitrates boluses, and application of other recommended treatment (low dose diuretics, non-invasive ventilation when indicated, and preventive low molecular weight heparin). Each centre are randomized to the order in which they will switch from “control period” to “intervention period”. All centers begin the trials with the control period for two weeks, then after each two-weeks step a new centre will be in the intervention period. At the end of the trial, all clusters will receive the intervention regimen. The primary outcome is the number of days alive and out of the hospital at 30 days. Discussion: If our hypothesis is confirmed, this trial will strengthen the level of evidence of AHF guidelines and stress the importance of the associated early and comprehensive treatment of precipitating factors. This trial could be the first to report a reduction in short term morbidity and mortality in elderly AHF patients. Registration: NCT03683212, prospectively registered on September 25th 2018 Keywords: Elderly, acute heart failure, emergency department

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