Aseptic efficacy of prefilled syringes in a polluted environment

INTRODUCTION: To evaluate the aseptic efficacy of prefilled syringes compared with ampules when used in a polluted environment similar to that at a disaster site. METHODS: The researchers tested epinephrine, 0.1%, atropine sulfate, 0.05%, and lidocaine hydrochloride solutions, 2% (Group A) as well as lidocaine hydrochloride, 10%, sodium bicarbonate, 8.4%, and glucose solutions, 50% (Group B), that frequently are used for intravenous injection and intravenous infusion respectively in Disaster Medicine. Each of these solutions in 10 prefilled syringes (PFSs) and 10 ampules was placed in a box of contaminated soil along with needles and empty syringes for ampules. In the box, each was taken out of its package, all syringes were connected with a needle, and empty syringes were filled with a solution. After this procedure, all syringes were taken out of the box to check their contents for bacterial contamination. RESULTS: No bacterium was observed in any of the 10 PFS samples of Group A and B solutions. In contrast, out of 10 ampule samples, six of the 10 samples containing epinephrine, nine of the 10 containing atropine sulfate, all 10 samples containing lidocaine hydrochloride, 2%, and all of the ampule samples containing Group B solutions tested positive for bacteria. A statistically significant difference was observed between the PFS and ampule samples in all six solutions. CONCLUSION: Results indicate that, in environments with airborne contaminants, the use of prefilled syringes may be useful for preventing bacterial contamination of the medicine inside.     

The use of multidose vials and fingerstick blood sampling devices in Korean emergency departments and intensive care units

This study was performed to compare compliance with standard precautions for the use of multidose vials (MDVs) and fingerstick devices in emergency departments (EDs) and intensive care units (ICUs). Between December 2007 and February 2008, 389 nurses from the EDs or ICUs of six university-affiliated hospitals in Korea were asked to complete the questionnaire. A total of 338 (86.9%) nurses completed the survey, corresponding to 159 of 184 ED and 179 of 205 ICU nurses. A comparison of MDV use in EDs and ICUs indicated a significant difference only in disinfection of the rubber septum of heparin vials; 88.1% of ED nurses and 96.6% of ICU nurses stated that they always disinfected the rubber septum of heparin vials whenever drawing medication (P = 0.003). The use of separate fingerstick devices for each patient (71.7% vs. 54.5%) and disinfection of these devices after each use (36.5% vs. 26.0%) were more common in ED nurses. The rate of good hand hygiene was lower in ED nurses, both before (43.7% vs. 74.3%) and after (64.6% vs. 91.6%) the use of fingerstick devices (P < 0.001 for both). There is a need to improve compliance with standard precautions, especially hand hygiene, in EDs.     

Titrated intravenous opioids from the same syringe: an infection risk?

OBJECTIVE: (1) To compare the rate of contamination of syringes prepared under laminar flow conditions in pharmacy with those prepared by nurses in the emergency department; (2) to determine whether the time elapsed since preparation or number of doses given affected the contamination rate; (3) to determine whether any adverse effects resulted from bacterially contaminated drugs. METHODS: Prospective, blinded trial exploring the effect of method of preparation, time since preparation, and number of doses given on contamination rates and infective adverse events associated with bacterially contaminated specimens. RESULTS: The rate of bacterial contamination was 12% (95% confidence interval 6% to 18%). There was no difference in contamination rate in respect of method of preparation, number of doses given, or time since preparation. No infective complications were identified. CONCLUSIONS: Abandonment of titrated intravenous opioids is not justified by the results. However, there is concern about the use of this technique of pain control for immunocompromised patients and those with prosthetic heart valves.     

Occupational Exposure to Blood and Body Fluids among Health-Care Workers in Serbia

Objectives

The aim of this study was to examine the epidemiology of occupational accidents and self-reported attitude of health-care workers (HCWs) in Serbia.

Subjects and Methods

A cross-sectional study was conducted among HCWs in selected departments of five tertiary care hospitals and in one secondary care hospital in February 2012. A previously developed self-administered questionnaire was provided to HCWs who had direct daily contact with patients. χ² test and Student''s t test were used for statistical analysis of the data.

Results

Of the 1,441 potential participants, 983 (68.2%) completed the questionnaire: 655 (66.7%) were nurses/medical technicians, 243 (24.7%) were physicians and 85 (8.6%) were other personnel. Of the 983 participants, 291 (29.6%) HCWs had had at least one accident during the previous year and 106 (40.2%) of them reported it to the responsible person. The highest prevalence (68.6%) of accidents was among nurses/technicians (p = 0.001). Accidents occurred more often in large clinical centers (81.1%; p < 0.001) and in the clinical ward, intensive care unit and operating theater (p = 0.003) than in other departments. Seventy-six (13.1%) nurses/medical technicians had an accident during needle recapping (p < 0.001). Of all the HCWs, 550 (55.9%) were fully vaccinated, including significantly more doctors (154, 63.4%) than participants from other job categories (p < 0.001).

Conclusion

There was a relatively high rate of accidents among HCWs in our hospitals, most commonly amongst nurses and staff working in clinical wards, intensive care units and operating theaters. The most common types of accidents were needlestick injuries and accidents due to improper handling of contaminated sharp devices or occuring while cleaning instruments or by coming into contact with blood through damaged skin or through the conjunctiva/mucous membranes.Key Words: Needlestick injuries, Health-care workers, Body fluids, Occupational exposure, Underreporting     

Calfactant sterility in multiple doses from single-use vials

BACKGROUND: Calfactant is an exogenous surfactant used to treat and prevent respiratory distress syndrome in the newborn infant. It is available in single-use preservative-free vials, but contains enough volume to provide multiple doses to small infants. OBJECTIVE: To measure the preservation of calfactant sterility at 12- and 24-hour intervals following initial violation of vial contents and to extrapolate cost savings associated with product conservation. METHODS: A prospective sterility study was performed using calfactant suspension obtained from vials prescribed for infants who had received their dose in the delivery room or the neonatal intensive care unit (NICU). After initial vial entry, test vials were stored in the NICU pharmacy satellite under refrigeration (temperature range 2.2-7.2 degrees C). Re-entry of test vials and sample removal was performed 12 and 24 hours after initial entry with an 18- or 20-gauge needle. All samples were removed by a neonatal respiratory therapist and placed into 3-mL latex-free, Leur-lok plastic syringes and examined by 3 culture media: MacConkey agar, blood agar, and thioglycollate broth. RESULTS: A total of 89 surfactant samples from 45 vials were cultured; 45 at a mean time of 13.36 hours (range 11-41) and 44 at a mean time of 25.8 hours (range 22-60) after initial vial entry. These samples represented the technique of multiple respiratory therapists. All samples were negative for bacterial growth at 24 and 48 hours (beta = 0.9). CONCLUSIONS: Results from this short-term sterility study represent an initial step in the evaluation of multiple doses of surfactant from a single-use vial. The data suggest that 1-2 re-entries into a vial of calfactant, within 24 hours after the initial breach, can be a safe and economical method of providing more than a single dose of surfactant to infants weighing <1 kg. We encourage each institution to reproduce these findings before applying this concept to their patients.     

Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

OBJECTIVE: To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation. DESIGN: Prospective cohort study. SETTING: The adult medical and coronary intensive care units of a tertiary care, university-based medical center. PATIENTS: Thirty-eight patients admitted to the intensive care units. MEASUREMENTS AND MAIN RESULTS: We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 +/- 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p <.001). The two nurses' and intensivist's sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively. CONCLUSIONS: The CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.     

Role expansion in intensive care: survey of nurses' views.

The study described here is an investigation of intensive care unit (ICU) nurses' perceptions of how their role is expanding. Six specific skills were selected for consideration. A questionnaire was distributed to nurses working in ICUs in three different hospitals. Questions were based around issues such as education and assessment policies, the transfer of work between nurses and other groups of workers and the effects of ICU nurses accumulating additional skills. Completed questionnaires were received from 33 participants (68.75% response rate). The results showed that most of the nurses were carrying out the skills suggested. The training provided to underpin skill development was a balance of teaching and supervision. However, assessment practices varied. The majority of nurses felt that the existing training programmes were adequate. Data revealed that a range of duties could be released from their role and taken over by other workers, such as technicians and health care assistants. Participants suggested that the crucial element of the nursing role was the incorporation of many activities into the provision of continuous one-to-one total patient care. This was the aspect of work that was reported as being the most satisfying. It was perceived that patients benefited from nurses extending their role in the areas discussed.     

Increasing the executive rate of standard central venous catheter care

The purpose of this project was to increase the executive rate of standard nursing care of central venous catheters. The average rating of the procedure used by our nurses in caring for central venous catheters in our unit was 58.5%. Reasons why our rating failed to reach 100% included: (1) there was no clear, detailed explanation of the aseptic technique of standard nursing care of central venous catheters; (2) nurses were too busy to complete the detailed steps necessary to the procedure; (3) nurses were unfamiliar with standard nursing care of central venous catheters. Observation, analysis, literature review and discussions with the Infection Control Team were the measures we adopted to improve the standard nursing care of central venous catheters in our unit. Through the application of what we learned we increased our average rating of standard nursing care of central venous catheters to 100%.     

End-of-life care in the pediatric intensive care unit: attitudes and practices of pediatric critical care physicians and nurses

OBJECTIVE: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN: Cross-sectional survey. SETTING: A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.     

A systematic approach to improving medication safety in a pediatric intensive care unit

Safety and quality improvement are major issues in children's hospitals. Improving pediatric medication safety often takes on a larger role in pediatric units than in adult units due to the larger size differences and dose ranges found in a pediatric intensive care unit. This article reviews the literature and our own experience at the CS Mott Children's Hospital, University of Michigan, to improve medication safety. The issues identified include (1) an effective pediatric medication safety governance structure within a larger hospital, (2) practice standardization strategies for physicians, nurses, and pharmacists, (3) use of pharmacy technicians as unit medication managers, which reduces medication costs and decreases nursing time spent hunting for medications, and (4) methods to improve the safety culture in a pediatric intensive care unit.     

Incidence and nature of epidemic nosocomial infections.

Nosocomial bloodstream infections continue to be a major cause of morbidity and mortality. Approximately 8% of all nosocomial infections reported in the United States are primarily bloodstream infections. These infections prolong hospital length of stay, increase mortality, and raise the overall cost of healthcare. A contaminated infusate administered through a central venous catheter is one of the commonly identified causes of nosocomial bacteremia. In most cases, contamination of the infusate occurs extrinsically during manipulation of the fluid before its administration to the patient. Failure to use aseptic technique and poor hand washing often are the cause. In addition to improved staff education, surveillance for nosocomial bloodstream infections continues to be the cornerstone of prevention.     

Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy.

BACKGROUND: Nurse-to-patient ratios in the intensive care unit are associated with postoperative mortality, morbidity, and costs after some high-risk surgery. OBJECTIVE: To determine if having 1 nurse caring for 1 or 2 patients ("more nurses") versus 1 nurse caring for 3 or more patients ("fewer nurses") in the intensive care unit at night is associated with differences in clinical and economic outcomes after hepatectomy. METHODS: Statewide observational cohort study of 569 adults who had hepatic resection, 1994 to 1998. Hospital discharge data were linked to a prospective survey of organizational characteristics in the intensive care unit. Multivariate analysis was used to determine the association of nighttime nurse-to-patient ratios with in-hospital mortality, length of stay, hospital costs, and specific postoperative complications. RESULTS: A total of 240 patients at 25 hospitals had fewer nurses; 316 patients in 8 hospitals had more nurses. No significant association between nighttime nurse-to-patient ratios and in-hospital mortality was detected. The overall complication rate was 28%. By univariate analysis, patients with fewer nurses had increased risks for pulmonary failure (5.8% vs 1.6%, relative risk, 3.6; 95% CI, 1.3-10.1; P=.006) and reintubation (10.8% vs 1.9%, relative risk, 5.7; 95% CI, 2.4-13.7; P<.001). By multivariate analysis, patients with fewer nurses had increased risk for reintubation (odds ratio, 2.9; 95% CI, 1.0-8.1; P=.04) and a 14% increase (95% CI, 3%-23%; P=.007) or an additional $1248 (95% CI, $384-$2112; P = .005) in total hospital costs. CONCLUSIONS: Fewer nurses at night is associated with increased risk for specific postoperative pulmonary complications and with increased resource use in patients undergoing hepatectomy.     

对设置专科护士的调查与思考

目的调查医护人员对设置专科护士有关问题的看法，对专科护理人才的培养提出建议与设想。方法采用自行设计的调查问卷，分层抽取8所医院的242名护士和79名医生作为调查对象。结果（1）护士最初学历、目前学历、目标学历分布呈向高学历递增的态势；（2）护士认为合适的群体学历比例为硕士5．25％、本科15．38％、大专45．82％、大专以下33．55％；（3）医生、护士对设置专科护士的认同性高，一致认为需要设置专科护士的科室为ICU、急救科、CCU、手术室和产科。结论（1）培养和设置专科护士适应时代发展步伐，但尚需在护士整体学历上有进一步提升；（2）建议在ICU、急救科、CCU、手术室和产科重点培养和率先设置专科护士；（3）应立足于本地区的专科资源，整合其优势资源，形成专科护理教育的培训基地。     

Limitation and withdrawal of intensive therapy at the end of life: practices in intensive care units in Mumbai, India

OBJECTIVE: To describe the practices in intensive care units in Mumbai hospitals regarding limitation and withdrawal of care at the end of life. DESIGN: Review of prospectively collected data. SETTINGS: Intensive care units of four major hospitals (two private tertiary referral general hospitals, one mixed public and private cancer referral hospital, and one large public hospital). PATIENTS: Hospital and intensive care unit patients who died during the study period. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We measured the percentage of hospital deaths occurring inside and outside intensive care units and the incidence of withholding intubation, withholding other therapy, and withdrawing therapy for deaths in the intensive care unit. The proportion of hospital deaths that occurred in an intensive care unit was 14% in the cancer hospital, 23% in the public hospital, and 58-73% in the two private hospitals (chi-square test for trends, p < .0001). Of the 143 deaths that occurred in intensive care unit, limitation of care occurred in 49 patients. Twenty-five percent of these patients were not intubated terminally, 67% were initially intubated and ventilated but failed to recover and subsequently had no further escalation of therapy, and 8% had withdrawal of therapy. Therapy was limited in 19% of deaths in the public hospital intensive care unit (odds ratio, 0.44; 95% confidence interval, 0.2-0.97) vs. 40%, 41%, and 50% of deaths in the other three intensive care units. CONCLUSIONS: Therapy is limited in a significant proportion of intensive care unit patients. Significant differences in the practice of limitation of therapy exist between public and private hospitals. Lack of access to a limited number of intensive care unit beds, especially in the public hospital, may constitute implicit limitation of care.     

An outbreak of acinetobacter infection associated with the use of a ventilator spirometer.

Although respiratory therapy equipment is a well-known source of nosocomial infection, ventilator spirometers have not been previously implicated. We report 17 Acinetobacter calcoaceticus variety anitratus infections traced to contaminated spirometers. Isolates from infected patients were recovered from urine, sputum, wounds, and blood. A review of attack rates for Acinetobacter was prompted by a dramatic increase in blood culture isolates. Prospective surveillance of intensive care environment, personnel, and patients established that Bennett MA-1 spirometers constituted the major reservoir of infecting organisms. Despite daily sterilization, 30% of spirometers in use were found to be contaminated. The hands of 12% of intensive care nurses and 10% of respiratory therapists cultured were found to be colonized. In addition to the infected patients, 28 other patients on spirometer-equipped ventilators were judged to be colonized by Acinetobacter following examination of sputa and/or mouthwashings. Following discontinuation of spirometer use and following increased emphasis on proper handwashing, the incidence of Acinetobacter infections dropped dramatically. Antibiosis in the intensive care environment and a deterioration in aseptic awareness serve to make Acinetobacter an environmental opportunist of increasing importance.     

Handwashing practice and policy variability when caring for central venous catheters in paediatric intensive care.

It has been estimated that there may be as many as 150,000 healthcare associated infections (HCAI) in Australia each year, contributing to 7,000 deaths, many of which could be prevented through the implementation of appropriate infection control practices. Contact with contaminated hands is a primary source of HCAI. Intensive care staff have been identified as one of the least adherent groups of health care professionals with handwashing; they are less likely to practise hand antisepsis before invasive procedures than staff working in other patient care specialties. The study examined the self-reported clean and aseptic handwashing practices of nurses working in paediatric intensive care units (PICUs) across Australia and New Zealand, the patterns in variation between nurses' reported handwashing practices and the local policies, and patterns in the duration of procedural handwashing for specific procedures. A survey was undertaken in 2001 in which participating tertiary paediatric hospitals provided copies of their infection control policies pertaining to central venous catheter (CVC) management; five nurses on each unit were asked to provide information in relation to their handwashing practices. Seven hospitals agreed to participate and 30 nurses completed the survey. The study found an enormous level of variation among and between nurses' reported practices and local policies. This variation extended across all aspects of handwashing practices - duration and extent of handwash, type of solution and drying method used. The rigour of handwashing varied according to the procedure undertaken, with some evidence that nurses made their own risk assessments based on the proximity of the procedure to the patient. In conclusion, this study's findings substantiate the need for standardisation of practice in line with the current Centers for Disease Control and Prevention Guidelines, including the introduction of alcohol handrub.     

Medicare intensive care unit use: analysis of incidence, cost, and payment

OBJECTIVE: To determine the incidence, cost, and payment for intensive care unit services among Medicare beneficiaries. DESIGN: Retrospective observational database cohort study. SETTING: All nonfederal hospitals with intensive care unit beds (n = 5003) paid through the inpatient prospective payment system (IPPS). PATIENTS: We used all fiscal year 2000 Medicare IPPS hospitalizations with consistent payment information (n = 10,657,587). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined the distribution of cost and payments overall, by hospital type, and by diagnosis related group. Intensive care was used in 2,353,208 cases (21.1%). The overall incidence was 59.8 cases per thousand beneficiaries in the aged (65+) population, increasing with age from 36.2 (65-69) to 91.6 (85+). Intensive care unit patients cost nearly three times floor patients (4,135 dollars vs. 5,571 dollars), with two thirds of costs associated with the intensive care unit portion of the stay, 2,278 dollars per intensive care unit day. However, intensive care unit cases were paid at a rate only twice floor cases (11,704 dollars vs. 5,835 dollars). Only 83% of costs were paid for intensive care unit patients, compared with 105% for floor patients, generating a 5.8 billion dollars loss to hospitals when intensive care unit care is required. There was a linear association between the percent intensive care unit in a diagnosis related group and the percent paid, with payment >90% of cost only in diagnosis related groups with >/=60% intensive care unit cases. We found that teaching hospitals were better paid than nonteaching hospitals (87% vs. 78% of costs, respectively), but this was only due to indirect medical education payments. CONCLUSIONS: Intensive care is common, expensive, and poorly paid in the Medicare population. Few diagnosis related groups have a large enough intensive care unit population to ensure adequate payment. Additional diagnosis related groups for conditions common to the intensive care unit would improve payment and enable incentives for efficiency.     

The magnet process and the perceived work environment of nurses

BACKGROUND: Several studies have described the work environment of nurses from magnet and nonmagnet hospitals, but there have been no studies of nurses from hospitals in the magnet application process. OBJECTIVES: To compare the differences between characteristics of hospitals and nurses from three hospital types: magnet hospitals, hospitals in the process of applying for magnet certification, and nonmagnet hospitals, and how nurses from these hospitals perceive their work environment. METHODS: In a national, cross-sectional survey of critical care nurses, the Perceived Nursing Work Environment (PNWE) instrument was administered to measure nurses' perceptions of their work environment. RESULTS: Data were available from 2,092 nurse surveys. Over a third of the respondents were from in-process hospitals and almost half were from nonmagnet hospitals. The majority of nurses were female and from large hospitals in the Atlantic region. The mean age of nurses was 39.5 years and the mean years of work experience in the intensive care unit (ICU) was 10.2 years. Higher nurse scores were significantly associated with magnet certification on one subscale of the PNWE, nursing competence. DISCUSSION: Nurses from magnet hospitals had a positive perception of nursing competence in their work environment. Further research is necessary to examine the nurse work environment and to determine if the characteristics of magnet hospitals have changed.