Bacterial contamination of cystic fibrosis clinics

BackgroundRespiratory pathogens from CF patients can contaminate inpatient settings, which may be associated with increased risk of patient-to-patient transmission. Few data are available that assess the rate of bacterial contamination of outpatient settings. We determined the frequency of contamination of CF clinics and the effectiveness of alcohol-based disinfectants in reducing hand carriage of bacterial pathogens.MethodsWe conducted a point prevalence survey and before–after trial in outpatient clinics at 7 CF centers. The study examined CF patients with positive respiratory cultures for Pseudomonas, Staphylococcus, Stenotrophomonas or Burkholderia species. Hand carriage and environmental contamination with respiratory pathogens were assessed during clinic visits (Part I) and the effectiveness of hand hygiene performed by CF patients (Part II) was determined using molecular typing of recovered isolates.ResultsIn Part I (n = 97), the contamination rate was 13.6%. Pseudomonas and S. aureus, including methicillin-resistant strains, were cultured from patients' hands (7%), the exam room air (8%), and less commonly, environmental surfaces (1%). In Part II (n = 100), the hand carriage rate of pathogens was 13.5% and 4 participants without initial detection of pathogens had hand contamination when recultured at the end of the clinic visit.ConclusionsRespiratory pathogens from CF patients can contaminate their hands and the clinic environment, but the actual risk of patient-to-patient transmission in the outpatient setting remains difficult to quantify. These findings support several recommendations CF infection control recommendations including hand hygiene for staff and patients, contact precautions for certain pathogens, and disinfecting equipment and surfaces touched by patients and staff.     

The Contribution of a Bacterially Isolated Environment to the Prevention of Infection in Seriously Burned Patients

A new system of patient protection from bacterial crossinfection called the Bacteria Controlled Nursing Unit (BCNU) is described, based on strict environmental control of a 6 x 10 foot area surrounding the patient's bed rather than the entire patient room or isolation ward, plus the ability to deliver all medical care without entering the protective environment and maintaining all monitoring, life support, and i.v. equipment outside the controlled environment. The clinical effectiveness of this system in the treatment of burn patients has been studied and compared with the effectiveness of single room isolation on a burn isolation ward and conventional isolation techniques on an open burn ward. The studies show that the BCNU is significantly more effective in preventing bacterial cross-contamination than conventional precautions (3.8% vs. 13.1%, P < 0.001; and 8% vs. 22.8%, P < 0.001) over a two and four week period. The studies also indicate that there was a significant increase in the probability of infection occurring following cross-contamination than occurring after auto-contamination (65% vs. 39%, P < 0.005), emphasizing the importance of preventing cross-contamination in reducing the overall infection rate in seriously burned patients. Clinical evaluation of the unit proved it to be compatible with intensive nursing and medical care without increasing the nurse to patient ratio. The unit provided sufficient control of bacterial cross-infection to allow reduction in mortality and improvement in the effectiveness of burn care through routine prompt excision of burn eschar and immediate wound closure to be carried out in severe and massively burned patients without a limiting threat of bacterial burn wound sepsis.     

Outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery: a retrospective review of perioperative setting and outcome.

STUDY OBJECTIVE: To report the rapid shift from inpatient to outpatient surgery that occurred after opening an outpatient preoperative evaluation clinic and the perioperative complications and mortality rates before and after this intervention. DESIGN: Monthly variations of total volume of procedures and percentages of outpatient procedures were analyzed retrospectively using control charts over two consecutive 10-month periods before and after the intervention. For each type of procedure (inpatient vs. outpatient), the perioperative complications and 30-day mortality rates were compared between periods. SETTING: The Veterans Affairs Palo Alto Health Care System, Palo Alto, California. PATIENTS: Patients who underwent 3,159 inpatient or outpatient procedures in the main operating room suite during the control period were compared with patients who underwent 3,190 procedures in the same operating room suite during the intervention period. INTERVENTION: The establishment of an outpatient preoperative evaluation clinic. MEASUREMENTS AND MAIN RESULTS: For each period, the total monthly surgical volume (inpatient and outpatient), perioperative complications, deaths within 30 days of surgery, and the number of procedures performed on patients classified as ASA physical status III, IV, or V were analyzed. The monthly total number of procedures was stable over both periods, but the monthly percentage of outpatient procedures departed from its baseline immediately after establishing the clinic (control period: 24.7%; study period: 45.4%; p < 0.0001). Finally, the perioperative complication rate did not change for outpatient procedures but increased for inpatient procedures (control period: 2.31%; study period: 3.50%; p < 0.05). The 30-day mortality rate remained unchanged for inpatient and outpatient procedures. CONCLUSIONS: Establishing an outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery at a government funded hospital without a concomitant increase in perioperative morbidity or mortality.     

Trauma center downstream revenue: the impact of incremental patients within a health system

BACKGROUND: The purpose of this study is to assess the downstream clinical and financial impact of a trauma, burn, and emergency surgery service at an academic Level I trauma center. METHODS: All patients admitted to the trauma, burn, and emergency surgery service from fiscal years 2002 to 2004 were identified. Clinical and financial data including inpatient and outpatient activity were analyzed for 365 days (downstream) after initial service admission. Data were divided into total service, trauma and burn, inpatient, outpatient, hospital, and professional revenue. RESULTS: In all, 3,679 patients were admitted during the study period with total initial revenue approaching $103 million. Of these, 1,566 patients were subsequently admitted for downstream inpatient activity, resulting in almost $26 million in subsequent inpatient revenue. The initial patient admissions resulted in over 17,000 clinic visits during the course of the 3 study years. Professional revenue resulted in over $14 million for the initial admission and $6.1 million in downstream revenue during the study period. CONCLUSIONS: Trauma, burn, and emergency surgical services result in both substantial initial and downstream revenue for the hospital (inpatient and outpatient) and professional components. Services committed to caring for the injured and emergent patients substantially contribute to the institutional financial strength.     

Bacterial contamination in the environment of hospitalised children with cystic fibrosis

Pathogenic bacterial colonisation in Cystic Fibrosis patients is associated with a poor prognosis; thus, protective measures need to be taken to prevent their transmission. We studied the extent of contamination in the environment of hospitalised children with cystic fibrosis (CF) associated with specific activities.We assessed the levels of bacterial contamination in 432 air and surface samples collected from various locations in our CF centre over a three-month period: the bedrooms, corridor, communal showers, school, leisure centre and the respiratory functional explorations (RFE) unit. Staphylococcus aureus and Pseudomonas aeruginosa strains found in bedrooms and the RFE were compared with those found in patient expectorations using pulsed field gel electrophoresis.In all sampling locations, there were high levels of airborne contamination just after the presence of patients or nursing staff. In the bedrooms, the amount of S. aureus or P. aeruginosa in the air, at wake-up and after physiotherapy, were significantly higher than that after the bedroom had been cleaned. For P. aeruginosa, 33% of isolates were multiresistant to antibiotics; 50% of the colonised patients had the same P. aeruginosa strain in their sputum as in air taken from their bedroom. P. aeruginosa was detected in 23% of samples taken from the surfaces in the showers after patient washing. Very low levels of pathogenic bacteria were found in samples from the other locations.Overall, activities with the highest risk of contamination in the CF ward are physiotherapy and washing in the communal shower room. We therefore recommend to open windows after physiotherapy and to implement a strong decontamination after showers.     

Reduced hospitalisation of burns patients following a multi-media campaign that increased adequacy of first aid treatment

CONTEXT: Concern engendered by a previous study that showed inadequate first aid for burn injuries was prevalent in the community led to a novel multi-media public health campaign ensued to address the issue. OBJECTIVE: To determine whether this public health campaign influenced behaviour by altering first aid treatment for burn injuries (BFAT). DESIGN, SETTING AND POPULATION: Prospective intervention study. Consecutive patients with acute burn injuries over two 4-month intervals, presenting to a regional burn service, Auckland, New Zealand. This research was ethically approved by the Local Research Ethics Committee. MAIN OUTCOME MEASURES: Demographics, burn size, adequacy of burn first aid, outpatient/inpatient wound care and operative intervention requirement. RESULTS: Adequacy of BFAT improved following the campaign (59% versus 40%, P=0.004). Fewer inpatient admissions (64.4% versus 35.8%, P<0.001) and surgical procedures (25.6% versus 11.4%, P<0.001) were undertaken following the campaign with a corresponding increase in outpatient care. Greatest decreases were observed in Maori and Pacific Islanders, and in children <10 years old. CONCLUSIONS: Adequacy of BFAT together with a reduction in the numbers of patients requiring inpatient surgical care was improved by a multi-media public awareness campaign.     

Foot and ankle injuries during the Athens 2004 Olympic Games

Background

The purpose of this study was to assess the level of air contamination with bacteria after surgical hydrodebridement and to determine the effectiveness of hydro surgery on bacterial reduction of a simulated infected wound.

Methods

Four porcine samples were scored then infected with a broth culture containing a variety of organisms and incubated at 37°C for 24 hours. The infected samples were then debrided with the hydro surgery tool (Versajet, Smith and Nephew, Largo, Florida, USA). Samples were taken for microbiology, histology and scanning electron microscopy pre-infection, post infection and post debridement. Air bacterial contamination was evaluated before, during and after debridement by using active and passive methods; for active sampling the SAS-Super 90 air sampler was used, for passive sampling settle plates were located at set distances around the clinic room.

Results

There was no statistically significant reduction in bacterial contamination of the porcine samples post hydrodebridement. Analysis of the passive sampling showed a significant (p < 0.001) increase in microbial counts post hydrodebridement. Levels ranging from 950 colony forming units per meter cubed (CFUs/m³) to 16780 CFUs/m³ were observed with active sampling of the air whilst using hydro surgery equipment compared with a basal count of 582 CFUs/m³. During removal of the wound dressing, a significant increase was observed relative to basal counts (p < 0.05). Microbial load of the air samples was still significantly raised 1 hour post-therapy.

Conclusion

The results suggest a significant increase in bacterial air contamination both by active sampling and passive sampling. We believe that action might be taken to mitigate fallout in the settings in which this technique is used.     

Ketamine anesthesia for tangenital excision of burn eschar: a burn unit procedure

The burn eschar is the major source of infection in the severely burned patient, and it hampers healing and prevents skin grafting. Tangenital excision has been shown to be safe for rapid removal of the eschar. For the last 14 months we have used this method beginning about 7 days postinjury. Our burn unit is composed of a four-bed, horizontal, laminar airflow isolation system, and transfer out of the sterile environment to the operating room would expose the patient to airborne contamination. Intramuscular ketamine anesthesia was used to allow major debridement to be carried out in the unit itself. Forty-five patients aged 18 months to 71 years have undergone 150 excisions in the burn unit under anesthesia with no complications. The burns ranged from 20 to 75% of body surface (mean, 40%). Because ketamine is a cardiorespiratory stimulant, ventilation and vital signs were well maintained. Psychological side effects of ketamine were minimal, particularly in the younger age group.     

Outpatient burn data: An untapped resource

Introduction

The National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared.

Methods

Outpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients’ and outpatients’ data parameters in the TRACS v5.0 database was also recorded.

Results

Data were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26 ± 19 years vs. 32 ± 22 years, p = 0.01) with a smaller burn size (2.5 ± 7% vs. 6.8 ± 12%, p < 0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p < 0.001).Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues.Injury was more likely to be caused by flame in inpatients (p < 0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p = 0.079). Outpatients were more likely to be injured with a contact burn (p < 0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p = 0.0497), but less likely to be related to recreational activity (p = 0.006) or arson/abuse/assault (p = 0.0158). An experienced TRACSv5.0 user required 11 ± 0.6 min to enter an inpatient record and 6 ± 0.6 min to enter an outpatient record in the system (p = 0.002).

Conclusions

Inpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.     

Do burn patients need burn specific multidisciplinary outpatient aftercare: research results

In a cross-sectional study of patients 12-24 months after a burn injury, the need for a multidisciplinary burn specific outpatient clinic was examined in relation to aftercare consumption, physical and psychological problems. Four hundred and twenty nine patients were assessed by means of three self-report questionnaires: IES, SCL(PTSD-SL) and BSHS-SV-S. Results indicated that the current aftercare providers are almost exclusively medical doctors and that a quarter of the patients are dissatisfied with received aftercare. However, dissatisfaction about current aftercare was not the only criterion to determine whether patients wanted burn-specific aftercare. The severity of psychological and physical problems predicted interest in a multi-disciplinary outpatient clinic. Self-reported psychological and physical problems were found to be related to one another. Univariate logistic regression outcomes suggested that patients with serious psychological and physical problems are more likely to express interest in a burn-specific outpatient clinic, but that, in a multivariate regression analysis, physical problems and psychological problems measured on the SCL(PTSD-SLEEP) do not contribute to the prediction of the interest in a burn-specific outpatient clinic anymore once symptoms of PTSD are taken care of. Results suggest that psychological aftercare for burn patients needs to be improved. Possible steps to improve aftercare to meet patients' needs are discussed.     

Burns in Turkish children and adolescents: nine years of experience

AIM: The aim of this study was to describe information about burns that occur in children and adolescents in Turkey. PATIENTS AND METHODS: The subjects were 362 patients whom were younger than 18 years who were treated at 3 burn centers in 2 different regions of Turkey between 1997 and 2005. The data collected for each case were age, gender, place of residence, cause and extent of burn, body sites affected, environment in which the injury occurred, interval from injury to arrival at a burn center, hospitalization status (inpatient versus outpatient), surgical treatment, and mortality. RESULTS: The 362 patients comprised 35.5% of all 1021 burn victims admitted during the study period. There were 183 boys and 179 girls (ratio 1:0.98) and the mean total body surface area burned was 17.7+/-16.5%. The highest proportion of patients were in the 1-6 years age group. Non-bath (not immersed) hot water scalding (216 cases, 59.7%) was the leading burn cause. The most common environment in which burn injury occurred was the home. The trunk was the body site most frequently affected (62.7%). 241 (66.6%) subjects lived in urban environments and 121 (33.4%) lived in rural areas. 171 patients (47.2%) were taken directly to the burn units, whereas the others (52.8%) were referred from other medical centers. 124 (34.3%) subjects were treated as outpatients and 238 (65.7%) were hospitalized. The overall mortality rate was 8.6% (31 deaths). Of the 238 inpatients, 92 (38.7%) were treated with daily dressings only, 128 (53.8%) required debridement, and 75 (31.5%) needed both debridement and grafting. CONCLUSION: Every country needs a nationwide public education system that is aimed at preventing burns and ensuring that burn victims receive proper first aid and age-appropriate, specialized burn care.     

Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care

Burn care often involves procedures that result in significant pain experiences for patients which, in turn, can lead to poorer physical and psychological health outcomes. Distraction and virtual reality (VR) are an effective adjunct to pharmacological interventions in reducing pain. Much of the research that has demonstrated efficacy for VR in burn care has involved expensive and extensive technology. Thus, identifying cost-effective, feasible, acceptable, and effective approaches to apply distraction within routine burn care is important. The objective of this mixed-methods study was to evaluate key stakeholder (i.e., patients, providers) perceptions of feasibility, acceptability, and effectiveness for the use of low-cost VR technology during routine burn care with adult patients. Ten adult patients used VR during burn care dressing changes in an outpatient clinic setting, after which they completed a satisfaction survey and individual qualitative interview. Providers also completed a satisfaction/perception survey after each participant’s care. Quantitative and qualitative results from both patient and provider perspectives consistently supported the feasibility and utility of applying low-cost VR technology in this outpatient burn clinic setting. Special considerations (e.g., aspects to consider when choosing an apparatus or application) stemming from stakeholder feedback are discussed.     

Environmental scan of mental health supports across Canadian burn centers: A healthcare providers’ perspective

BackgroundEarly mental health care and psychosocial support after burn injury provided by a variety of specialists and non-mental health professionals is instrumental in prevention of long-term mental health sequalae such as post-traumatic stress, depressive or substance use disorders. Diversity of mental health supports available to burn survivors vary across geography, resulting in variation of long-term mental health outcomes following burn injury.MethodsA mixed-methods study utilizing a semi-structured questionnaire to explore resources available for burn survivors in Canada as an inpatient, outpatient, and more broadly in the aftercare community. Interviews were completed with 17 Canadian burn centers, with a variety of burn care professionals.ResultsIn the continuum of burn care, a lack of available mental health professionals in certain regions and in the outpatient and community phases was observed. Emerging themes demonstrated the need for regular screening for mental health concerns among burn survivors and providing up to date discharge resources. In addition, increasing educational opportunities available to burn care staff with respect to burn survivor mental health was emphasized. Lastly, the importance of proactive and prolonged psychological support for burn survivors as they progress through an outpatient, rehabilitation and community setting was underlined.ConclusionsIdentification of burn care practices and resources across Canada provides the opportunity to compare, unify and improve gaps in care that exist across the Canadian burn network.     

Multiple-use atomizers in outpatient otolaryngology clinics are not necessarily an infectious risk.

OBJECTIVE: We sought to determine the risk of bacterial transmission from multiple-use atomizers in an outpatient otolaryngology clinic. STUDY DESIGN AND SETTING: Atomizers in 6 examination rooms were analyzed for bacterial contamination. Sterility of associated tubing from 1 atomizer was assessed. Multidose drug solutions in the atomizers (phenylephrine and tetracaine) were cultured multiple times over a 2-week period. Serial dilutions of the original sample were cultured to minimize inhibitory effects of antiseptic agents in the drug formulations. RESULTS: No bacteria were recovered from tubing cultures. Only 2 (0.6%) of 336 cultures of the drug solutions yielded bacterial growth. In both cases, coagulase-negative Staphylococcus was recovered in 1 of the dilutions prepared from original samplings. CONCLUSION: Multiple-use atomizers that contain phenylephrine and tetracaine solutions with bacteriostatic preservatives in an outpatient otolaryngology clinic do not yield significant bacterial growth and, when used as described, do not pose an infectious risk of bacterial transmission between patients.     

Does the outpatient setting provide the best environment for medical student learning of urology?

PURPOSE: To determine in which environment medical students learn clinical urology most effectively, we retrospectively reviewed a natural experiment in which medical students were randomly assigned to complete the 1-week rotation in clinical urology in an outpatient/clinic based or inpatient/operative setting. MATERIALS AND METHODS: Exit surveys were completed by 25 of the 39 medical students (64%) who had just completed the mandatory 1-week rotation in urology. Students were asked to record on a 5-point scale the amount learned in regard to 13 urological topics and skills, and to document the number of patient encounters experienced per topic and skill. RESULTS: Students randomized to the outpatient/clinic based setting tended to be 1) more likely to have exposure to a greater number and breadth of patients with common urological problems, 2) more likely to perform pertinent physical examination skills and 3) more likely to perceive that they learned more about a given curricular topic or skill. CONCLUSIONS: Our data indicate that the outpatient/clinic based setting may be a higher yield environment for medical students learning clinical urology compared with the inpatient/operative setting. The development of a validated means to assess actual student learning in clinical urology is needed to confirm these findings.     

Correlation of clinical outcome of integra application with microbiologic and pathological biopsies

BACKGROUND: Integra, a dermal replacement template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic sheet is a postexcisional treatment for deep partial to full thickness burns where autograft is limited. This study correlates Integra histology and quantitative microbiology cultures with clinical outcomes after autografting. METHODS: Charts of 29 burn patients who underwent Integra treatment and neodermis biopsy at the time of ultra thin autografting were reviewed. We analyzed microbial contamination, inflammatory reaction, and autograft take. RESULTS: The mean burn size and age were 43% total body surface area and 39 years old, respectively. In quantitative neodermis cultures, 90% of samples had bacterial growth; nine samples (31%) had > 10(5) colony forming units per gram. The most common organism was Staphylococcus aureus (31%). Patients with quantitative bacterial counts >10(5) CFU/g received targeted systemic antibiotics. Integra take (83%) and autograft take (92%) were acceptable even in patients with high bacterial counts (78% Integra take; 86% autograft take). More than 50% of biopsies had dermal regeneration similar to normal dermis; foreign body reactions were unusual. Histologic evidence of inflammation, especially polymorphonuclear cells, was increased in biopsies with high bacterial counts. CONCLUSION: Integra and autograft take can be acceptable even with high bacterial counts if wounds are treated with appropriate targeted topical and systemic antibiotics in the presence of microbial contamination. Neodermis biopsies showed fibrous in-growth congruent with existing Integra fibers with minimal foreign body reaction. These data support Integra use as a safe and effective treatment modality in patients with major burns.     

Effectiveness of prophylactic antibiotics in the outpatient treatment of burns

We compared wound infection rates in 133 outpatient burns treated with prophylactic antibiotics in our emergency room and 161 similar, untreated burns. Infection rates in the treated and untreated groups were 3.8% (5/133) and 3.1% (5/161), respectively. Since this was an observational cohort study, it was necessary to demonstrate the comparability of treated and untreated groups with respect to risk factors for infection, including patient age, size, location, and etiology of the burn injury, time since injury, and presence of co-morbidity. The groups were found to be comparable for all risk factors except size of burn: larger burns were over-represented in the treated group (p less than 0.05). Even after controlling for size, antibiotic use did not lower the infection rate. These results argue strongly against routine use of systemic antibiotics in the treatment of outpatient burns.     

Using a plastic sheet to prevent the risk of contamination of the burn wound during the shower

The shower technique for hydrotherapy was used in the treatment of the burn patients in our burn center. Before showering, the shower trolley (stretcher) was draped with a sterilized disposable plastic sheet to decrease the potential for seeding surface bacteria to open burn wounds. The patients were washed on the draped shower trolley. Samples for culture were taken from the surface of the shower trolley (stretcher) before it was draped with the sterilized disposable plastic sheet following the treatment of a patient. The samples were taken once a week for the first 6 months and only once a month for the last 42 months. At the period of 48 months (4 years), a total of 67 samples were obtained. Results of cultures of all the samples were negative. No patients were contaminated from the surface of the shower trolley during the shower. The use of the sterilized disposable plastic sheet proved to be a most effective procedure to decrease the risk of contamination between patients during the shower.