Archive for March 31st, 2008

OMNI Postings of 3/31/08

Posted by Paul Rega, MD — published on March 31st, 2008
Postings # 780, 781, 783, 784, 785, 789. 
This is a LA Times story about a talk from the Chicago cardiology conference.  A study looked at 1,010 patients who suffered a moderate or severe heart attack and sought treatment at hospitals that could not perform angioplasty. Patients were given the second-generation clot-busting drug, tenecteplase. Fifty percent of the patients were then transferred to another hospital to receive angioplasty within six hours; the other half were given conventional medical treatment. Altogether, the incidence of recurrent heart attack was six percent in the drug group, compared with 3.3 percent” of angioplasty patients. Furthermore, recurrent chest pain occurred in 2.2 percent of drug patients, compared with 0.2 percent of angioplasty patients.  According to one of the researchers, the findings suggest that after “patients receive [clot-busting drugs], there is no value in remaining at that hospital.”   This is a good study to show outlying ERs that they should call the helicopter and move that patient to TTH.  Unless it’s a “flight by ground” then they can just stay the hell where they are.  Damn it!
This news article describes a prisoner who escaped from the hospital while under guard.  It seems that his police keeper took off his handcuffs to let him pee and the miscreant slipped out a second bathroom exit.  Currently, the local police is on the trail following all yellow drops leading away from the hospital.
The above isn’t quite as bad as the following story about a female patient who just delivered several days earlier and who was  raped in the hospital.  These cases are being presented to keep us aware that we aren’t immune to lawbreakers, actual and potential, while we are working in the ER.
I wouldn’t eat any Honduran cantaloupes for a while.  The recall is growing.  In fact, there are more contaminated cantaloupes than there are voters for Ralph Nader!
This abstract from Acad Emerg Med concluded that nebulized racemic albuterol was better than nebulized epinephrine in the treatment of bronchiolitis.  Keep in mind that in this study, the kiddies received 3 doses of albuterol compared to 1 dose of epinephrine.  So I’m not sure if we’re comparing apples with apples, so to speak.

Malignant Hyperthermia

Posted by Paul Rega, MD — published on March 31st, 2008

Intro:  If ever involved with a suspected case of malignant hyperthermia, you can call the malignant hyperthermia hotline 24/7:  In USA and Canada:1 (800) 644-9737.

http://medical.mhaus.org/index.cfm/fuseaction/OnlineBrochures.Display/BrochurePK/BCD9151D-3048-709E-5A445BC0808B4767.cfm

PREOPERATIVE

A  Ask about personal and family past history of Malignant Hyperthermia or
      Adverse Anesthesia reactions (unexplained fever or death during anesthesia). 
      Be Aware of clinical signs of MH.
B  Body temperature monitoring for all patients undergoing general anesthesia for
      other than brief procedures.
C  Capnographic monitoring for all patients undergoing general anesthesia. 
D  Dantrolene: have dantrolene available wherever MH trigger anesthetics are
      used.

INTRAOPERATIVE

Primary Survey / Clinical Signs

A  Awareness: are you suspecting an MH Crisis? 
      Airway: severe masseter spasm (difficult to open the mouth).
B  Breathing: difficult to ventilate and/or intubate due to masseter spasm or
      severe Body rigidity after succinylcholine. 
      Body temperature high (late sign).
C  Capnography: elevation of end tidal CO2 despite proper ventilation & adequate
      fresh gas flows with properly functioning anesthesia ventilating apparatus. 
      Circulation: cardiac arrhythmias, tachy/bradycardia, hyper/hypotension.
D  Drugs: are you using triggering agents (succinylcholine, potent halogens)?
E  Exposure/ Examine the patient: skin color, perfusion, temperature, urine color,
      extremities, muscle tone.

Emergency Treatment

A  Ask for Help/Ask for the MH cart and for dantrolene. 
      Agents/Anesthesia: Stop anesthesia triggering agents and the surgery.
B  Breathing: hyperventilate with 100% oxygen.
C  Cooling, if the patient is hot: insert large intravenous bore catheters.  Give
      Cold intravenous fluids 15 cc/ kg IV.  Irrigate the wound, stomach
      and bladder with cold saline.
      Call MH Hotline:
      1-800-644-9737 or 1-315-464-7079
D  DANTROLENE:  give dantrolene IV, 2.5 mg/kg, and repeat the dose until
      the signs are controlled.
E  Check Electrolytes, especially potassium.

Secondary Steps

A  Acidosis? Assess initial and subsequent arterial or venous blood gases. 
      Is there mixed metabolic and respiratory acidosis?
B  Bicarbonate? 1-2 mEq/kg guided by pH, Base deficit.
C  Circulation/monitoring: consider arterial line, central venous catheter,
      laboratories: arterial/venous blood gases, CBC, Coagulation tests, CK,
      myoglobin levels.
D  Dysrhythmias: generally subside with resolution of the hypermetabolic
      phase of MH.  Arrhythmias can be treated with amiodarone, lidocaine,
      procainamide, adenosine, or other drugs indicated according to the ACLS
      protocol. Remember impact of hyperkalemia.
      Diuresis: assure diuresis greater than 1 ml/kg/h.
E  Electrolytes: if hyperkalemic, treat with bicarbonate, glucose/insulin, calcium.
F  Follow up: A: Arterial and venous blood gases. B: Body temperature (core)
      avoid hyper/hypothermia. C: end-tidal CO2, CK, Coagulation tests. D: Diuresis
      (urine output and color). E: Electrolytes.

POST-OPERATIVE

Post-Crisis Problems

A  Alkalinize urine & diurese, monitor for ARF (acute myoglobinuric renal failure).
B  Beware hypothermic, hyperkalemic, hypokalemic, hypervolemic overshoot—
      serial monitoring of filling pressures, fluid balance, electrolytes, temp, K, Ca,
      coags., and Hct may require recorrection.
C  Creatine Kinase (CK) levels track severity of rhabdomyolysis: if present,
      beware of renal failure, which may follow marked rhabdomyolysis. 
      Compartment Syndrome is rare, but requires serial monitoring of extremities
      and abdominal girth or bladder pressures after severe insults. 
D  DIC with coagulopathy, thrombocytopenia, hemolysis, and abnormal bleeding
      may follow major crises with severe shock and/or severe hyperthermia.
E  Elevated liver functions are often observed 12-36 hours post-MH crisis.
F  Follow CNS function serially after MH Crisis: magnitude of crisis may or may
      not correlate with CNS insult.
G  Good communication and follow-up is essential among medical specialists in
      the post-resuscitation and monitoring phase of the MH crisis for prevention of
      secondary crisis-related organ insults. Care may be transferred from an
      anesthesia care provider to a pediatric or adult medical or surgical intensivist,
      provided good information about the MH crisis and post-resuscitation
      management is maintained 

Post-Acute Phase

A  Aware of recrudescence signs.
      Ask the relatives about anesthesia problems/neuromuscular disorders.
B  Biopsy: Send the patient to a biopsy center for evaluation.
C  Contact MHAUS for further information/referral of patient.
D  Dantrolene 1 mg/kg IV q 4-6h and continued for 24-48h after an episode of
      Malignant Hyperthermia. 
      Documentation: submit forms to the national/international North American
      MH Registry of MHAUS: www.mhreg.org

ANESTHESIA FOR MH-SUSCEPTIBLE PATIENT

A  Anesthesia machine preparation: change circuits, disable or remove the
      vaporizers, flush the machine at a rate of 10 L/min for 20 min.
      Anesthesia:  Use local or regional anesthesia but general anesthesia with
      non-triggering agents is acceptable. Safe drugs include: barbiturates,
      benzodiazepines, opioids, nondepolarizing neuromuscular blockers and
      their reversal drugs, and nitrous oxide.
B  Body temperature monitoring.
C  Cpnography: Close monitoring for early signs of MH.
D  Dantrolene available.
      Discharge, if no problems, after 2.5 hours.

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categories: Emergency Medicine

Go with a drug-coated stent

Posted by Paul Rega, MD — published on March 31st, 2008

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=ahqH4851_09I

Bloomberg News, 3/31/08 reports on research from the cardiology conference in Chicago.

“[d]rug-coated stents are safe for heart attack patients and may improve their chances of survival,” according to research presented at the American College of Cardiology meeting in Chicago. Dr. Laura Mauri, chief scientific officer of the Harvard Clinical Research Institute in Boston, and colleagues looked at “[a] database of 7,216 patients in Massachusetts.” The researchers found that “15.5 percent of patients getting drug-coated stents needed a repeat procedure within two years to clear their arteries, compared with 20.8 percent of those with older, bare-metal devices.” Furthermore, “Death rates were 10.4 percent” among patients who received drug-coated stents, “versus 13.2 percent” among those who received bare-metal devices.

Dr. Mauri, one of the researchers said, “This study confirms that the same benefits that drug-eluting stents offer other patients in preventing restenosis [re-narrowing] of the coronary arteries are still there for patients with MI, and there doesn’t appear to be any trade-off in increased risk of repeat MI or death.”

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categories: Emergency Medicine

Nurses: Gone with the wind

Posted by Paul Rega, MD — published on March 31st, 2008

From the publication The Future of the Nursing Workforce in the United States: Data, Trends and Implications, comes this statement:  “Patients should brace for a severe shortage of nurses, which could reach 500,000 by 2025.” 

1 

Researchers “said the demand for registered nurses is expected to continue to grow at 2 percent to 3 percent per year,” while the “supply of registered nurses is expected to grow very little as large numbers of nurses begin to retire, or leave work.”

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categories: Emergency Medicine

Angioplasty or bust

Posted by Paul Rega, MD — published on March 31st, 2008

Intro:  From a cardiology conference.  A study looked at 1,010 patients who suffered a moderate or severe heart attack and sought treatment at hospitals that could not perform angioplasty. Patients were given the second-generation clot-busting drug tenecteplase. Fifty percent of the patients were then transferred to another hospital to receive angioplasty within six hours; the other half were given conventional medical treatment. Altogether, the incidence of recurrent heart attack was six percent in the drug group, compared with 3.3 percent” of angioplasty patients. Furthermore, recurrent chest pain occurred in 2.2 percent of drug patients, compared with 0.2 percent of angioplasty patients.  According to one of the researchers, the findings suggest that after “patients receive [clot-busting drugs], there is no value in remaining at that hospital.”  

LA Times, 3/31/08:  Improvements in angioplasty in the last few years have made the procedure for unblocking coronary arteries much safer, allowing cardiologists to perform procedures they were reluctant to do in the past.

The procedures include performing angioplasty after clot-busting drugs have been given and using it in hospitals that don’t have a heart surgery team available for emergencies, researchers said during a weekend cardiology meeting in Chicago.

The net effect is that angioplasty, which is generally considered to be much more effective than drugs for treating heart attacks, should be available to many more patients, researchers said.

The findings “really could change practice and open up opportunities for patients to get more optimal treatment,” said Dr. Bonnie Weiner of St. Vincent Hospital in Worcester, Mass., president of the Society for Cardiovascular Angiography and Interventions.

More than 75% of hospitals in the U.S. do not routinely perform angioplasty, also known as percutaneous coronary intervention — most because they do not have heart surgeons on staff to make repairs if the procedure punctures an artery or causes some other damage.

When patients arrive at such a hospital after a heart attack, the only choice is to administer clot-busting drugs within the 90-minute “golden window” in which treatment is most effective.

Once such therapy has been administered, cardiologists have been reluctant to transfer patients to another hospital to undergo angioplasty out of fear that the procedure would cause excess bleeding and endanger their lives.

The fear now appears to be groundless and counterproductive, Dr. Warren J. Cantor of the Southlake Regional Health Centre in Newmarket, Ontario, Canada, reported Sunday at a meeting of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions.

Cantor reported on 1,010 patients who suffered a moderate or severe heart attack and sought treatment at hospitals that could not perform angioplasty.

All were given the second-generation clot-busting drug tenecteplase, which has fewer problems than older drugs. Half were then transferred to another hospital to receive angioplasty within six hours; the other half were given conventional medical treatment.

Cantor said the results were dramatic.

Overall, 16.6% of patients who received only drugs suffered another heart attack, severe chest pains or died in the 30 days after the procedure, compared with 10.6% of those who received prompt angioplasty. That was a 46% reduction.

The incidence of recurrent heart attack was 6% in the drug group, compared with 3.3% in the angioplasty group. Recurrent chest pain occurred in 2.2% of drug patients, compared with 0.2% of angioplasty patients.

There was no excess bleeding in the patients who underwent angioplasty.

“What it says is that when patients receive [clot-busting drugs], there is no value in remaining at that hospital,” Cantor said. “The best strategy is to transfer them to an angioplasty center to undergo the procedure within six hours.”

Added Dr. Steven Bailey of the University of Texas Health Sciences Center at San Antonio: “Such a large benefit to the patient . . . is reassuring that this should be a process that we begin to adopt in order to care for the majority of patients who have heart attacks.”

Nonemergency angioplasty has been more controversial because medical guidelines call for it to be performed only in a hospital where a backup surgical team is available in case problems arise. Several states ban the practice except in emergencies.

Such prohibitions were imposed because years ago emergency surgery was required for about 8% of patients who underwent angioplasty, said Dr. Michael Kutcher of Wake Forest University.

Today that figure has shrunk to 0.2% to 0.4%.

As a result, a growing number of small hospitals without surgical backup have been attempting the procedure — which can earn them as much as $15,000 per incident — and the evidence suggests that the practice is safe, Kutcher told the meeting Saturday.

Hospitals also argue that performing the elective surgeries helps staffers to maintain proficiency.

Using a national patient registry maintained by the American College of Cardiology, Kutcher and his colleagues compared results from 9,029 patients who had angioplasty at 61 small hospitals with those from 299,132 patients at 404 hospitals with backup teams between January 2004 and April 2006.

They found no significant difference in deaths between the two types of facilities, once they factored in the age of the patients and the severity of the illness.

Success rates and the number of complications were also similar, Kutcher said, suggesting that the procedure can be done safely at smaller hospitals.

The findings “could have a huge impact in this country,” particularly in rural areas where hospitals that perform angioplasty can be hours away by car, said Dr. W. Douglas Weaver of the Henry Ford Hospital in Detroit, president-elect of the American College of Cardiology.

But Kutcher and others cautioned that the findings should not be used to support the “wild development” of new stand-alone programs for angioplasty.

It is crucial, Weiner said, that hospitals perform a minimum number of procedures to maintain their efficacy in surgery, and that they compare their results to national norms to ensure their results are acceptable.
http://www.latimes.com/features/health/medicine/la-sci-heart31mar31,1,110641.story

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categories: Emergency Medicine

PCR and Bioterror Agents

Posted by Paul Rega, MD — published on March 31st, 2008

Samuel Yang MD, Richard E. Rothman MD, PhD, Justin Hardick MS, Marcos Kuroki BS, Andrew Hardick MS, Vishal Doshi MD, Padmini Ramachandran MS, Charlotte A. Gaydos MPH, DrPH (2008) Rapid Polymerase Chain Reaction-based Screening Assay for Bacterial Biothreat Agents
Academic Emergency Medicine 15 (4) , 388–392 

ABSTRACT 

Objectives: To design and evaluate a rapid polymerase chain reaction (PCR)-based assay for detecting Eubacteria and performing early screening for selected Class A biothreat bacterial pathogens.

Methods: The authors designed a two-step PCR-based algorithm consisting of an initial broad-based universal detection step, followed by specific pathogen identification targeted for identification of the Class A bacterial biothreat agents. A region in the bacterial 16S rRNA gene containing a highly variable sequence flanked by clusters of conserved sequences was chosen as the target for the PCR assay design. A previously described highly conserved region located within the 16S rRNA amplicon was selected as the universal probe (UniProbe, Integrated DNA Technology, Coralville, IA). Pathogen-specific TaqMan probes were designed for Bacillus anthracis, Yersinia pestis, and Francisella tularensis. Performance of the assay was assessed using genomic DNA extracted from the aforementioned biothreat-related organisms (inactivated or surrogate) and other common bacteria.

Results: The UniProbe detected the presence of all tested Eubacteria (31/31) with high analytical sensitivity. The biothreat-specific probes accurately identified organisms down to the closely related species and genus level, but were unable to discriminate between very close surrogates, such as Yersinia philomiragia and Bacillus cereus.

Conclusions: A simple, two-step PCR-based assay proved capable of both universal bacterial detection and identification of select Class A bacterial biothreat and biothreat-related pathogens. Although this assay requires confirmatory testing for definitive species identification, the method has great potential for use in ED-based settings for rapid diagnosis in cases of suspected Category A bacterial biothreat agents.

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categories: Emergency Medicine

Hand Hygiene: Fact/Fiction

Posted by Paul Rega, MD — published on March 31st, 2008

Intro:  This is a succinct review about hand hygiene, its science and its problems in the hospital.  Studies have shown that physicians are the most non-compliant and that ERs have a poor record in terms of compliance. 

Citation:  S. Hugonnet, D. Pittet (2000) Hand hygiene—beliefs or science?
Clinical Microbiology and Infection 6 (7) , 348–354

Hand hygiene—beliefs or science?

  • Infection Control Program, Department of Internal Medicine, University of Geneva Hospitals, Geneva, Switzerland

Over a century has passed since Ignaz P. Semmelweis demonstrated the association between hand hygiene and nosocomial infections, but this simple procedure is still not recognized by many healthcare workers as one of the most important measures to prevent cross-transmission of microorganisms. A relatively large amount of research has been done, in particular to try to understand why compliance remains so low, in order to implement successful promotion campaigns. This research has generated a fair amount of strong scientific data which are sometimes misunderstood and misused because of myths or certain beliefs. Observational or intervention studies have consistently shown a number of risk factors associated with non-compliance, such as high workload, professional category, or type of ward. Others are thought to be barriers to adequate compliance but have not yet been properly assessed. These include skin irritation due to hand hygiene agents, lack of knowledge of hand hygiene recommendations, or lack of institutional policy. Future interventions to promote hand hygiene will need to address these risk factors, and target the individual healthcare worker, as well as the group or institution if a significant degree of success is to be achieved.

In 1847, Ignaz P. Semmelweis, a Hungarian-born obstetrician, performed the first experimental study which clearly demonstrated that appropriate hand hygiene does prevent puerperal infections and maternal deaths [ 1]. Since then, hand hygiene has been considered by most healthcare professionals to be the simplest and most cost-effective measure to prevent cross-transmission of microorganisms and nosocomial infections [ 2,3].

Despite this, healthcare workers (HCWs) show a certain reluctance to translate Semmelweis’ message into their daily clinical practice. Indeed, hand hygiene and adherence to recommended practices have been extensively studied, and the vast majority of the observational studies report compliance rates that are unacceptably low, usually below 50% [ 4–15] ( Table 1). As a logical consequence, the issue of hand hygiene became a priority among infection control practitioners, and a great deal of research has been done to better understand the process of hand contamination, cross-transmission, the factors explaining non-compliance, and the interventions needed to improve adherence to hand hygiene recommendations. Tremendous progress has been made, new research questions have arisen, but some gaps in our knowledge remain and controversy is ongoing.

Table 1 Compliance with hand hygiene in different hospital settings

Year Setting Compliance Author

Interestingly, the debate surrounding hand hygiene has a tendency to become intermingled with myths, personal beliefs and facts. The aim of this review is to attempt to clarify the state of our present knowledge and to separate what is science from simple beliefs or opinions.

Importance of hand hygiene in the prevention of nosocomial infections

 

This is the central concept underlying the whole discussion around hand hygiene and the efforts employed to increase awareness of its importance. However, it is still argued that there is no compelling evidence to support the need for rigorous hand hygiene procedures to prevent nosocomial infections [ 16]. From our point of view, this issue is no longer a subject of debate. As recently reviewed by Larson [ 17], seven quasi-experimental hospital-based studies of the effect of hand hygiene on the risk of nosocomial infection were published between 1977 and 1995 [ 12,18–23]. In one of these, endemic MRSA was eliminated in 7 months in a neonatal intensive care unit following the introduction of a new hand disinfectant [ 19]. Another study reported an MRSA outbreak involving 22 infants in a neonatal unit, which could not be controlled despite intensive and comprehensive measures until another disinfectant was widely introduced [ 20]. Other studies to examine the effects of hand hygiene promotion on the risk of infection were conducted in schools or daycare centers [ 24–27], as well as in the community [ 28–30]. Despite the limitations of these studies in terms of study design, lack of control for confounding factors or power, most reports showed a temporal relation between improved hand hygiene practices and reduced infection rates.

In addition to these above-mentioned studies, outbreak investigations have suggested an association between infections and understaffing or overcrowding that was consistently linked with poor compliance to hand hygiene [ 31–33]. During an outbreak, Fridkin et al investigated risk factors for central venous catheter-associated bloodstream infections [ 33]. After adjustment for confounding factors, the patient-to-nurse ratio remained an independent risk factor for bloodstream infection, suggesting that nursing staff reduction below a critical threshold may have contributed to this outbreak by jeopardizing adequate catheter care. More recently, Vicca studied and demonstrated the relationship between understaffing and the spread of MRSA in an intensive care unit [ 34]. These findings tend to show indirectly that an imbalance between workload and staffing leads to relaxed basic control measures, such as hand hygiene, and the spread of microorganisms.

We recently investigated an outbreak of Enterobacter cloacae in our neonatal intensive care unit [ 35] which showed that the daily number of hospitalized children exceeded the maximal capacity of the unit, resulting in an available space per child well below standard recommendations [ 36]. In parallel, the number of staff on duty was significantly below the number required by the workload, and this conjunction resulted in relaxed basic infection control measures. Compliance with hand hygiene before device contact was only 25% during the workload peak but increased to 70% after the end of the understaffing and overcrowding period. Continuous surveillance showed that being hospitalized during this period carried a 4-fold increased risk of acquiring a nosocomial infection. This study not only shows the association between workload and infection but also highlights the intermediate step: low compliance with hand hygiene procedures.

Do these data provide sufficient evidence to state that there is a causal link between hand hygiene and nosocomial infections? It would seem to be the case, as several of the Bradford–Hill criteria for causality are met: consistency of the association, temporal sequence of the association, and plausibility and coherence of the association.

Handwashing or hand disinfection?

Table 2 Observed risk factors for non-compliance with hand hygiene

Risk factors

The skin harbors mainly two types of microorganisms, the resident and the transient or contaminant flora [ 37]. The resident flora (coagulase-negative staphylococci, Corynebacterium species, Micrococcus species) has a low pathogenic potential unless introduced into the body by invasive devices, and is difficult to remove by mechanical means. On the other hand, the transient flora (typically Escherichia coli, Pseudomonas aeruginosa) has a short-term survival rate on the skin, but with a high pathogenic potential, and is responsible for most nosocomially acquired infections resulting from cross-transmission.

The aim of hand hygiene is to decrease hand colonization with transient flora. The ideal technique should be quick to perform, reduce hand contamination to the lowest possible level, and be free from significant side-effects on the skin. Hand hygiene can be achieved either through handwashing, or hand disinfection. Handwashing refers to the action of washing hands with an unmedicated detergent and water, or water alone to remove dirt and loose transient flora to prevent cross transmission [ 2,37]. Hygienic handwash refers to the same procedure when an antiseptic agent is added to the detergent. Hand disinfection refers to any action where an antiseptic solution is used to clean hands, either medicated soap or alcohol. Some experts may refer to the action of degerming with detergent-based antiseptics or alcohol [ 17]. Hygienic handrub consists of rubbing hands with a small quantity (2–3 mL) of a highly effective and fast-acting antiseptic agent. Because alcohols have excellent activity and the most rapid bactericidal action of all antiseptics, they are the preferred agents for hygienic handrub. The other main antiseptics include iodophors, chlorhexidine gluconate, triclosan, phenol derivatives and quaternary ammonium compounds, and have been recently reviewed by Rotter [ 37].

Plain soap with water can physically decrease the load of microorganisms to a certain level, but antiseptic agents are necessary to obtain a significantly stronger reduction or elimination [ 2,38–40]. To be effective, time spent washing hands is crucial, since the mean log10 reduction of hand contamination reaches 0.6–1.1 after 15 s, 1.8–2.8 after 30 s, up to 3 after 1 min, and up to 3.3 after 2 min. In contrast, a solution containing at least 50% of n-propanol achieves a 3.7 log10 reduction in bacterial count after 30 s of exposure. Rotter showed that hand hygiene with unmedicated soap and water removed, at best, some of the transient flora mechanically, whereas preparations containing antiseptic or antimicrobial agents not only removed transient flora mechanically, but also chemically killed contaminating and colonizing flora with long-term residual activity. It is important to recall that hand disinfection is significantly more efficient than standard handwashing with soap and water or water alone [ 37,41], particularly when contamination is heavy [ 42–44]. However, as standard handwashing was the preferred technique for a long time, there appears to be a certain reluctance to adopt alternative methods of achieving hand hygiene.

Alcohol-based handrubs are well suited for hygienic hand disinfection for the following reasons: (1) optimal antimicrobial spectrum (active against all bacteria, and most clinically important viruses, yeast and fungi); (2) no wash basin necessary for their use and easy availability at the bedside; (3) application does not cause microbial contamination of the HCW’s uniform; (4) fast-acting. After extensive reduction following hand disinfection with an alcohol preparation, it takes the resident skin flora several hours to become completely restored [ 37]. Since alcohol alone does not have any lasting effect, another compound with antiseptic activity, such as chlorhexidine gluconate, is sometimes added to the hand disinfection solution to obtain a prolonged effect. We recently investigated the colonization of HCWs’ hands during routine patient care under various clinical situations, and the effect of hand hygiene on decolonization [ 45]. In the multivariate analysis, we found that HCWs who washed their hands with unmedicated soap had an excess of 52 colony-forming units (CFUs) on their fingertips when compared to those who had used a hand disinfectant solution.

BARRIERS and RISK FACTORS FOR NON-COMPLIANCE

Although it appears to be an extremely simple action to perform, compliance with hand hygiene recommendations has been repeatedly documented as being low ( Table 1). Identification of the associated risk factors is of utmost importance to the design of appropriate targeted promotion campaigns, and numerous studies have been undertaken to clarify this issue. The list of potential barriers to hand hygiene is extremely long and heterogeneous; some are related to personal beliefs or behavior, others to institutional policies and constraints; some have been assessed in observational or even intervention studies, while others are simply reported by HCWs. For clarity, we will use the term ‘risk factors’ for independent factors of non-compliance, and ‘barriers’ for opinions or beliefs.

Table 3 Self-reported factors for poor adherence to hand hygiene recommendations

Barriers

Risk factors

Risk factors for non-compliance with hand hygiene have been determined objectively in several observational studies or interventions to improve compliance ( Table 2) [ 9,46–52]. Among these, being a physician or a nursing assistant, rather than a nurse, was almost consistently associated with reduced compliance. Similarly, the use of automated sinks also predicted non-compliance [ 53].

We conducted a hospital-wide observational study to estimate compliance with hand hygiene and assess risk factors for non-compliance [ 15]. We observed 2834 opportunities for hand hygiene. Overall compliance was 48%. Factors that independently predicted non-compliance were:

This study confirmed low compliance with hand hygiene in a teaching institution, and suggested that targeted educational programs may be useful. The results also suggested that full compliance with current guidelines may be unrealistic [ 15,52,54].

Perceived barriers

Apart from these well-documented risk factors, a large number of factors potentially jeopardizing adequate compliance with hand hygiene have been cited in the literature [ 9,15,46,48–51]. The main reasons reported by HCWs for the lack of adherence with hand hygiene recommendations include: skin irritation by hand hygiene agents, inaccessible hand hygiene supplies, interference with HCW–patient relation, patient needs perceived as a priority, wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, and the perceived lack of scientific evidence showing a definitive impact of improved hand hygiene on nosocomial infection rates ( Table 3). Finally, a trend towards lower compliance among males as compared to females was reported several times, but did not remain an independent risk factor.

Skin irritation by hand hygiene agents probably constitutes an important barrier to appropriate compliance [ 55], and this issue has been recently reviewed by Larson [ 17]. The superficial skin layers contain water to keep the skin soft and pliable, and lipids to prevent dehydration of the corneocytes. Hand cleansing can increase skin pH, reduce lipid content, increase transepidermal water loss, and even increase microbial shedding. However, the relative importance of skin irritation as a risk factor for non-compliance has not been assessed, even though it is regularly incriminated by HCWs as such. Consequently, several actions need to be taken to improve the acceptability of the agent and reduce its side-effects. HCWs need to be better informed about the possible effects of hand hygiene agents: a free service should be made available for those who present side-effects; emollients should be added to the solution since, in addition, they may protect against cross-infection as well as keeping the resident skin flora intact; and the use of hand lotions should be encouraged to help protect skin and reduce microbial shedding. Possible interactions between hand protection and antimicrobial agents should, however, be evaluated in appropriately designed studies. Finally, it is important to recall that alcohol-based formulations for hand disinfection are less irritant on skin than any antiseptic or non-antiseptic detergents. Indeed, to our knowledge, Boyce et al [ 56] performed the first clinical trial to compare side-effects on skin when using an alcoholic hand gel regimen with soap and water. The study was prospective and randomized with a cross-over design, and the skin was assessed by three methods: self-assessment, visual assessment by a study nurse, and estimation of the epidermal water content by measurement of the electrical capacitance of the skin. The three measurement methods were consistent and showed no significant changes of the skin when using the alcohol-based gel, whereas dryness and irritation of the skin increased when using soap and water.

Poor access to hand hygiene supplies, whether sink, soap, medicated detergent, or waterless alcohol-based handrub solution, is certainly an important barrier to adequate adherence. The most flagrant example is the inconveniently located sink that obliges the HCW to leave the patient’s bedside. This puts a time-burden on HCWs that renders adequate adherence with hand hygiene recommendations simply impossible [ 15,54]. System modifications might solve this problem by providing, for example, individual bottles of alcohol-based handrub solution for pocket carriage, and dispensers available in the immediate vicinity of each patient care location. The observational study performed by Bischoff et al [ 57] illustrates this point. Despite some methodological limitations, they showed that compliance with hand hygiene increased after alcohol-based waterless dispensers were made available, initially at a ratio of 1 dispenser per 4 beds. Interestingly, compliance was even higher when this ratio was 1 : 1, stressing the importance of the ease of access.

Wearing gloves might represent a barrier for compliance with hand hygiene. Indeed, HCWs might wear gloves with the primary intention of protecting themselves and not the patient, and may be unaware that contamination on gloves is just the same as on hands. Furthermore, it has been shown that contamination on the skin of gloved hands occurs, implying that hand hygiene is vital after glove removal [ 58]. Failure to remove gloves after patient contact or between care on dirty and clean body sites on the same patient has to be considered as non-compliance with hand hygiene recommendations [ 15]. Non-compliance has been identified among glove users in at least two studies [ 59,60].

Lack of knowledge of hand hygiene guidelines, recognition of hand hygiene opportunities during patient care and awareness of the risk of cross-transmission of microbial pathogens constitute barriers to hand hygiene compliance. Furthermore, some HCWs believed that they washed their hands when necessary even when observations indicated that they did not [ 9,18,61–63]. Guidelines delineating indications for hand hygiene exist, but do not rely on evidence-based studies of contamination of hands [ 39,64]. However, it is of utmost importance to identify patient care activities associated with colonization of the hands, in order to elaborate meaningful recommendations. In the study we mentioned earlier [ 45], we observed 417 episodes of care; each observation period started after the initial hand hygiene procedure and ended at the end of a coherent episode of care or when the HCW proceeded to clean his/her hands, and hand contamination was quantitated. Colonization of the hands was constant over time and almost linear, with an acquisition on average of 16 CFUs per minute of care on ungloved hands. The rate of colonization was dependent on the type of activity, as high as 21 CFUs/min for respiratory care, whereas no significant colonization occurred during simple skin contact or housekeeping activities. Activities that were most strongly associated with contamination were respiratory care and direct patient contact (both 20 CFUs/min). Not surprisingly, handling body fluid or secretions, or rupture in the sequence of patient care, were also associated with high bacterial hand contamination, even after adjustment for confounding factors. Hand hygiene guidelines need to be revisited, taking into account such information, so as to help HCWs recognize at least those opportunities that carry the highest risk of cross-contamination during the sequence of patient care.

The lack of scientific information on the definitive impact of improved hand hygiene on nosocomial infection rates is repeatedly reported as a barrier to appropriate adherence to hand hygiene recommendations. As discussed previously, and although there are scientific data to refute this statement, it definitely needs to be taken into account and calls for more education and lobbying.

Some other reported reasons for non-compliance include the lack of hand hygiene promotion, active participation at individual and institutional level, the frequent absence of a role model provided by senior staff, the lack of institutional priority, and the lack of an institutional safety climate. This shows that parameters associated with non-compliance with hand hygiene recommendations are not uniquely related to the individual HCW, but also to the group and institution he/she belongs to. We therefore agree with Kretzer and Larson [ 49] that interventions targeted at individuals are insufficient to induce sustained change, and that other factors such as environmental constraints and the institutional climate need to be taken into account. These authors have extensively reviewed and proposed a theoretical model to promote hand hygiene, but the successful implementation of these concepts has not been published so far.

Conclusions

The issue of hand hygiene as an important measure to prevent nosocomial infection is among the top priorities of any infection control practitioner, but the understanding of this topic is often distorted by many long-standing beliefs, misunderstandings, or unproven statements. However, a great deal of research has been accomplished that provides convincing data on the association between hand hygiene and nosocomial infections, hand colonization during patient care, advantages and disadvantages of various hand hygiene techniques or agents, and risk factors for non-compliance. These data need to be used to convince care-givers, design interventions, and trigger behavioral modifications so to improve adherence to recommendations for hand hygiene. Obviously, some gaps in our knowledge remain and need to be addressed through appropriate research. One of these, and not the least, is to determine the most effective components of a campaign to promote hand hygiene so as to achieve a full recognition among healthcare workers of the importance of this seemingly simple gesture.
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categories: Emergency Medicine

Wearable Hygiene Dispensers

Posted by Paul Rega, MD — published on March 31st, 2008

Janet P. Haas RN, DNSc, CIC, Elaine L. Larson RN, PhD, CIC (2008) Impact of Wearable Alcohol Gel Dispensers on Hand Hygiene in an Emergency Department
Academic Emergency Medicine 15 (4) , 393–396

ABSTRACT

Objectives: Compliance with hand hygiene (HH) by health care workers is widely recognized as the most effective way to decrease transmission of infection among patients. However, compliance remains poor, averaging about 40%. A potential barrier to compliance is convenience and accessibility of sinks or alcohol hand sanitizer dispensers. The purpose of this study was to assess the use of a personal alcohol gel dispensing system, compared with the traditional wall-mounted alcohol gel dispenser and sinks in an urban hospital’s emergency department (ED).

Methods: This was a quasi-experimental trial of a personal wearable alcohol hand sanitizer dispenser. Observations of ED staff HH were performed in the month before intervention and during three intervention phases over a 2.5-month period.

Results: A total of 757 HH opportunities were observed: 112 before and 432 after patient contact, 72 after contact with the patient’s environment, 24 before invasive procedures, and 117 after body fluid contact. HH compliance improved during the first intervention period, but improvement was not sustained. There was no significant improvement in HH from baseline to the final intervention period. The wearable alcohol gel dispenser was used for 9% of HH episodes.

Conclusions: Availability of a wearable dispenser was not associated with a significant improvement in use of alcohol products for HH. These results support other studies in which only transient success was reported with a single intervention; greater success in sustaining increased HH compliance has been reported with use of multimodal approaches in which increased availability of products may be a part of the intervention.

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categories: Emergency Medicine

ER Stat Lab

Posted by Paul Rega, MD — published on March 31st, 2008

 Adam J. Singer MD, Peter Viccellio MD, Henry C. Thode Jr PhD, Jay L. Bock MD, PhD, Mark C. Henry MD (2008) Introduction of a Stat Laboratory Reduces Emergency Department Length of Stay
Academic Emergency Medicine 15 (4) , 324–328

ABSTRACT

Objectives: Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour.

Methods: This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS.

Results: There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296–553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients.

Conclusions: Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour.

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categories: Emergency Medicine

ER Treatment of Bronchiolitis

Posted by Paul Rega, MD — published on March 31st, 2008

Paul Walsh MB, BCh, BAO, John Caldwell PharmD, Kemedy K. McQuillan MD, Steven Friese MD, Dale Robbins PA-C, Stephen J. Rothenberg PhD (2008) Comparison of Nebulized Epinephrine to Albuterol in Bronchiolitis
Academic Emergency Medicine 15 (4) , 305–313 

 

ABSTRACT 

Objectives: To compare the effect of nebulized racemic epinephrine to nebulized racemic albuterol on successful discharge from the emergency department (ED).

Methods: Children up to their 18th month of life presenting to two teaching hospital EDs with a clinical diagnosis of bronchiolitis who were ill enough to warrant treatment but did not need immediate intubation were eligible for this double-blind randomized controlled trial (RCT). Patients received either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Disposition was decided 2 hours after the first nebulizer. Successful discharge was defined as not requiring additional bronchodilators in the ED after study drug administration and not subsequently admitted withi