Abstract
The Journal Watch feature is provided as a service to our readers. The intention is to highlight new research and other developments in infection prevention and control and related fields, published elsewhere. A brief description of each article and its main findings are given here; readers are encouraged to refer to the full published article for the details of the work. The editorial management group would welcome feedback and recommendations for articles to feature in this column; for comments and recommendations please contact the editor:
The articles in this Journal Watch for the March issue of JIP are an eclectic collection. They range from ‘everyday’ subjects, such as hand hygiene but addressed through innovative approaches, in this case Positive Deviance, to less common but hopefully interesting issues, e.g. probiotics for Clostridium difficile. In addition, I am very pleased to say, we have our first article suggested by a reader. This is exactly the kind of interaction with the journal that the editorial in this issue calls for and is very welcomed. So, if you see a paper that you believe the readers of JIP need to know about, let me know!
The first article is the one suggested by a reader, from The Lancet, and is a trial of antimicrobial urinary catheters to reduce urinary tract infection (UTI);
This large multicentre randomised controlled trial is interesting for a number of reasons, not least the results which I will come to. The authors note that while a Cochrane Review has stated that antimicrobial catheters can reduce bacterial contamination of urinary catheters, their utility in preventing symptomatic UTI remains uncertain. This is the first interesting point; trials need to measure outcomes that affect the patient experience. The second point is that the trial [must have] received a pleasingly flexible approval from the relevant ethics committee that allowed for retrospective consent for inclusion in the trial from individuals catheterised in an urgent situation (after randomisation). Such flexibility in a situation of genuine equipoise should be commended. The trial itself started from the assumption that the interventions (silver alloy-coated or nitrofural-impregnated catheters) needed to lead to a 3.3% absolute reduction in UTI to make it worth changing from routine care/control (polytetrafluoroethylene (PTFE)-coated latex catheter) assuming a UTI rate of 11%. The results do not support the routine use of antimicrobial catheters; of circa 7000 patients randomised in 14 NHS hospitals, 90% were available for analysis. Rates of UTI were close to identical between the silver and control groups, and the reduction in the nitrofural group was less than the 3.3% considered clinically relevant (10.6% versus 12.6%) and was not statistically significant, albeit with a cautious threshold of p < 0.025. Some may argue that the nitrofural catheters showed enough benefit to consider their use, though the authors caution against this. This paper and the associated commentary (Leone, 2012) merit a complete read as the detail is interesting and stimulating.
Two articles from the American Journal of Infection Control (AJIC) give us two very different perspectives on the issues of the continuing challenge of improving hand hygiene compliance. The first looks at the use of ‘Positive Deviance’ and the second highlights that the use of technology is an increasingly popular avenue for hand hygiene interventions.
In contrast to the above study, this paper does not report on a very robust study providing data that are high up in the traditional hierarchy of evidence-based practice, but it is still interesting for a number of reasons. The first and most important of these is innovation; I have commented previously that many of us working in infection prevention and control believe that approaches that address human behaviour are vital if we are to reduce healthcare associated infections (HCAI). This study adopts just such an approach; ‘Positive Deviance’. I do not claim any expertise in this approach, so read the paper with interest. For more information on Positive Deviance see http://www.positivedeviance.org/about_pd/index.html (accessed 18 January 2013). Essentially the theory relies on the theory that ‘…in every community there are certain individuals or groups (the positive deviants), whose uncommon but successful behaviours or strategies enable them to find better solutions to a problem than their peers. These individuals or groups have access to exactly the same resources and face the same challenges and obstacles as their peers.’ Simplistically it appears to suggest giving people the opportunity to innovate. In this case the researchers asked the teams in two clinical areas to identify ideas to improve hand hygiene; the ideas described are a little vague but include changing the locations of alcohol-based hand rub (ABHR) dispensers and other workflow suggestions. Another innovation in this paper is a system that they call a ‘nurse call’ system; this is not what you might imagine if familiar with the term in UK hospitals, but what sounds like a system for nurses to ‘clock in and out’ of patient rooms, thus enabling measurement of patient contact time. The study showed an increase in use of ABHR and also some reductions in HCAI in the two areas concerned. There were no control areas, and while the data seem consistent for the time period shown (up to 18 months in one area), it remains to be seen if the effect can be wholly attributed to the intervention and is sustainable. Finally the ‘use’ of ABHR was measured using electronic counters in the dispensers, which leads very neatly into the other AJIC paper in this Journal Watch.
The authors of this interesting study describe, quite succinctly, the limitations of an observational hand hygiene audit; the time and resources to conduct it, the potential for ‘Hawthorne effect’ (though this is a subject of some debate), the opportunity cost associated with staff spending time conducting observations and the risk of bias when these data are used to measure quality; i.e. are used for judgement. This study compares a traditional hand hygiene observation with the use of electronic counters installed in the dispensers for ABHR and soap, to measure hand hygiene in response to a typical hand hygiene intervention. The study was conducted in two intensive care units. After a ‘wash out’ period and 15-week baseline period, the 15-week-long intervention consisted of posters with hand hygiene feedback data, education and discussions with staff. During the wash-out period, the researchers validated the automated measurement devices by checking that, over a number of 1 hour periods, their measurements matched observed hand hygiene episodes. The results are interesting; over the 30 weeks there were over 300 hours of observation (i.e. more than 10 hours/week, so quite intense), which included some nights and weekends. There were over 400,000 dispenser counts over the same period. The observed correlation between direct observation and electronic measurement was low with observation only explaining 41% of the weekly variation in electronic counts (weighted least squares regression, r2 = 0.41, P = 0.02). Perhaps more interestingly, the observed hand hygiene failed to increase following the intervention on both units, but the electronic measurement did show increases on both. This suggests that even intensive direct observation is potentially insensitive to changes in hand hygiene activity (the converse explanation is less plausible; i.e. that the electronic measurement increase seen is some kind of artefact). There are, of course, a number of limitations to electronic measurement, not least of which is the lack of context and the rich data that accompany it, and from which we learn, e.g. what was the indication for hand hygiene? These types of technological innovations are becoming increasingly popular … watch this space!
The final two papers in this Journal Watch concern the impact of contact precautions on healthcare-worker activity and the use of probiotics to prevent Clostridium difficile associated diarrhoea.
While there is a reasonable consensus in the literature that the use of contact precautions can lead to adverse effects on patients, these authors cite adverse events, depression, delirium and poorer quality of care as examples, the efficacy of contact precautions in the prevention of transmission of epidemiologically important organisms is still debated. This paper reports a large multicentre observational study of the impact of placing patients under contact precautions on the activities of healthcare workers (HCW). Importantly, the activities observed included both those required by contact precautions and some indicators of possible adverse effects. The study consisted of observing randomly selected patient rooms (with or without contact precautions in place) at randomly selected times in four different hospitals and in different acute clinical settings; intensive care units and medical/surgical wards. The observations were made without informing staff as to their purpose with, as required, a prepared story about the reason for the observers’ presence that was unrelated to the study. The results are interesting for a number of reasons. First, they confirm that patients who are being managed in this way get less attention than normal; both the frequency and duration of HCW visits were significantly lower for contact precautions patients than for others. Interestingly, though perhaps not surprisingly, although frequency was lower in intensive care units (ICUs), duration was not. There was a trend for patients on contact precautions to receive fewer visitors though this was not significant. The results for compliance with precautions are both interesting and not encouraging. Compliance with gown and glove use was only 60%–70%, and compliance with hand hygiene was generally low at around 30%–50% on entry and exit, respectively. The only ‘good news’ was that HCW compliance with hand hygiene was significantly higher on leaving patient rooms in contact precautions patients than others (63% versus 47%, p < 0.001). Overall these results suggest there is still a long way to go if contact precautions are to deliver the intended outcome of eliminating the transmission of important and unwanted organisms between our patients.
This is a long, detailed and complicated paper and is included for two main reasons; the first is simply that Clostridium difficile is an important organism that causes significant problems for most, if not all, of those working in infection prevention and control. With that in mind, this paper is, I hope, interesting to readers as it is an important summary of the state of the art with regard to the role of probiotics in preventing ‘CDAD’ (Clostridium difficile-associated diarrhea – the preferred term of these authors). The second reason for including this paper is that it is an excellent example of a well conducted and reported systematic review and is worth reading for that reason alone. Systematic reviews with, where possible, meta-analyses are the engine of evidence-based changes to practice and should rarely, if ever, be ignored. A detailed explanation of the methods and comprehensive results is beyond the scope of this Journal Watch feature and a full read of the paper is strongly recommended; but I will highlight some of the key findings. The headline result is that probiotics reduce the risk of CDAD by an average of 66% (95% CI: 76 to 51%) and that the incidence of adverse effects was no higher in those receiving probiotics. Further detail in the paper includes sub-group analyses by adults/children, dose of probiotic, species, single versus multiple species and studies with differing risks of bias.
There are many papers published every week/month that may be of interest to readers of JIP and I can only review a fraction of them. Readers are strongly encouraged both to refer to the full articles cited here, as well as to those published in JIP, and to send suggestions for articles to include in this column to me at the address at the top of this Journal Watch feature.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.