Category: Hospitals

Categories : Diseases, Syndromes and Conditions HospitalsTags :

Toss Out Hospital Sinks Colonised by MDRO, Evidence Suggests

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Methicillin-resistant Staphylococcus aureus (MRSA) bacteria. Credit: CDC

An outbreak of a pandrug-resistant nosocomial pathogen was interrupted by not using hospital sinks during COVID, according to Basma Mnif, Professor of Microbiology at Habib Bourguiba University Hospital of Sfax, Tunisia. In her presentation at the 14th SAFHE Southern African Healthcare Conference, she said that infection control methods to eradicate the pathogen failed and that other research indicated it was necessary to replace the sinks entirely.

Multidrug-resistant organisms (MDRO) are a growing threat in hospitals, especially to critically ill patients.

Over 2017 to 2021, 90 critically ICU patients in a Tunisian hospital were infected with pandrug-resistant Proteus mirabilis strains. This is the first known long-term outbreak by pandrug-resistant P. mirabilis strains.

P. mirabilis is an uncommon nosocomial pathogen causing opportunistic infections. P. mirabilis survives well in the natural environment and is increasingly implicated in nosocomial outbreaks worldwide.

The all-cause mortality rate in the infected was 47%, with patients ranging in age from 16 to 78 years. The average length of stay before infection was 23.56 days.

An outbreak was recognised in April 2017, and IDC measures were taken to contain it. The outbreak was suppressed but reoccurred in July and December. Analysis revealed overlapping ICU stays of infected patients, suggesting horizontal, intra-ICU transmission. Lab analysis of phenotypes revealed two clones, A and B, both with drug resistance genes, to which a third clone was added in 2018. This Clone C proved to have resistance to all known antibiotics.

During the COVID pandemic in 2020, hospital sinks were not used and enhanced infection prevention interventions were deployed. This period coincided with a complete absence of P. mirabilis infections. The outbreak resumed in 2021, with the same three clones causing infections in patients.

“The outbreak intermission during COVID could be related to the enhanced protection measures implemented during this period,” Prof Mnif noted, “but we think that the sinks are in fact the reservoirs of these MDRO, and must in fact be removed and replaced, and the chemical disinfection that we had performed was not sufficient to control the outbreak.”

The outbreak highlighted the need for proper infection control protocols. Hospital wastewater is a major source of outbreaks, Prof Mnif pointed out. A study found that “over the past 20 years, there have been 32 reports of carbapenem-resistant organisms in the hospital water environment.”

She said when it came to replacing the sinks, hospitals should “respect FGI guidelines, especially in having sufficient depths of the sink, deep enough to prevent splashing.” Having sufficient pressure and splash reduction measures such as splash guards are also important, Prof Mnif added.

Although there are CDC guidelines to help prevent colonisation, there is no clear strategy for eradication for when a sink is colonised. There is likely genetic interchange between organisms in biofilms, something which needs to be investigated further, as well as means of eradication.

Categories : Expert Opinion HospitalsTags :

Proper Handwash Basin Design and Use is Critical to Controlling AMR

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Photo by Piron Guillaume on Unsplash

Some 10 million people annually are projected to die annually from antimicrobial resistance AMR in 2050, says Briëtte Du Toit, Programme Manager and Training Coordinator at Infection Control Africa Network (ICAN). While efforts to develop new antibiotics and conserve current ones are under way, it is vitally important to limit hospital-acquired infections as this is where many resistant strains spread. One of the key ways of controlling this is through the proper use of handwash basins, which necessitates a collaboration between the medical and engineering disciplines.

Presenting at the 14th SAFHE Southern African Healthcare, Du Toit stressed the importance of proper handwashing protocol and the critical importance of handwash basin design and placement to control the spread of hospital-acquired infections amid rising antimicrobial resistance.

The simple protocol of hand washing is perhaps one of the most important in modern medicine. In the past, clinicians might perform and autopsy and then deliver a child, all without washing their hands. It was only until the mid 1800s when Hungarian doctor Ignaz Semmelweis discovered the importance of hand washing, causing infection rates to plummet after the introduction of this most simple of protocols.

In modern hospitals, handwash basin design and placement, along with inadequate water supply and inadequate knowledge on the part of staff, contributes to inadequate hand washing and therefore high infection rates, Du Toit pointed out.

The design of handwash basins may seem straightforward, but there are many factors to consider. Water may drop onto other surfaces, or splash onto HCWs’ clothes. If medical supplies are stored nearby, then stray water droplets may also land on them.

A study of handwash basins showed that only 23% of basins were used for handwashing, while the remainder were used for a variety of activities including waste disposal. Of the basins used for waste disposal, 55% were contaminated. Another study showed that, in the ICU setting, washbasins were used for handwashing a mere 4% of the time. A sluice is also needed in close proximity to patients, otherwise staff will use handwash basins for incorrect disposal of body fluids.

Having the outlet directly beneath the tap as in a traditional domestic basin increases contamination. A bowl depth less than 19cm also contributed to contamination. Without a bowl cover, 9% of gowns and 6% of hands were found to be contaminated with gram-negative bacili (GNB), versus 2% of gowns and 0% of hands when a cover was present.

Significant improvements were also seen in ‘water-free’ protocols at the point of care, which involved the extensive use of disposable wipes, bottled water and practices such as using electric shaving. The implementation of water-free protocols at one hospital saw a drop in GNB colonisations from 26.3 to 21.6 / 1 000 ICU admission days. An even greater effect was seen for long-term ICU stays, with a 3.6 fold-reduction for stay exceeding 14 days.

Du Toit concluded by stressing the importance of collaboration between the medical and engineering fields, sharing data. Engineers should also be on IPC committees. Likewise, medical personnel should be part of the project team during building and renovations.

Categories : Healthcare Politics and Regulations HospitalsTags :

Battling to Increase Nurse Numbers, SA Looks Abroad

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Image by Hush Naidoo from Unsplash
Image by Hush Naidoo from Unsplash

The addition of specialist nurses by the Department of Home Affairs to the critical skills list has drawn renewed attention to and criticism of the chronic shortage of nurses in South Africa.

According to a statement by Life Healthcare last year, the country would need as many 26 000 additional nurses in 2022 to meet growing demand.

“Nurses have been on the frontline of the efforts to combat COVID for over two years. They are understandably exhausted and require our support as they continue to deliver quality care to our patients,” the group said, adding that it was embarking on programme to train an additional 3000 nurses per year.

In an open letter on the situation, the Hospital Association of South Africa (HASA) said that there was considerable training capacity and willingness from private sector hospitals, while also noting that the transition to new nursing qualifications has interrupted nurse training.

Last week, following engagement with the Minister of Health, South African Nursing Council, Health Professions Council of South Africa, public hospital CEOs and other experts, the DHA published an updated critical skills list, which was expanded to include specialist nurses and medical specialists.

The registered nurse specialties are intensive/critical care, psychiatric, peri-operative, trauma and paediatric nursing, as well as midwife specialists.

What many seen as the government’s inaction over the situation has not gone without criticism.

Speaking to the the Sunday Tribune, Sibongiseni Delihlazo of the Democratic Nursing Organisation of SA said that they were “extremely angry that we have to import specialist nurses because of the government’s actions.”

He points to falling numbers of nurses being produced each year and the shutting of nursing colleges as a sign of government neglect. World Health Organization studies showed a worldwide nursing shortage of 10 million positions by 2030, which needed an 8% annual increase in new nurses.

“Our country has not adhered to the warning, but has done the opposite,” he said.

Delihlazo said that most nursing students received government funding which was drying up, yet the population growth continued as did public healthcare system demand.

Public healthcare was not releasing nurses for specialist training, as doing so would cause the system to crumbled, Delihlazo said. In addition, local nurses are being effectively poached by first world nations.

“We could have produced our own nurses in a country with serious unemployment issues. The government doesn’t have a strategy to keep our nurses,” he said.

Categories : Hospitals Medical IndustryTags :

Mediclinic Agrees to £3.7bn Buyout by Remgro Consortium

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After turning down a previous bid, Mediclinic has agreed to a £3.7 billion buyout by a consortium consisting of investment group Remgro Limited and Mediterranean Shipping Company (MSC).

The buyout will give Remgro and MSC, through a jointly owned subsidiary, a 50/50 stake in the healthcare company.

The offer still has to be cleared by 75% of Mediclinic’s shareholders (Remgro is already a shareholder), but according to the The Daily Maverick, Mediclinic’s CFO, Gert Hattingh, the company’s directors consider the terms of the sale to be fair and reasonable. In addition, regulatory approval must be granted in South Africa, Namibia, Switzerland and Cyprus for the acquisition to proceed.

The current bid is offering 504 pence per share, a 35% increase on the first rejected offer, according to MoneyWeb. With the £3.7 billion buyout, Mediclinic has an implied enterprise value of roughly £6.1 billion.

Mediclinic operates 74 hospitals as of March this year, with 50 hospitals in Southern Africa (three of which are in Namibia), 17 hospitals in Switzerland, seven in the UAE and a 200-bed hospital due to open in Saudi Arabia.

The 72-year-old Johann Rupert who leads Remgro and has a 7% ownership, is South Africa’s richest person, with a personal fortune of $8.8bn, according to the most recent estimate by Forbes.

Commenting on the acquisition, Dame Inga Beale, Chair of Mediclinic, said: “The recommended offer represents a near-term value realisation for Mediclinic shareholders at an attractive premium.

“Over 39 years, Mediclinic has developed into the leading international healthcare services group it is today. During this time, Remgro has remained a supportive long-term shareholder. Together with SAS, the Consortium’s resources will put Mediclinic in a strong position to continue to serve patients through our broad range of high-quality healthcare services.”

Categories : HospitalsTags :

Study Shows that Not Everyone can Adjust to Shift Work

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Photo by SJ Objio on Unsplash

A new study of French hospital workers have challenged the widely held belief that shift workers adjust to the night shift over time, using data drawn from wearable sensors.

By monitoring groups of the hospital workers working day or night shifts during their working and free time, the researchers have shown that not only does night work significantly disrupt both sleep quality and circadian rhythms, also that workers can experience such disruption even after years of night shift work.

Their findings, reported in eBioMedicine, are the most detailed analysis of the sleep and circadian rhythm profiles of shift workers yet attempted, and the first to also monitor body temperature. This key circadian rhythm is driven by the brain pacemaker clock, and coordinates the peripheral clocks in all organs.

In addition, the research demonstrates the value of telemonitoring technology for identifying early warning signs of disease risks associated with night-shift work opening up intervention opportunities to improve the health of workers.

The study compared 63 night-shift workers, working three or more nights of 10 hours each per week, and 77 day-shifters alternating morning and afternoon shifts at a single university hospital near Paris. Both groups wore accelerometers with chest surface temperature sensors throughout the day and night for a full week.

The accelerometer measured movement intensity and served as an estimate for participants’ sleep duration, how regular were their circadian rhythms, and whether that sleep was disrupted by movement. Patterns in the chest surface temperature gave a further indication of the participants’ circadian rhythm, which coordinates rest-activity phases, varying core body temperature, and an array of other bodily rhythms.

Analysis of interruptions to sleep and rhythmic variations in core body temperature showed that night-shift workers had less than half the median regularity and quality of sleep of their day-shift colleagues. 48% of the night-shift workers had a disrupted circadian temperature rhythm.

Using information from questionnaires on the participants’ chronotypes, they also found that the centre of sleep for those working the night shift didn’t correlate with their respective chronotype, ie their morningness or eveningness orientation. This meant they were not sleeping in synch with their internal clocks.

Even workers with years of being on night shifts still showed these negative effects on circadian and sleep health. The more years of night work they had, the more severe the circadian disruption – contradicting widely held assumptions about night work adaptation.

This helps explain why previous studies have shown an association between disrupted circadian rhythms with long term health risks, such as cancer and cardiovascular disease.

Professor Bärbel Finkenstädt from the University of Warwick Department of Statistics said: “There’s still an assumption that if you do night work, you adjust at some stage. But you don’t. We saw that most workers compensate in terms of quantity of sleep, but not in terms of quality during the work time.”

Dr Julia Brettschneider of the University of Warwick Department of Statistics said: “I think there’s a misunderstanding that night shift work is just an inconvenience, whereas it can be linked to serious health risks. We can’t avoid shift work for many professions, like healthcare workers, so we should be thinking about what can be done in terms of real-world adjustments to improve working conditions and schedules of shift workers. A better understanding of the biological mechanisms helps to find answers to this question.

“Together with our PhD student Yiyuan Zhang, we have developed a statistical analysis framework that enables the discovery of patterns and predictive factors in the complex data sets created by wearable tech.”

Professor Francis Lévi from Université Paris-Saclay further added: “Nearly 20% of the night workers could not even adjust their circadian rhythms during their free time, with the severity of impairment tending to increase with the number of years of night work. The telemonitoring technology, and analysis methods we have set up make it now possible to objectively evaluate circadian and sleep health in night workers in near real time, and design prevention measures for individual workers whenever necessary.”

In future research, the team may look at more long-term outcomes, such as diseases such as cancer that have been linked to circadian disruption.

Source: University of Warwick

Categories : General Interest HospitalsTags :

Another Fire Breaks Out at Charlotte Maxeke

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Source: Pixabay CC0

In what is becoming something of a regular occurrence for Gauteng hospitals, another fire has broken at beleaguered Charlotte Maxeke Academic Hospital on Tuesday night. Fortunately, the fire was contained to a currently unused parking area in a damaged section of the hospital. The situation was deemed not to be serious enough to warrant a patient evacuation.

A fire in April 2021 caused the closure of seven wards, with some 200 beds. Reopening had long been delayed, and there have been complaints of thefts of equipment and construction material. Alleged corruption has continued to dog the full reopening of the 1088-bed academic hospital, overloading other hospitals and also impacting the training of student doctors.

An investigation by Spotlight revealed a number of factors for the 2021 fire including ageing infrastructure, essential equipment such as fire doors not working, low water pressure and incompatible fire hydrants (due to theft), a lack of evacuation plans and a fire service that was woefully underequipped.

Gauteng department of health spokesperson Motalatale Modiba gave a report on the latest fire: “Late on Tuesday night, security personnel reported that there was smoke that seemed to be coming from one of the structures. Firefighters for the City of Joburg immediately responded to the situation and managed to contain the fire which was confined to a small section of the level two parking.”

“The level two parking is one of the areas that was affected by the April 2021 fire and is currently under props and not accessible to the public or staff except for construction people,” Modiba said.

“Upon assessment of the situation clinicians on site together with the facility’s head of disaster made a call that the situation did not warrant for patients to be evacuated as the smoke from the fire was not too thick or high risk for inhalation.”

This comes after two fires broke out within weeks of one another at Steve Biko Academic Hospital.

Categories : HospitalsTags :

Slight Safety Edge for Ringer’s Lactate over Standard Saline

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Intravenous IV drip
Source: Marcelo Leal on Unsplash

A new US study has found that Ringer’s lactate may be a better and safer treatment option for emergency department and hospital patients than saline solution, especially in sepsis.

According to the study of nearly 150 000 hospital patients, which was published in JAMA Network Open, Intermountain Healthcare researchers found that patients who received Ringer’s lactate solution instead of normal saline for IV fluids had a lower risk of kidney injury and death than when they were given saline.

Saline solution has long been the standard for IV solution with more than 200 million litres administered to hospital patients annually in the US.

Intermountain researchers found that patients who were given Ringer’s lactate as an alternative to saline solution had a 2.2% reduced risk of kidney injury and death.

Joseph Bledsoe MD, principal investigator of the study, said: “That might not sound like a big difference but considering how many patients receive IV fluids every day, it could lead to a major improvement in health outcomes. For our health system alone, that’s 3000 people every year who may avoid complications from normal saline, at no additional cost.”

For this large-scale, study researchers encouraged clinicians, through education and electronic order entry alerts, to use Ringer’s lactate solution rather than saline solution for IV fluid treatment.

Saline solution is a combination of sodium chloride and water at a concentration of 9g of salt per litre (0.9%) which are levels higher than blood, commonly called normal saline.

Mounting evidence points to intravenous normal saline solution increasing the risk of metabolic acidosis, acute kidney injury, and death. This could be due to normal saline having higher levels of chloride and being slightly more acidic than fluids in the human body.

Though they have different ingredients, both Ringer’s lactate and normal saline are used for replacing fluids and electrolytes in hospital patients who have low blood volume or low blood pressure.

Ringer’s lactate contains electrolytes more similar to blood plasma than saline solution. Ringer’s lactate, which is a type of balanced crystalloid, is also much closer to human fluid pH and did not show the same related risk of kidney injury, in line with previous smaller studies.

The study included 148 423 adult patients admitted to the emergency department or inpatient units at 22 Intermountain Healthcare hospitals in Utah and Idaho between November 1, 2018, and February 29, 2020.

At 30 days post treatment, researchers found a 2.2% reduction in major adverse kidney events, including persistent kidney dysfunction, new initiation of dialysis, and death in patients who were given Ringer’s lactate rather than normal saline solution during their emergency department or hospital treatment course.

The impact was even greater on patients with sepsis and on patients who received more fluids as part of their treatment. Not all patients benefit from Ringer’s lactate – patients with brain injury may still benefit from normal saline, but further studies are needed.

Researchers determined that before the study, approximately 25% of patients received Ringer’s lactate, and 75% received normal saline solution. Afterward, the percentages flipped to 25% receiving normal saline and 75% Ringer’s lactate.

Researchers found that nudges in the Intermountain electronic order system were more effective in changing clinician habits than relying on education.

“Given the success of nudges in making this change, our success could be replicated in other health systems and allows for sustained improvement,” said Dr. Bledsoe. “Given the scope of this study, and its success in addition to previous studies, hospitals around the country should consider what they use for IV fluids, too.”

In an editorial about these findings published in the same issue of JAMA Network Open, Matthew W. Semler, MD, MSc, assistant professor of medicine at Vanderbilt University Medical Center, wrote that the study “raises important questions about the choice between Ringer’s lactate solution and saline and, more broadly, how we should make evidence-based choices between widely available, commonly used treatment alternatives in acute care.”

Source: News-Medical.Net

Categories : Hospitals Substance UseTags :

Greater Hospitalisation or ED Visit Risk for Cannabis Users

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Photo by RODNAE Productions from Pexels

Compared to non-users, cannabis users have 22% higher rates in emergency department (ED) visits and hospitalisations, according to new research findings. The study, published in BMJ Open Respiratory Research revealed that serious physical injury and respiratory-reasons were the two leading causes of ED visits and hospitalisations among cannabis users.

The findings suggest an association between cannabis use and negative health events, which the researchers say should underline the need to educate and remind the public of the harmful impacts of cannabis on health.

“Our research demonstrates that cannabis use in the general population is associated with heightened risk of clinically serious negative outcomes, specifically, needing to present to the ED or be admitted to hospital,” said Dr Nicholas Vozoris, lead author, a respirologist at St. Michael’s and an associate scientist at the hospital’s Li Ka Shing Knowledge Institute.

“Unlike tobacco, there is some uncertainty or controversy regarding the adverse health impacts of cannabis. Some individuals may perceive that cannabis has some health benefits and is otherwise benign. Our research highlights to those using – or considering to use – cannabis, that this behaviour is associated with important negative health events.”

To compare health outcomes among cannabis users and individuals who don’t use cannabis, researchers used data collected in a survey of individuals who self-reported cannabis use and linked it with health administrative data for Ontario residents.

Using propensity score matching, researchers compared the health outcomes of nearly 4800 individuals who reported any cannabis use in the preceding 12 months with the health outcomes of over 10 000 individuals never-users, or having used cannabis only once and more than 12 months ago. Researchers incorporated 31 different variables while matching study participants to minimise an unfair comparison, including demographics, multiple physical and mental health diseases, and tobacco, alcohol and illicit drug use.

The study’s main aim was to see if there was a link between cannabis use and respiratory-related hospitalisation or ED visits. No significant associations were found between cannabis use and respiratory-related ED visits, hospitalisations, or death from any cause. However, they did find that overall visits to the ED or hospitalisations for any reason was significantly higher among cannabis users.

In addition to having greater odds of ED visits or hospitalisation, the findings show that one of every 25 cannabis users will go to the emergency department (ED) or be admitted to hospital within a year of using cannabis.

Among the reasons for ED visits or hospitalisations of cannabis users, acute trauma was the most common, with 15% of cannabis users who got medical attention receiving it for this reason, and 14% receiving care for respiratory reasons.

“The results of our research support that health care professionals and government should discourage recreational cannabis consumption in the general population,” noted Dr Vozoris.

Source: EurekAlert!

Categories : Antibiotics HospitalsTags :

Antibiotic Stewardship and Sepsis Management: Achieving the Best of Both

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Photo by Anna Shvets on Pexels

Lessening sepsis’s deadly effects means quickly recognising its signs and symptoms, and initiating antibiotic treatments, but some experts have wondered whether this may contribute to antibiotic overuse, especially with time-to-treatment performance measures. A new study published in JAMA Internal Medicine showed that it was possible to effectively treat sepsis while engaging in antibiotic stewardship.

The study led by Hallie Prescott, MD, of the University of Michigan Health Division of Pulmonary and Critical Care and Vincent Liu, MD, of Kaiser Permanente Division of Research, looked at data from more than 1.5 million patients from 2013–2018. Patients included came to the emergency department with signs of systemic inflammatory response syndrome (SIRS), which includes increased heart rate, abnormal body temperature, among other signs.

The research team analysed antibiotics use in these patients, including number receiving antibiotics, when treatment started, treatment duration medications and the broadness of spectrum of the antibiotics.

“We showed in the overall cohort, that antibiotic use decreased. There was a slight decrease in the proportion treated within 48 hours, a more impressive decrease in the average number of days of antibiotic treatment, and also a decrease in the use of broad-spectrum antibiotics,” said Dr Prescott.

About half of the people who met the criteria for SIRS received antibiotics within 12 to 48 hours after admission, a practice that decreased slightly over time. At the same time, 30-day mortality, length of hospitalisation, and the development of multi-drug resistant bacteria also decreased.

“This study adds to our national conversation about how to combat sepsis most effectively. It also confirms that we now need to look for new opportunities to mitigate sepsis by finding patients at high risk before they arrive at the hospital, identifying hospitalised patients most likely to benefit from specific treatments, and enhancing their recovery after they survive sepsis,” said Dr Liu.

Dr Prescott agrees: “The pushback has been [time-to-treatment for sepsis] should not be a performance measure because it’s going to cause more harm than good, and I think our data shows it probably does more good than harm. We have shown that 152 hospitals have been able to make improvements in stewardship and sepsis treatment at the same time, contrary to popular belief.”

Source: Michigan Medicine – University of Michigan

Categories : HospitalsTags :

Physicians Prescribe Less Analgesic Medication during Nightshifts

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Physicians prescribe less analgesic medication during nightshifts than during the day, according to a new study published in PNAS.

In the first part of the study, 67 doctors were given empathy assessment tasks in the morning and asked to respond to simulated patient scenarios. These doctors were either at the end of a 26-hour shift or just beginning their workday. The study found that doctors who recently completed night shift showed less empathy for patient’s pain. For example, these physicians’ exhibited decreased emotional responses to pictures of people in pain and consistently scored their patients low on pain assessment charts.

In the second part of the study, the researchers looked at actual medical decisions made by emergency room doctors in the United States and Israel. Analysed 13 482 discharge letters for patients who came to the hospital in 2013–2020 with a chief complaint of pain, they found that physicians were 20–30% less likely to prescribe an analgesic during nightshifts (compared to daytime shifts) and in amounts less than generally recommended by the World Health Organization. “They’re tired and therefore they’re less empathic to patients’ pain. When we looked at ER doctors’ discharge papers, we found that they prescribed fewer painkillers,” explained Professor Shoham Choshen-Hillel from the Hebrew University of Jerusalem (HU)’s School of Business Administration and Federmann Center for the Study of Rationality, who led the study.

The bias persisted after adjusting for patients’ reported level of pain, patient and physician’s demographics, type of complaint, and emergency department characteristics. “Our takeaway is that nightshift work is an important and previously unrecognised source of bias in pain management, likely stemming from impaired perception of pain. The researchers explain that even medical experts, who strive to provide the best care for their patients, are susceptible to the effects of a nightshift,” noted co-lead author HU Psychology Department’s Dr Anat Perry.

Looking ahead, the researchers suggest implementing more structured pain management guidelines in hospitals. Another important implication relates to physician work structure, and the need to improve physicians’ working schedules. “Our findings may have implications for other workplaces that involve shiftwork and empathic decision-making, including crisis centres, first responders, and the military. In fact, these results should probably matter to all people who are sleep-deprived,” added co-lead author Dr Alex Gileles-Hillel from Hadassah Medical Center and HU.

Source: ScienceDaily