Pediatric Care Setting Research Articles

719 Developing Paediatric Pain Maps in the Accident and Emergency Department

Background and aims: The College of Emergency Medicine has consistently identified pain score recording as essential in the provision of adequate analgesia in the Paediatric acute care setting. This study recorded patients' stated pain scores in realtime at set defined time points.Methods: A prospective, observational pilot study utilising convenience sampling of children aged 5 - 15 years was conducted in the Ormskirk District General Hospital Paediatric Emergency Department, UK (20,815 presentations pa) 10 - 24th July 2009. Self-reported pain scores in acute pain were recorded every 15 minutes for 4 hours, using a combination of a numeric rating scale from 0-10 and the Wong-Baker FACES pain scale.Results: During the study period 54 patients were enrolled, 7.27 % (n = 743) of the attendances, with 47 completing the 4 hour pain score period.All patients showed a reduction in their pain scores compared to their pain score on presentation. Maximal pain score reduction occurred within 1 hour (varied treatment regimes - medical / nonmedical). Some patients showed secondary peaks in pain towards 4 hours.Conclusions: Mapping patients' pain through sequential pain scoring should provide valuable information to predict intervention responses and in the future may be facilitated by a patient-controlled real-time pain assessment electronic device. In addition we envisage calculating the area under the curve for pain versus time graphs, which may make us re-evaluate moderate pain regimes.

The power of a standardized bleeding score in diagnosing paediatric type 1 von Willebrand’s disease and platelet function defects

A predictive standardized bleeding questionnaire (Vicenza score), previously validated for identifying individuals with type 1 von Willebrand's disease (VWD), has never been prospectively validated in tertiary care paediatric settings. The aim of this study was to assess the Vicenza score's predictive power in identifying type 1 VWD, low von Willebrand factor (VWF) and platelet function defects (PFD) in a prospective cohort of patients, 0-17 years old, referred to a paediatric haematology clinic for evaluation of a bleeding disorder. Before the initial visit, caregivers consented to answer the questionnaire via telephone. Patients' medical records were reviewed after haematological evaluation. VWF:Ag or VWF:RCo<30 IU dL(-1) were labelled 'definite type 1 VWD' while 30-50 IU dL(-1) were labelled 'Low VWF'. PFA-100 screening followed by abnormal electron microscopy and/or platelet aggregation studies diagnosed a PFD. At least one haemorrhagic symptom was present in 99 of the 104 children who completed the study (mean number of symptoms 2.87, mean Vicenza score 3.24). Eight met criteria for 'definite type 1 VWD', 23 for 'low VWF' and 13 for 'PFD'. The sensitivity, specificity, and positive and negative predictive value (NPV) of the Vicenza score demonstrated poor diagnostic utility with the exception of high specificity in ruling out 'definite type 1 VWD'. The NPV was comparably high with qualitative (>2 bleeding symptoms) and quantitative (Vicenza score ≥ 2) criteria. The Vicenza score has limited predictive value in paediatric tertiary care settings. While the NPV of excluding 'definite type 1 VWD' is high, simpler qualitative criteria is similarly predictive.

A framework for clinical teaching: A passion-centered philosophy

Clinical nurse educators are facing a number of new challenges in pediatric acute care settings that necessitate revisions to their teaching approaches. In this paper, we present a theoretical discussion of a philosophy of nursing education based on a passion for teaching that, when implemented by clinical nursing faculty, promotes positive learning environments in which nursing students feel supported, valued, and engaged. A revised leadership framework, as originally set out by Day (2004), is utilized to explore the essential philosophical underpinnings of passion that nurse educators may consider as they seek to promote positive student outcomes in clinical nursing education. Beatty et al. (2009) argued that there is a growing conviction that every teacher needs a carefully formulated teaching philosophy. Similarly, we contend that all clinical nurse educators critically evaluate their understanding of the meanings and experiences that motivate and frame their values of teaching. We suggest that teaching with passion promotes the development of a positive learning environment and lends itself to rewarding and successful learning experiences.

A Conceptual Framework for Advanced Practice Nursing in a Pediatric Tertiary Care Setting: The SickKids’ Experience

Advanced practice nurses (APNs) at The Hospital for Sick Children (SickKids) are pediatric healthcare providers who integrate principles and theories of advanced nursing with specialty knowledge to provide autonomous, independent, accountable, ethical and developmentally appropriate care in complex, often ambiguous and rapidly changing healthcare environments. Caring for children and adolescents requires culturally sensitive and family-centred approaches to care that incorporate a unique body of knowledge. Family-centred care is an approach to planning, delivery and evaluation of healthcare that is governed by the establishment of mutually beneficial partnerships among APNs, health professionals and children/families. The cornerstone of APN practice at SickKids is the recognition of "family" as the recipients of care. By valuing and developing relationships with families, APNs promote excellence in healthcare across the care continuum to optimize the child's and family's physical, emotional, social, psychological and spiritual well-being. This paper outlines the evolution of advanced practice nursing at SickKids, beginning with the introduction of APN roles in the 1970s and culminating in the current critical mass of APNs who have been integrated throughout the hospital's infrastructure. We describe the process used to create a common vision and a framework to guide pediatric advanced nursing practice.

The Power of a Standardized Bleeding Score in Diagnosing Pediatric Type 1 Von Willebrand Disease.

Abstract 1293Poster Board I-315 INTRODUCTIONType I von Willebrand disease (VWD) is the most common inherited bleeding disorder. Repetitive testing of von Willebrand factor (VWF) levels is necessary before the diagnosis can be safely ruled out, as VWF levels fluctuate in response to genetic and environmental factors. A predictive bleeding score (BS) could reveal individuals that may benefit from repetitive testing and those for whom repetitive testing is unlikely to be of benefit. While a standardized questionnaire (the Vicenza score) was developed to evaluate hemorrhagic symptoms, it was never prospectively validated for a pediatric population in a tertiary care setting. SUBJECTSThe study targeted children, ages 0 to 17 years, referred to the Hemostasis and Thrombosis Center (HTC) of Nationwide Children's Hospital for a coagulation evaluation as a result of bleeding symptoms, family history of a bleeding disorder and/or abnormal coagulation labs found during pre-operative screening. Children were excluded if they had a previously diagnosed bleeding disorder, if their caregiver did not speak English or if the child did not undergo VWF:Ag and VWF:RCo testing. METHODSPrior to the diagnosis or exclusion of a bleeding disorder in the child, caregivers consented to answer the questionnaire over the telephone. Descriptions of the Vicenza score are available online (http://www.euvwd.group.shef.ac.uk/bleed_score.htm). LABORATORY TESTINGA single VWF:Ag or VWF:RCo <30 IU/dL was classified as “Definite Type 1 VWD” while levels from 30-50 IU/dL were classified as “Low VWF” (http://www.nhlbi.nih.gov/guidelines/vwd). Platelet function analysis (PFA-100) screened for platelet function defects, with some patients undergoing follow-up platelet aggregation studies and/or platelet electron microscopy. Laboratory studies from other institutions were excluded from analysis. Patients' medical records were reviewed after hematologic evaluation, and the resultant data was analyzed with STATA 10.1 (Stata Corp., College Station, TX). RESULTSA total of 104 children (52 females and 52 males) with a mean age of 7.53 years (range 1 month to 17 years) were included. At least one hemorrhagic symptom was present in 99 of the 104 children (95%) with the mean number of symptoms being 2.87 (range 0 to 7). The mean Vicenza score was 3.24 (range -1 to 13). Of the 104 children, 8 met criteria for “Definite Type 1 VWD,” 23 met criteria for “Low VWF,” 14 were diagnosed with a “Platelet Function Defect,” and 2 children had bleeding secondary to Ehlers Danlos syndrome. Children with non-bleeding disorders (e.g. Factor XII deficiency) or no laboratory evidence of a bleeding disorder were classified as “No Bleeding Disorder.” In general, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive diagnostic likelihood ratio of the bleeding questionnaire demonstrated poor predictive value in our patient population with the exception of high specificity in ruling out “Definite Type 1 VWD” (Table). The NPV was comparably high with both qualitative (>2 bleeding symptoms) and quantitative (BS ≥2) criteria. CONCLUSIONSThe Vicenza score, previously validated in adults and in a pediatric primary care setting, appears to have limited predictive value in a pediatric tertiary care setting when evaluating patients with platelet function defects or low VWF levels. While the Vicenza score has a high NPV to exclude “Definite Type 1 VWD,” the use of simpler qualitative criteria is similarly predictive.TablePredictive power of the Vicenza score in a pediatric tertiary care population. (Sensitivity=SN; Specificity=SP; Positive predictive value=PPV; Negative predictive value=NPV; Positive diagnostic likelihood ratio=DLR+; Bleeding score=BS; Confidence interval=CI)PopulationCriteriaSN(%)SP(%)PPV(%)NPV(%)+95%CIDLR+Definite Type 1 VWD>2 bleeding symptoms62.546.98.993.8 (82.8-98.7)1.17BS ≥287.530.29.596.7 (82.8-99.9)1.25BS >3 or 5 in males and females37.572.910.393.3 (85.1-97.8)1.38Definite Type 1 VWD + Low VWF>2 bleeding symptoms58.147.932.172.9 (58.2-84.7)1.11BS ≥283.934.335.183.3 (65.3-94.4)1.28BS >3 or 5 in males and females41.978.144.876.0 (64.7-85.1)1.91Definite Type 1 VWD + Low VWF + Platelet Function Defect>2 bleeding symptoms59.150.046.462.5 (47.4-76.0)1.18BS ≥281.836.748.773.3 (54.1-87.7)1.29BS >3 or 5 in males and females40.981.762.165.3 (53.5-76.0)2.23 DisclosuresNo relevant conflicts of interest to declare.

The prevalence of pressure ulcers in four paediatric institutions

Pressure ulcers are a common nursing care issue in hospitals. They are associated with psychological and physical suffering, an increased morbidity and mortality rate and higher overall health care costs. The aim of the current study is to describe the frequency of pressure ulcers in a paediatric care setting and to identify the population at risk, as well as to assess the factors predisposing to the development of pressure ulcers. A point prevalence study. The study was conducted in four paediatric hospitals in the German-speaking part of Switzerland and included children from the age of 0-18 years. The method of data collection was a direct systematic inspection and assessment of the skin, taking into account the clinical condition of the patient for risk assessment. A valid risk assessment and data collection instrument was used and, each patient was assessed by a previously instructed rater pair. Of all possible patients, 81% (n = 155) were included. An overall pressure ulcer prevalence of 27.7% (including grade 1) was registered. Thirty-six patients (84%) had grade 1 ulcers, including many caused by external medical devices. Sixty-five per cent (n = 100) of all patients were considered at risk (Braden score < or = 20) of developing a pressure ulcer. Thirty-five per cent of patients in the risk group were afflicted with one or more pressure ulcers. The prevalence of pressure ulcers in paediatric patients is greater then previously appreciated and the problem requires further exploration. The high percentage of grade 1 pressure ulcers caused by medical devices requires nursing interventions to prevent lesions for these patients. The high prevalence rate in paediatric patients is disconcerting and requires further exploration in terms of interventions needed to improve outcomes for this patient group.

An Analysis of Drug Delivery Dynamics via a Pediatric Central Venous Infusion System: Quantification of Delays in Achieving Intended Doses

Pediatric patients frequently receive continuous infusions of drugs via central venous catheters in the intensive care unit and the operating room. This study characterized drug delivery profiles in a quantitative laboratory model of a standard pediatric central venous infusion system. We evaluated drug delivery via a standard pediatric 8-cm, 4-F double-lumen catheter. One syringe pump infused normal saline as the carrier fluid through a limb of a Y-piece connected to the catheter's 22-gauge distal lumen. Through the other limb of the Y-piece, a second syringe pump infused methylene blue, the model drug, at a constant rate of 0.5 mL/h. The volume delivered was collected every minute for quantitative analysis. We compared 2 mL/h and 12 mL/h total flow rates to mimic volume delivery to a 3-kg infant, and priming of the Y-piece with the model drug, to mimic resumption of a stopped drug infusion, versus no priming, to mimic a new infusion. Drug pump system start-up performance was measured to estimate this factor's contribution to infusion onset profiles. When initiating a new infusion of the model drug, the time to steady-state delivery at the catheter's end varied significantly among the studied scenarios as measured by the time to reach half of the targeted dose (t(50)). Onset of delivery with a low total flow was much slower (t(50) = 23.5 +/- 2.1 min) than with the high flow rate (t(50) = 15.7 +/- 2.9 min). Priming the drug limb of the connecting Y-piece with methylene blue substantially shortened the time to steady state (low flow t(50) = 12.7 +/- 0.6 min, high flow t(50) = 5.2 +/- 0.8 min). Time to cessation of drug delivery to the end of the catheter after stopping the drug pump was substantially shorter using the high carrier flow rate (t(50) = 3 +/- 0.5 min) compared with the low carrier flow rate (t(50) = 11.6 +/- 0.8 min). Drug pump system start-up performance contributed to onset delay. Current infusion techniques in the pediatric care setting can result in significant, unrecognized, and potentially hazardous delays in achieving delivery of intended drug doses to the patient. Total flow rate, priming of the infusion system, the dead volume of the fluid path, and the start-up performance of the infusion pump system contribute to delays in achieving targeted rates of drug delivery.

A randomized, comparative study of formoterol and terbutaline dry powder inhalers in the treatment of mild to moderate asthma exacerbations in the pediatric acute care setting

Formoterol is a fast-acting, long-acting beta-agonist. Its on-demand use by outpatients has been beneficial in controlling asthma. To evaluate the efficacy of formoterol as rescue medication for pediatric asthma exacerbation. A randomized, double-blind study was conducted on parallel groups involving 79 pediatric patients (mean [SD] age, 9.92 [2.5] years) with mild to moderate asthma exacerbations. They were treated with up to 3 doses of formoterol aerolizer, 12 microg, or terbutaline Turbuhaler, 0.5 mg (dry powder inhalers). Respiratory rate, clinical score, pulse oximetry, and spirometry were analyzed at baseline and 15 minutes after administration of each bronchodilator dose. All the patients received oral prednisolone, 1 mg/kg, at study entry, followed by a single daily dose for 4 days. Forty-one patients were treated with formoterol and 38 with terbutaline. The groups were comparable in age and in severity of asthma exacerbation. Both treatments resulted in similar clinical and functional improvement; 37 patients (47%) required 1 bronchodilator dose. Increases of 19.5% and 15.3% occurred in forced expiratory volume in 1 second in the formoterol and terbutaline groups, respectively. Therapeutic failures occurred in 2 patients. No adverse effects were observed. At 1-week follow-up, patients were stable, with pulmonary function close to normal. Formoterol therapy was at least as effective as terbutaline therapy in children and adolescents with mild and moderate asthma exacerbations.

Remote diagnosis of children dental problems based on non-invasive photographs - a valid proceeding?

Telemedicine models using commercially available technology have enabled high-quality illness care in paediatric primary care settings and markedly improved access. This fact should be explored in Pediatric Dentistry, considering that dental problems are very common in children at pre-school age and it becomes important to screen them as early as possible in order to promote the appropriate treatment. In this sense, we aim to know how telemedicine, or more specifically, teledentistry, could help on this process, evaluating the validity of children dental problems remote diagnosis based on non-invasive photographs, using accessible and low-cost technologies. Three photographs were taken for each of 66 children to be remotely analyzed by four dentists. Each dentist filled a web-based questionnaire for each child. The same children had a traditional in-person dental consultation that is used as a gold standard in this study. The results show sensitivity between 94% and 100% and specificity between 52% and 100%. The positive predictive value was between 67% and 100% and the negative predictive value between 94% and 100%. These results suggest that remote diagnosis of children dental problems based on non-invasive photographs constitute a valid resource when we pretend to exclude referred children to a dentist for treatment of dental problems, but further studies should be carried out to increase the validity of this proceeding to referring children for the same treatment.

Screening for Risky Alcohol Use Among Caregivers of Pediatric Trauma Patients: A Pilot Study

Injury is the leading cause of death for children and has been linked to caregiver drinking. Screening and brief intervention for risky drinking has been successful in adult trauma centers but has not been evaluated in caregivers of pediatric trauma patients. The purpose of this study was to investigate a pilot screening process for risky drinking caregivers, to determine rates of risky alcohol use, and to assess potential relationships between risky drinking and child safety behaviors. Caregivers of pediatric trauma patients were screened by trained injury prevention educators. The screening assessed risky drinking, tobacco and illicit drug use, and child safety behaviors. Data were analyzed using descriptive analysis, frequency comparisons, and univariate logistic regression. Over 7 months, 295 caregivers were screened; 32.5% (n = 96) screened positive for risky alcohol use. For 173 injured children, one caregiver was screened, and for 61 children, two caregivers were screened. In the one-caregiver group, 29% (n = 50) screened positive for risky drinking. For the two-caregiver group, in 18% (n = 11) of the cases, both caregivers screened positive, whereas in 39% (n = 24) only one caregiver screened positive. Males were more likely to screen positive (p < 0.01). Relationships between reported child safety behaviors and risky drinking were of interest, but not statistically significant. The results of our study demonstrate that a substantial number of caregivers of pediatric trauma patients will self-report risky drinking behaviors, and therefore, an opportunity exists for these families to receive the benefits of screening and brief intervention programs in pediatric trauma care settings.

A Healthy Weight Intervention for Children in a Dental Setting: A Pilot Study

There are twice as many U.S. children who are overweight or at risk of being overweight as there were 20 years ago. Dental care professionals have an opportunity to provide obesity prevention interventions to their patients. The authors present a dental office-based healthy weight intervention (HWI) protocol designed for all children. Preventive dental office visits are an opportunity for dental care professionals to provide HWIs to children. The authors found that the HWI they described is feasible and can be well-accepted in a pediatric dental care setting. Caregivers and dental care providers said they considered the HWI to be useful, and it was well-accepted by children. Healthy eating and lifestyle behaviors can have a positive effect on systemic health and oral health. Better food choices can reduce dental caries, and the prevention of obesity-related systemic diseases, particularly diabetes, can help patients maintain good oral health.

Selecting Developmental Surveillance and Screening Tools

1. Dennis Drotar, PhD* 2. Terry Stancin, PhD† 3. Paul H. Dworkin, MD‡ 4. Laura Sices, MD§ 5. Susan Wood** 1. *Professor of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 2. †Professor of Pediatrics, Psychiatry and Psychology, Case Western Reserve University and Metro Health Medical Center, Cleveland, Ohio 3. ‡Professor of Pediatrics, University of Connecticut School of Medicine, Farmington, Conn 4. §Assistant Professor of Pediatrics, Boston University School of Medicine, Boston, Mass 5. **Coordinator, Division of Behavioral and Developmental Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio The importance of surveillance and screening for developmental problems in primary care has been well recognized in scholarly reviews and practice guidelines. (1) The need for early detection of developmental problems in infants and young children in primary pediatric care settings stems from the high prevalence of such problems and the potential for early intervention for the child and family. Frequent longitudinal contact with young children and their families at critical times in their early development provides pediatricians and other practitioners with important opportunities to conduct developmental surveillance and screening to detect clinically significant developmental problems and institute early intervention. (1)(2)(3)(4) Early identification and referral to early intervention programs can ameliorate the negative consequences of developmental problems on children, families, and society. (3) However, studies have indicated consistently that many infants and young children who have clinically significant developmental delays are not detected in pediatric primary care. (1)(3)(4) As a consequence, critical opportunities for early intervention for young children who are at risk for developmental problems may be lost. (2)(5)(6)(7) To address this need, the American Academy of Pediatrics (AAP) developed a policy statement for identifying infants and young children who have developmental delays and disorders. (8) This statement is a significant advance in the clinical application of developmental screening in several respects. One is the recommendation to address parental concerns about development as one of several health topics in routine pediatric preventive care visits throughout the first 5 years after birth. Developmental surveillance, defined as a flexible, longitudinal, continuous, and cumulative process, is recommended for inclusion at every pediatric visit. The five components of developmental surveillance described in the AAP statement include: 1) eliciting and attending to the parent's concerns about his …

The diagnostic role of hyperferritinemia in a tertiary care pediatric rheumatology setting

Results More than 4000 determinations of ferritin requested by the study unit were performed between January 2004 and December 2007 by the central laboratory of the study hospital. Hyperferritinemia was found in 408 determinations in 87 patients. The most common specific diagnoses in patients with hyperferritinemia were the following: systemic juvenile idiopathic arthritis (sJIA) (48.3%), systemic lupus erythematosus (SLE) (5.7%), protein intolerance with lysinuria (4.6%), virus-associated haemophagocytic syndrome (3.4%), hematologic disorders (3.4%), juvenile dermatomyositis (2.3%), polyarticular JIA (2.3%), systemic vasculitis (2.3%), autoinflammatory syndrome (2.3%). Twelve patients (13.8%) had a nonspecific systemic inflammatory syndrome. Twenty-seven (31%) of the 87 patients with hyperferritinemia developed features consistent with MAS.

Team training: implications for emergency and critical care pediatrics

The field of team training is quickly evolving and data are emerging to support the close relationship between effective teamwork and patient safety in medicine. This paper provides a review of the literature on team training with specific emphasis on the perspectives of emergency and critical care pediatricians. Errors in medicine are most frequently due to an interaction of human factors like poor teamwork and poor communication rather than individual mistakes. Critical care settings and those in which patients are at the extremes of age are particularly high-risk, making emergency and critical care pediatrics a special area of concern. Team training is one approach for reducing error and enhancing patient safety. Currently, there is no single standard for team training in medicine, but multiple disciplines, including anesthesiology, emergency medicine and neonatology, have adapted key principles from other high-reliability industries such as aviation into crisis resource management training. Team training holds promise to improve patient safety in pediatric emergency departments and critical care settings. We must carefully delineate the optimal instructional strategies to improve team behaviors and combine these with rigorous outcomes assessment to diagnose team problems and prescribe targeted solutions, and determine their long-term impact on patient safety.

The role of patient isolation and compliance with isolation practices in the control of nosocomial MRSA in acute care

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin resistant Staphylococcus aureus (MRSA) transmission continues to rise. Various isolation practices are used to minimise MRSA transmission in acute care. However, the effectiveness of these practices has seldom been evaluated. Objectives This review sought to evaluate the efficacy of isolation practices in minimising MRSA transmission in the acute hospital setting and explore staff, visitor and patient compliance with isolation practices. This review updates a review published in 2002. Search strategy A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. Selection criteria All English language research reports published between 1990 and August 2005 that focused on the role of isolation practices on the nosocomial transmission of MRSA in adult, paediatric or neonatal acute care settings were eligible for inclusion in the review. Studies that evaluated multiple infection control strategies or control of MRSA outbreaks were excluded. The main outcome of interest was the incidence of new cases of MRSA. The secondary outcome was staff, visitor and patient compliance with the isolation practices. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Seven studies met the inclusion criteria. Given the small number of included studies and variable methodological quality, care must be taken when interpreting the review findings. There is some evidence that cessation of single room isolation and cohorting of MRSA patients does not increase nosocomial MRSA transmission when hand-washing compliance and standard precautions are maintained. Indeed, there is some evidence that reduced MRSA transmission can be achieved by improving compliance with contact precautions alone. The low level of hand hygiene compliance reported in the literature suggests that staff compliance with isolation practices is a significant factor in evaluating any infection-controlled intervention in the clinical setting. While staff compliance data are conflicting, regular audit and feedback of performance may improve compliance. Implications for clinical practice The heterogeneous nature of the topic and methodological weaknesses of included studies impairs the ability to aggregate data and develop specific practice recommendations. While this review presents evidence to suggest that ceasing single room or cohort isolation does not lead to increased MRSA transmission, these studies maintained high levels of hand hygiene or standard precautions. Additionally, the role of extraneous factors, such as environmental reservoirs, specific MRSA strains and patient mix, is unclear. None of the included studies measured financial, social or psychological factors associated with isolation practices. There is an urgent need for well-designed research with significant sample sizes to develop an evidence base upon which to underpin future clinical practice.

The role of patient isolation and compliance with isolation practices in the control of nosocomial MRSA in acute care

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin resistant Staphylococcus aureus (MRSA) transmission continues to rise. Various isolation practices are used to minimise MRSA transmission in acute care. However, the effectiveness of these practices has seldom been evaluated. Objectives This review sought to evaluate the efficacy of isolation practices in minimising MRSA transmission in the acute hospital setting and explore staff, visitor and patient compliance with isolation practices. This review updates a review published in 2002. Search strategy A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. Selection criteria All English language research reports published between 1990 and August 2005 that focused on the role of isolation practices on the nosocomial transmission of MRSA in adult, paediatric or neonatal acute care settings were eligible for inclusion in the review. Studies that evaluated multiple infection control strategies or control of MRSA outbreaks were excluded. The main outcome of interest was the incidence of new cases of MRSA. The secondary outcome was staff, visitor and patient compliance with the isolation practices. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Seven studies met the inclusion criteria. Given the small number of included studies and variable methodological quality, care must be taken when interpreting the review findings. There is some evidence that cessation of single room isolation and cohorting of MRSA patients does not increase nosocomial MRSA transmission when hand-washing compliance and standard precautions are maintained. Indeed, there is some evidence that reduced MRSA transmission can be achieved by improving compliance with contact precautions alone. The low level of hand hygiene compliance reported in the literature suggests that staff compliance with isolation practices is a significant factor in evaluating any infection-controlled intervention in the clinical setting. While staff compliance data are conflicting, regular audit and feedback of performance may improve compliance. Implications for clinical practice The heterogeneous nature of the topic and methodological weaknesses of included studies impairs the ability to aggregate data and develop specific practice recommendations. While this review presents evidence to suggest that ceasing single room or cohort isolation does not lead to increased MRSA transmission, these studies maintained high levels of hand hygiene or standard precautions. Additionally, the role of extraneous factors, such as environmental reservoirs, specific MRSA strains and patient mix, is unclear. None of the included studies measured financial, social or psychological factors associated with isolation practices. There is an urgent need for well-designed research with significant sample sizes to develop an evidence base upon which to underpin future clinical practice.

Role of MRSA reservoirs in the acute care setting

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin-resistant Staphylococcus aureus (MRSA) transmission continues to rise. The associated costs of increased hospital stay and patient mortality cause considerable burden to the health system. Objectives This review sought to evaluate the role of reservoirs, particularly the environment and equipment commonly found in the clinical area, in the transmission of MRSA within the acute hospital. This review updates a review previously completed by the authors and published by the Joanna Briggs Institute (2002). Search strategy A systematic search for relevant published or unpublished literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included Medline (1966-August Week 1 2005), CINAHL (1982-August Week 1 2005), EMBASE (1996-Week 33), as well as the Cochrane Library (Issue 3, 2005) and the Joanna Briggs Institute Evidence Library (August 2005). Selection criteria All research reports published between 1990 and August 2005 in the English language that focused on the role of the environment and equipment commonly found in the clinical area on the nosocomial MRSA transmission in adult, paediatric or neonatal acute care settings were considered. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Studies that scored less than the mean quality score were excluded from the review. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Forty-two papers met the review inclusion criteria, of which 18 obtained a quality score above the threshold and are included in this review. Seven studies reported general investigations of MRSA in the clinical environment and 11 studies explored specific environmental aspects. All studies used exploratory, descriptive or comparative designs. The evidence suggests that MRSA strains within the environment often match those found in patients within that environment. MRSA can be found in the air around MRSA colonised or infected patients. The degree of airborne contamination is significantly increased by activities that promote airflow. Although the site of MRSA colonisation or infection can influence the degree of environmental contamination, these data are inconsistent. Therefore, there is limited evidence for tailoring infection control interventions based on the sites of MRSA colonisation or infection. The evidence suggests that the type of materials used in clinical equipment can influence the effectiveness of cleaning techniques. Current routine cleaning practices, including conventional terminal cleaning, do not necessarily effectively eradicate MRSA from the environment. This review demonstrates that there is a link between the environment and hospital equipment and the transmission of MRSA within the acute hospital setting. Further well-designed research is urgently required to explore the efficacy of specific cleaning and decontamination methods, staff compliance with infection control practices and the range of factors that affect the incidence of MRSA contamination of the environment and equipment commonly found in the clinical area.

Role of MRSA reservoirs in the acute care setting

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin-resistant Staphylococcus aureus (MRSA) transmission continues to rise. The associated costs of increased hospital stay and patient mortality cause considerable burden to the health system. Objectives This review sought to evaluate the role of reservoirs, particularly the environment and equipment commonly found in the clinical area, in the transmission of MRSA within the acute hospital. This review updates a review previously completed by the authors and published by the Joanna Briggs Institute (2002). Search strategy A systematic search for relevant published or unpublished literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included Medline (1966–August Week 1 2005), CINAHL (1982–August Week 1 2005), EMBASE (1996–Week 33), as well as the Cochrane Library (Issue 3, 2005) and the Joanna Briggs Institute Evidence Library (August 2005). Selection criteria All research reports published between 1990 and August 2005 in the English language that focused on the role of the environment and equipment commonly found in the clinical area on the nosocomial MRSA transmission in adult, paediatric or neonatal acute care settings were considered. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Studies that scored less than the mean quality score were excluded from the review. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Forty-two papers met the review inclusion criteria, of which 18 obtained a quality score above the threshold and are included in this review. Seven studies reported general investigations of MRSA in the clinical environment and 11 studies explored specific environmental aspects. All studies used exploratory, descriptive or comparative designs. The evidence suggests that MRSA strains within the environment often match those found in patients within that environment. MRSA can be found in the air around MRSA colonised or infected patients. The degree of airborne contamination is significantly increased by activities that promote airflow. Although the site of MRSA colonisation or infection can influence the degree of environmental contamination, these data are inconsistent. Therefore, there is limited evidence for tailoring infection control interventions based on the sites of MRSA colonisation or infection. The evidence suggests that the type of materials used in clinical equipment can influence the effectiveness of cleaning techniques. Current routine cleaning practices, including conventional terminal cleaning, do not necessarily effectively eradicate MRSA from the environment. This review demonstrates that there is a link between the environment and hospital equipment and the transmission of MRSA within the acute hospital setting. Further well-designed research is urgently required to explore the efficacy of specific cleaning and decontamination methods, staff compliance with infection control practices and the range of factors that affect the incidence of MRSA contamination of the environment and equipment commonly found in the clinical area.

Role of MRSA reservoirs in the acute care setting.

Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin-resistant Staphylococcus aureus (MRSA) transmission continues to rise. The associated costs of increased hospital stay and patient mortality cause considerable burden to the health system. This review sought to evaluate the role of reservoirs, particularly the environment and equipment commonly found in the clinical area, in the transmission of MRSA within the acute hospital. This review updates a review previously completed by the authors and published by the Joanna Briggs Institute (2002). A systematic search for relevant published or unpublished literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review.Databases searched included Medline (1966-August Week 1 2005), CINAHL (1982-August Week 1 2005), EMBASE (1996-Week 33), as well as the Cochrane Library (Issue 3, 2005) and the Joanna Briggs Institute Evidence Library (August 2005). All research reports published between 1990 and August 2005 in the English language that focused on the role of the environment and equipment commonly found in the clinical area on the nosocomial MRSA transmission in adult, paediatric or neonatal acute care settings were considered. Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Studies that scored less than the mean quality score were excluded from the review. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Forty-two papers met the review inclusion criteria, of which 18 obtained a quality score above the threshold and are included in this review. Seven studies reported general investigations of MRSA in the clinical environment and 11 studies explored specific environmental aspects. All studies used exploratory, descriptive or comparative designs. The evidence suggests that MRSA strains within the environment often match those found in patients within that environment. MRSA can be found in the air around MRSA colonised or infected patients. The degree of airborne contamination is significantly increased by activities that promote airflow. Although the site of MRSA colonisation or infection can influence the degree of environmental contamination, these data are inconsistent. Therefore, there is limited evidence for tailoring infection control interventions based on the sites of MRSA colonisation or infection. The evidence suggests that the type of materials used in clinical equipment can influence the effectiveness of cleaning techniques. Current routine cleaning practices, including conventional terminal cleaning, do not necessarily effectively eradicate MRSA from the environment. This review demonstrates that there is a link between the environment and hospital equipment and the transmission of MRSA within the acute hospital setting. Further well-designed research is urgently required to explore the efficacy of specific cleaning and decontamination methods, staff compliance with infection control practices and the range of factors that affect the incidence of MRSA contamination of the environment and equipment commonly found in the clinical area.

The role of patient isolation and compliance with isolation practices in the control of nosocomial MRSA in acute care

Background Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin resistant Staphylococcus aureus (MRSA) transmission continues to rise. Various isolation practices are used to minimise MRSA transmission in acute care. However, the effectiveness of these practices has seldom been evaluated. Objectives This review sought to evaluate the efficacy of isolation practices in minimising MRSA transmission in the acute hospital setting and explore staff, visitor and patient compliance with isolation practices. This review updates a review published in 2002. Search strategy A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. Selection criteria All English language research reports published between 1990 and August 2005 that focused on the role of isolation practices on the nosocomial transmission of MRSA in adult, paediatric or neonatal acute care settings were eligible for inclusion in the review. Studies that evaluated multiple infection control strategies or control of MRSA outbreaks were excluded. The main outcome of interest was the incidence of new cases of MRSA. The secondary outcome was staff, visitor and patient compliance with the isolation practices. Data collection and analysis Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results Seven studies met the inclusion criteria. Given the small number of included studies and variable methodological quality, care must be taken when interpreting the review findings. There is some evidence that cessation of single room isolation and cohorting of MRSA patients does not increase nosocomial MRSA transmission when hand-washing compliance and standard precautions are maintained. Indeed, there is some evidence that reduced MRSA transmission can be achieved by improving compliance with contact precautions alone. The low level of hand hygiene compliance reported in the literature suggests that staff compliance with isolation practices is a significant factor in evaluating any infection-controlled intervention in the clinical setting. While staff compliance data are conflicting, regular audit and feedback of performance may improve compliance. Implications for clinical practice The heterogeneous nature of the topic and methodological weaknesses of included studies impairs the ability to aggregate data and develop specific practice recommendations. While this review presents evidence to suggest that ceasing single room or cohort isolation does not lead to increased MRSA transmission, these studies maintained high levels of hand hygiene or standard precautions. Additionally, the role of extraneous factors, such as environmental reservoirs, specific MRSA strains and patient mix, is unclear. None of the included studies measured financial, social or psychological factors associated with isolation practices. There is an urgent need for well-designed research with significant sample sizes to develop an evidence base upon which to underpin future clinical practice.