Policy In Intensive Care Unit Research Articles

Inapropriate use of antibiotics effective against gram positive microorganisms despite restrictive antibiotic policies in ICUs: a prospective observational study

BackgroundGram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin, and linezolid are frequently used in empirical treatment combinations in critically ill patients. Such inappropriate and unnecessary widespread use, leads to sub-optimal utilisation. However they are covered by the antibiotics restriction programme. This prospective observational study, evaluates gram-positive anti-bacterial utilisations in intensive care units (ICUs) with various evaluation criteria, to determine the frequency of inappropriate usage and the intervention targets required to ensure optimum use.MethodsThis clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital, Turkey. The total bed capacity was 55. Patients older than 18 years and who were prescribed gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid, and daptomycin) were included. Patients under this age or immunosuppressed patients (neutropenic,- HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. During the study period, 200 treatments were evaluated in 169 patients. The demographic and clinical features of the patients were recorded. Besides observations by the clinical staff, the treatments were recorded and evaluated by two infectious diseases specialists and two clinical pharmacists at 24-h intervals from the first day to the last day of treatment.SPSS software for Windows, (version 17, IBM, Armonk, NY) was used to analyse the data. Categorical variables were presented as number and percentage, and non-categorical variables were presented as mean ± standard deviation.ResultsIt was found that inappropriate gram-positive antibiotic use in ICUs was as high as 83% in terms of non-compliance with the selected quality parameters. Multivariate analysis was performed to evaluate the factors associated with inappropriate antibiotic use, increased creatinine levels were found to increase the risk of such use.ConclusionsIn spite of the restricted antibiotics programme, inappropriate antibiotic use in ICUs is quite common. Thus, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation of such use and optimal treatment doses.

Family members' beliefs and attitudes towards visiting policy in the intensive care units of Ghana.

AimThis study aimed to investigate family members' beliefs and attitudes towards the visiting policies of intensive care units (ICUs).DesignIt employed a descriptive cross‐sectional quantitative design.MethodThis study recruited four public hospitals in Ghana with a sample of 200 family members. The study was conducted using a self‐administered questionnaire. The data were collected and analysed with SPSS version 16.ResultsThis study revealed that while family members believed in the beneficial effect of adhering to open visiting policies in ICUs, their attitudes were sceptical and restrictive. Most family members preferred the acceptable number of visitors within 24 hr to be two, and according to them, only one person should be allowed to enter at a time. There was a meaningful relationship between the families' beliefs and religion (p = 0.02), educational level (p = 0.03) and family status (p = 0.02). Furthermore, a meaningful relationship was also observed between the families' attitudes and status (p = 0.04) and their level of education (p = 0.05). The studied family members showed concern in this regard and did not want the community style of visiting to be implemented, which could hinder patients' recovery.

Open intensive care units: a global challenge for patients, relatives, and critical care teams.

The aims of this study were to describe the current status of intensive care unit (ICU) visiting hours policies internationally and to explore the influence of ICUs' open visiting policies on patients', visitors', and staff perceptions, as well as on patients' outcomes. A review of the literature was done through MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The following keywords were searched: "visiting," "hours," "ICU," "policy," and "intensive care unit." Inclusion criteria for the review were original research paper, adult ICU, articles published in the last 10 years, English or Italian language, and available abstract. Twenty-nine original articles, mainly descriptive studies, were selected and retrieved. In international literature, there is a wide variability about open visiting policies in ICUs. The highest percentage of open ICUs is reported in Sweden (70%), whereas in Italy there is the lowest rate (1%). Visiting hours policies and number of allowed relatives are variable, from limits of short precise segments to 24 hours and usually 2 visitors. Open ICUs policy/guidelines acknowledge concerns with visitor hand washing to prevent the risk of infection transmission to patients. Patients, visitors, and staff seem to be inclined to support open ICU programs, although physicians are more inclined to the enhancement of visiting hours than nurses. The percentages of open ICUs are very different among countries. It can be due to local factors, cultural differences, and lack of legislation or hospital policy. There is a need for more studies about the impact of open ICUs programs on patients' mortality, length of stay, infections' risk, and the mental health of patients and their relatives.

Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units

Little is known about whether recommended strategies to prevent catheter-associated urinary tract infection (CAUTI) are being implemented in intensive care units (ICU) in the United States. Our objectives were to describe the presence of and adherence to CAUTI prevention policies in ICUs, to identify variations in policies based on organizational characteristics, and to determine whether a relationship exists between prevention policies and CAUTI incidence rates. Four hundred forty-one hospitals that participate in the National Healthcare Safety Network were surveyed in spring 2008. Two hundred fifty hospitals provided information for 415 ICUs (response rate, 57%). A small proportion of ICUs surveyed had policies supporting bladder ultrasound (26%, n = 106), condom catheters (20%, n = 82), catheter removal reminders (12%, n = 51), or nurse-initiated catheter discontinuation (10%, n = 39). ICUs in hospitals with ≥ 500 beds were half as likely as those in smaller hospitals to have adopted at least 1 CAUTI prevention policy (odds ratio, 0.52; 95% confidence interval: 0.33-0.86), and ICUs in hospitals where the infection control director reported always having access to key decision makers for planning were more than twice as likely as those with less access to have adopted a policy (odds ratio, 2.41; 95% confidence interval: 1.56-3.72). Little attention is currently placed on CAUTI prevention in ICUs in the United States. Further research is needed to elucidate relationships between adherence to CAUTI prevention recommendations and CAUTI incidence rates.

Survey of caregiver opinions on the practicalities of family‐centred care in intensive care units

To determine caregiver opinion on their intensive care unit's policies with regard to visiting hours, how families are informed and participate in patient care. Benefits of improving family access to the intensive care unit, information delivery and participation of families in care have been suggested. Survey of caregivers working in French-speaking intensive care units. An e-mail invitation to complete an online, closed-ended questionnaire was issued to caregivers registered in the mailing list of the French society of intensive care. Caregivers (n = 731) working in 222 adult and 41 paediatric intensive care units completed the questionnaire. Unlike in paediatric intensive care units, 58% of adult intensive care unit had restricted visiting hours (< 4 hour). However, 63% of respondents would recommend extended visiting periods. A 24-hour policy existed in 7% of adult intensive care units; 10% of respondents from these intensive care units thought reducing visiting periods would be very useful or essential; 81% thought that a 24-hour policy contributed to improved relations with families; and only 9% thought that it was a hindrance to care. Over 90% of caregivers thought that families should be informed of patient progress in a designated room in the presence of the patient's nurse and that patient records should report family meetings. This policy was only implemented in half of the cases. Family participation in care procedures was strongly encouraged in only 0·5% of adult intensive care units. Intensive care unit caregivers are in favour of longer visiting hours, increased use of designated rooms for, and nurse participation in, meetings with families. Although caregivers do not associate families with care procedures, they considered that their presence during most interventions should be authorised. Our results could help in implementing intensive care unit policies concerning visiting hours, how families are informed and participate in patient care.

Prevalence of antimicrobial resistance among gram-negative isolates in an adult intensive care unit at a tertiary care center in Saudi Arabia

BACKGROUND AND OBJECTIVES:Patients in the ICU have encountered an increasing emergence and spread of antibiotic-resistant pathogens. We examined patterns of antimicrobial susceptibility in gram-negative isolates to commonly used drugs in an adult ICU at a tertiary care hospital in Riyadh, Saudi Arabia.METHODS:A retrospective study was carried out of gram-negative isolates from the adult ICU of King Fahad National Guard Hospital (KFNGH) between 2004 and 2009. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method.RESULTS:The most frequently isolated organism was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pnemoniae, Stenotrophomonas maltophilia, and Enterobacter. Antibiotic susceptibility patterns significantly declined in many organisms, especially A baumannii, E coli, S marcescens, and Enterobacter. A baumannii susceptibility was significantly decreased to imipenem (55% to 10%), meropenem (33% to 10%), ciprofloxacin (22% to 10%), and amikacin (12% to 6%). E coli susceptibility was markedly decreased (from 75% to 50% or less) to cefuroxime, ceftazidime, cefotaxime, and cefepime. S marcescens susceptibility was markedly decreased to cefotaxime (100% to 32%), ceftazidime (100% to 35%), and cefepime (100% to 66%). Enterobacter susceptibility was markedly decreased to ceftazidime (34% to 5%), cefotaxime (34% to 6%), and pipracillin-tazobactam (51% to 35%). Respiratory samples were the most frequently indicative of multidrug-resistant pathogens (63%), followed by urinary samples (57%).CONCLUSION:Antimicrobial resistance is an emerging problem in the KFNGH ICU, justifying new more stringent antibiotic prescription guidelines. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to eliminate major outbreaks in the future.

Identifying the Perception of Needs of Family Members Visiting and Nurses Working in the Intensive Care Unit

Recent initiatives encourage a family presence during cardiopulmonary resuscitation and invasive procedures and more open visitation policies in intensive care units (ICUs). This study investigated perceptions of needs of those visiting and working in six ICUs. The needs of family members visiting patients with critical illness and nurses working in ICUs were measured using the Critical Care Family Needs Inventory. Data were collected prospectively using a convenience sample of 101 patients, family members, and nurses. Hierarchical cluster analysis identified the themes of (a) emotional resources and support, (b) trust and facilitation of needs, (c) treatment information, and (d) feelings. Family members and nurses differed significantly on three of the four themes (p = .000). This is important information for neuroscience nurses and other healthcare professionals to consider in providing care, setting visiting policies in ICUs, and developing approaches such as family-centered care.

Let MRSA-positive patients live a normal life

Methicillin-resistant Staphylococcus aureus (MRSA) infections have represented a serious burden in the USA and in Japan for years [1,2]. The incidence of MRSA is especially high in intensive care units (ICUs). MRSA is also becoming more prevalent in Europe, but with significant differences in the frequency of MRSA between single countries [3]. Patient-to-patient transmission in healthcare settings, usually via contaminated hands, clothes, or equipment of healthcare workers, has been a major factor accounting for the increase in MRSA incidence and prevalence in acute care facilities. More and more patients become MRSA-positive, often causing harmless colonization and sometimes causing infection. Special management of these patients is required in a clinical setting. Guidelines for preventing the spread of MRSA mostly recommend contact precautions and isolation of infected or colonized patients in a single room or cohort. These measures include grouping the patients geographically with designated staff. The recommended measures are very complex, time consuming and expensive. Methicillin resistance in S. aureus bacteraemia is associated with significant increases in length of hospitalization and hospital charges, at least partially as a result of the demanded additional measures [4]. A questionnaire analysis from England showed large variations in MRSA policies in ICUs [5]. As a policy, 24% of the ICUs do not isolate their MRSA patients. Also, in Germany, 34% of the ICUs do not isolate MRSA patients in a single room [6]. Fifteen percent of the English ICUs have specified wards that do not accept MRSA patients. These policies lead to a delay in ICU discharge of 63% [5]. The question which arises is the following: is the evidence for recommendations to control the spread of MRSA, especially isolation in a single room, strong enough and does it justify the additional costs, workload and loads for the patients? A before and after study in two ICUs found no tangible benefit from moving patients, in whomMRSA infection had been detected, into cohort-isolation care [7]. However, a major characteristic of this study is the excellent nursing staff of the participating ICUs, with a nurse-to-patient ratio of 3.3–4.3 per 24 h. Obviously in these circumstances, no benefit fromphysical isolation can be expected, since it will not substantially alter the number of contacts with, or proportion of, nursing staff exposed to MRSA carriers. The study shows the possible influence on results by the attendant circumstances. On the other hand, a systematic review of isolation policies found four series providing the strongest evidence that intensive control measures, including patient isolation, were effective in controlling MRSA [8]. Nevertheless, no well-designed study allows the role of isolation measures to be assessed alone. Hand washing is the most effective and economic intervention shown to reduce transmission of pathogens and nosocomial infection rates. Isolation precautions are unable to increase compliance with hand disinfection [9]. Studies have shown that 80% of staff dressing MRSA-infected wounds may carry the organism on their hands for up to 3 h. This carriage can be almost completely eradicated by immediate washing with liquid soap and water after patient contact [10,11]. In the study by Harbarth et al. [12], 1771 new cases of MRSA were reported in 9 years, including 158 MRSA bacteraemias. For the first 4 years, no control measures were in place and the total incidence of new MRSA cases and MRSA bacteraemias numbers rose rapidly. The first 2 years after the introduction of single-room isolation, together with screening and eradication, totalled to a stabilization of MRSA rates and a start in the decline of MRSA bacteraemias. The addition over the next 3 years of a hand-hygiene programme with documented improved compliance coincided with a yearly fall in MRSA bacteraemias rates, to less than one-third of the pre-intervention level. This work provided stronger evidence that an effective Correspondence and offprint requests to: Christine Geffers, Institute of Hygiene and Environmental Health, Charite – University Medicine, Heubnerweg 6, D 14059 Berlin, Germany. E-mail: christine.geffers@charite.de