Room Entry Research Articles

MRSA Transmission in Intensive Care Units: Genomic Analysis of Patients, Their Environments, and Healthcare Workers.

Methicillin-resistant Staphylococcus aureus (MRSA)-and now USA300 MRSA-is a significant intensive care unit (ICU) pathogen; healthcare worker (HCW) contamination may lead to patient cross-transmission. From September 2015 to February 2016, to study the spread of MRSA, we enrolled HCWs in 4 adult ICUs caring for patients on MRSA contact precautions. Samples were collected from patient body sites and high-touch surfaces in patient rooms. HCW hands, gloves, and personal protective equipment were sampled pre/post-patient encounter. Whole genome sequencing (WGS) was used to compare isolates from patients, HCWs, and environment. There were 413 MRSA isolates sequenced (38% USA300, 52% USA100) from 66 patient encounters. Six of 66 HCWs were contaminated with MRSA prior to room entry. Isolates from a single patient encounter were typically either USA100 or USA300; in 8 (12%) encounters both USA300 and USA100 were isolated. WGS demonstrated that isolates from patients, HCWs, and environment often were genetically similar, although there was substantial between-encounter diversity. Strikingly, there were 5 USA100 and 1 USA300 clusters that contained similar strains (<22 single-nucleotide variants [SNVs], with most <10 SNVs) within the cluster despite coming from different encounters, suggesting intra- and inter-ICU spread of strains, that is, 4 of these genomic clusters were from encounters in the same ICU; 5 of 6 clusters occurred within 1 week. We demonstrated frequent spread of MRSA USA300 and USA100 strains among patients, environment, and HCWs. WGS identified possible spread within and even between ICUs. Future analysis with detailed contact tracing in conjunction with genomic data may further elucidate pathways of MRSA spread and points for intervention.

Out of Darkness.

Out of Darkness.

Surgical Infection Society Guidance for Operative and Peri-Operative Care of Adult Patients Infected by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2).

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated viral infection (coronavirus disease 2019, COVID-19) is a virulent, contagious viral pandemic that is affecting populations worldwide. As with any airborne viral respiratory infection, surgical and non-surgical patients may be affected. Methods: Review and synthesis of pertinent English-language literature pertaining to COVID-19 infection among adult patients. Results: COVID-19 disease that requires hospitalization results in critical illness approximately 25% of the time and requires mechanical ventilation with positive airway pressure. Acute kidney injury, a marked hypercoagulable state, and sometimes myocarditis can be features of COVID-19 in addition to the characteristic severe acute lung injury. Even if not among the most seriously afflicted, older patients with medical comorbidities are both predisposed to infection and risk increased morbidity and mortality, however, all persons presenting for surgical intervention should be suspected of infection (and thus transmissibility) even if asymptomatic. Although most elective surgery has been curtailed by administrative or governmental fiat, patients will still need urgent or emergency operative intervention for time-sensitive disease processes such as malignant neoplasia or for true emergencies such as perforated viscus or traumatic injury. It is possible to provide safe surgical care for SARS-CoV-2-positive patients and minimize nosocomial transmission to healthcare workers. Conclusions: This guidance will facilitate appropriate protection of patients and staff, and maintenance of infection control measures to assist surgical personnel and facilities to prepare for COVID-19-infected adult patients requiring urgent or emergent operative intervention and to provide optimal patient care.

Preoperative Warming Reduces Intraoperative Hypothermia in Total Joint Arthroplasty Patients.

Perioperative hypothermia (PH) is common in patients undergoing total joint arthroplasty (TJA). A previous study at our institution identified the largest drop in core body temperature between preoperative holding and induction of anesthesia. This study evaluates the effect of preoperative warming measures on PH in TJA patients. A retrospective review was conducted of 672 patients undergoing TJA at our institution between April 1 and October 31, 2017. Under the new normothermia protocol, patients received warmed intravenous fluids and forced-air warming gowns in the preoperative holding area. Time and temperature data for the perioperative period were collected from the electronic health record. Chi-square and paired t-tests were used to compare between total knee arthroplasty and total hip arthroplasty patients and between new and old protocols. In the new protocol, 173 of 672 (26%) patients were hypothermic at incision compared with 140 of 383 (37%) patients in the previous protocol (P < 0.05). The largest drop in core body temperature occurred between preoperative holding and induction of anesthesia. The duration of time from operating room entry to incision was less for normothermic than for hypothermic patients. The duration of hypothermia was similar between new and old protocols overall, but markedly fewer total hip arthroplasty patients remained hypothermic for the entire surgery under the new protocol. Adding forced-air warming preoperatively to our warming protocol reduced the rate of PH by approximately 30%. The time from entry into the operating room to the start of surgery should be minimized because patients are vulnerable to PH during this interval.

Slated versus actual operating room entry time in a British Columbia health authority.

To determine how frequently the published operating room (OR) schedule of case start times correlated with the actual OR entry time for elective cases in the Fraser Health Authority (FHA) in British Columbia, Canada. Society guidelines recommend periods of fasting of two hours prior to the induction of general anesthesia, but patients frequently end up fasting much longer. This review aimed to determine when patients arrive in the OR-either earlier than their scheduled time or later. The premise of some is that patients often arrive earlier, and advising short fasting times on the basis of the OR slate time is unreliable. I wished to determine whether this fear is justified. The computerized OR management database was queried for slated time of entry and actual time of entry for elective surgical cases in 11 hospitals in the FHA. The difference in slated vs actual entry time of patients (in 30 min blocks) was reviewed to examine the proportion of patients entering the OR earlier than 90 min from their slated time. Additionally, anesthesiologists from the Royal Columbian/Eagle Ridge Hospitals were surveyed for their recall of case delays that were related to inappropriate consumption of fluids. One hundred and twenty-three thousand eight hundred and sixty-five cases from 11 hospitals over a 32-month period were analyzed. A very small proportion of cases (753 of 123,865 cases, 0.6%) entered the OR earlier than 90 min from their slated time. Relatively few cases were actually cancelled because of inappropriate fluid consumption in the recall of anesthesiologists in two institutions. In the FHA, the OR schedule is a reliable guide to providing instructions on timing of preoperative fluid consumption in appropriately selected elective surgical patients. Quality of care and patient satisfaction will safely be enhanced by limiting the period of fasting for elective surgical patients.

Contamination of health-care workers' hands with Escherichia coli and Klebsiella species after routine patient care: a prospective observational study

ObjectiveTo compare the frequency of health-care worker (HCW) hand contamination by Escherichia coli versus Klebsiella species after patient care and to determine activities associated with contamination. MethodsWe conducted a prospective observational study at two tertiary-care centres. We observed HCWs caring for patients colonized/infected with E. coli or Klebsiella. HCW hands were cultured before room entry and after patient care. Contamination was defined as detecting E. coli or Klebsiella on HCW hands. Risk factors for contamination were analysed using logistic regression. Patient-to-HCW transmission was confirmed by pulsed-field gel electrophoresis (PFGE). ResultsWe performed 466 HCW observations: 290 from patients with E. coli, 149 with Klebsiella, and 27 with both species. Eighty-seven per cent of observations (404/464) occurred in patients who had received chlorhexidine bathing within 2 days. HCW hand contamination rates were similar between E. coli (6.2%; 18/290) and Klebsiella (7.4%; 11/149) (p 0.6). High-risk activities independently associated with contamination were toilet assistance (OR 9.34; 95% CI 3.10–28.16), contact with moist secretions (OR 6.93; 95% CI 2.82–17.00), and hygiene/bed-bathing (OR 3.80; 95% CI 1.48–9.80). PFGE identified identical/closely related isolates in the patient and HCW hands in 100% (18/18) of E. coli and 54.5% (6/11) of Klebsiella observations. ConclusionsWe did not find a difference in HCW hand contamination rates between E. coli and Klebsiella after patient care. Hand hygiene should be reinforced after high-risk activities. Discrepancies in matching patient and HCW hand isolates occurred more frequently for Klebsiella than for E. coli; differences in species-level transmission dynamics might exist.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018. Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly. Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group. Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups. The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change. ClinicalTrials.gov Identifier: NCT02223455.

592. Assessment of Time Spent in the Room by Nurses and Nursing Assistants on a Pediatric Ward by Patient Isolation Status and Demographics

BackgroundPublished reports have raised concern that RNs spend less time in hospital rooms of patients requiring isolation precautions. Other patient-related factors including race/ethnicity, primary language, and socio-economic factors reportedly influence the mean time spent in the room by RNs and certified nursing assistants (CNAs). At a children’s hospital the automated hand hygiene monitoring system (AHHMS) has motion sensors that detect patient room entry and exit and sensors that detect hand hygiene events. Time spent in patient rooms by RNs and CNAs was examined using AHHMS data captured for patients on a 24-bed pediatric hospital ward for multiple patient characteristics to evaluate factors influencing the duration of visits.MethodsRNs and CNAs routinely wore badges with infrared signal technology to monitor hand hygiene compliance, generating time-stamped data for room entries and exits, identified by user job category. Over a 30 day period, April 2016, RN and CNA time in the room was compared by patient characteristics including: length of stay, white yes/no, Hispanic yes/no, interpreter needed yes/no, and isolation status of contact-droplet, contact, or none. Mean minutes spent in the room for RNs and CNAs were evaluated with a random-effects linear model and gamma distribution.ResultsAdmissions for 220 patients occurred in the 24 rooms during the evaluation period; 88 RNs and 28 CNAs completed 18,641 time-stamped room entries and exits. The natural log of patient length of stay (hours) was significantly associated with increased RN and CNA minutes spent in the room (P < 0.001). Interpreter required was not associated with time in the room (P = 0.72), nor was race (P = 0.60), nor was Hispanic ethnicity (P = 0.81). There were no significant differences in time spent in the room for contact, contact-droplet, and no isolation (P = 0.92).ConclusionData derived from infrared signal AHHMS badges can provide insight into RN and CNA care patterns. Isolation status and patient demographics were unrelated to mean RN and CNA time in the room. Patient length of stay was the only predictor of increased nursing time spent providing direct patient care. These results contrast with previous reports demonstrating fewer nursing interactions based on patient demographics or isolation.Disclosures All authors: No reported disclosures.

1189. Effectiveness of Multimodal Intervention Strategies to Improve Hand Hygiene Compliance at an Academic Medical Center

BackgroundSince the early 19th century, hand hygiene (HH) has been recognized as the most important factor in preventing healthcare-associated infections (HAI). Still, improving HH compliance is a major hurdle for most healthcare facilities. Our study objective was to evaluate effectiveness of bundled intervention tools in increasing hand hygiene (HH) compliance.MethodsThe study was performed at the University of Mississippi Medical Center located in Jackson, MS. A multidisciplinary HH team was established in January 2016. Team members included infection prevention, nurse managers, physician, resident, housekeeping, process engineers, and ancillary staff. Hand hygiene compliance was determined based on room entry and exit observations. Intervention strategies were based on Joint Commission Center’s Targeted Solutions Tool (TST) to identify barriers in HH compliance, standardization of data collection, covert observer training and Just-in-time training of providers. Other strategies implemented included education and feedback, rewards and recognition, and system change measures during the 3-year study period (timeline in Table 1). Hand hygiene compliance was calculated based on number of compliance opportunities/total number of observations. One-way Analysis of Variance (ANOVA) was performed to analyze HH data. We did not assess the concomitant reduction in HAI rates as simultaneous HAI prevention strategies confounded analysis.ResultsBased on total 95,491 observations performed (January 2016- December 2018), there was a statistically significant improvement in HH compliance during the study period from 66.5% in 2016 to 73% in 2017 and 79.5% in 2018 (P = 0.04).ConclusionAt our institution, we observed a 56% improvement in hand hygiene compliance over 36-months timeframe. Multidisciplinary team involvement and multimodal intervention strategies play crucial role in improvement and sustainment of HH compliance. Disclosures All authors: No reported disclosures.

Application of regional cerebral oxygen saturation monitoring in predicting postoperative delirium in elderly patients

Objective To evaluate the application of regional cerebral oxygen saturation (rSO2) in predicting postoperative delirium (POD) in elderly patients. Methods A total of 140 elderly patients were enrolled in this study. The value of rSO2, mean arterial pressure (MAP), heart rate, pulse oxygen saturation (SpO2) and end-tidal carbon dioxide partial pressure (PETCO2) were monitored at the time of room entry (t0), double-lung ventilation during anesthesia induction (t1), double-lung ventilation during lateral position (t2), single-lung ventilation during lateral position (t3), and extubation after surgery (t4). Meanwhile, the baseline of rSO2, minimum rSO2 (rSO2min), mean rSO2 (rSO2mean) and maximum percentage drop in rSO2 (rSO2%max) were recorded. The patients were divided into a POD group (n=24) and a non-POD group (n=116), according to the definition of POD. The independent risk factors of POD were determined using multivariate Logistic regression, and receiver operating characteristic curve(ROC) analysis was performed to assess the accuracy of rSO2 in predicting POD. Results POD was present in 24 patients among 140 elderly patients (17.1%). At t3 point, the levels of rSO2 were significantly decreased in the POD group compared with the non-POD group (P 0.05). In the POD group, its age and rSO2%max were significantly higher than that in the non-POD group, while its rSO2min and rSO2mean were significantly lower than that in the non-POD group (P<0.05). Logistic regression analysis showed that, age and rSO2%max were the independent risk factors for POD. ROC curve showed that the area under receiver operating characteristic curve (AUC) of rSO2%max was 0.893 (95%CI 0.829-0.939) at a cutoff value of 15.59%. The specificity and sensitivity of rSO2%max in predicting POD were 79.31% and 91.67%, respectively. Conclusions rSO2%max is the independent risk factor for POD in elderly patients after surgery, and rSO2%max>15.59% is considered a potential predictor of POD. Key words: Regional cerebral oxygen saturation; Delirium; Elderly patients; Predictor

Does Attending Surgeon Presence at the Preinduction Briefing Improve Operating Room Efficiency?

To examine if attending surgeon presence at the preinduction briefing is associated with a shorter time to incision. Retrospective cohort study and survey. Tertiary academic medical center. A retrospective cohort study was conducted of 22,857 operations by 141 attending surgeons across 12 specialties between August 3, 2016, and June 21, 2018. The independent variable was attending surgeon presence at the preinduction briefing. Linear regression models compared time from room entry to incision overall, by service line, and by surgeon. We hypothesized a shorter time to incision when the attending surgeon was present and a larger effect for cases with complex surgical equipment or positioning. A survey was administered to evaluate attending surgeons' perceptions of the briefing, with a response rate of 68% (64 of 94 attending surgeons). Cases for which the attending surgeon was present at the preinduction briefing had a statistically significant yet operationally minor reduction in mean time to incision when compared with cases when the attending surgeon was absent. After covariate adjustment, the mean time to incision was associated with an efficiency gain of 1.8 ± 0.5 minutes (mean ± SD; P < .001). There were no statistically significant differences in the subgroups of complex surgical equipment and complex positioning or in secondary analysis comparing service lines. The surgeon was the strongest confounding variable. Survey results demonstrated mild support: 55% of attending surgeons highly prioritized attending the preinduction briefing. Attending surgeon presence at the preinduction briefing has only a minor effect on efficiency as measured by time to incision.

Peek or Push: An Examination of Two Types of Room Clearing Tactics for Active Shooter Event Response

Prior to the modern era of active shooter events, the standard training for patrol officers responding to an ongoing shooting event required the responding patrol officer(s) to contain the shooter in the building where the attack was occurring, control access to the location, attempt to communicate with the shooter, and call the Special Weapons and Tactics (SWAT) team. Recently, research has been undertaken to empirically examine different law enforcement response options. This article details one such experiment. The article details a tactic known as the peek. Utilizing an experimental design, we present findings regarding the peek room entry technique.

Effectiveness of a multisite personal protective equipment (PPE)-free zone intervention in acute care.

Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions. Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls. All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases. A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE. We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently. HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.

Pilot study: an intensive care unit sleep promotion protocol

PurposeDisturbances, such as in-room activity and sound, are significant sources of sleep disruption among critically ill patients. These factors are potentially modifiable. We tested the impact of an intensive care...

Impact of an automated hand hygiene monitoring system and additional promotional activities on hand hygiene performance rates and healthcare-associated infections.

Determine the impact of an automated hand hygiene monitoring system (AHHMS) plus complementary strategies on hand hygiene performance rates and healthcare-associated infections (HAIs). Retrospective, nonrandomized, observational, quasi-experimental study. Single, 93-bed nonprofit hospital. Hand hygiene compliance rates were estimated using direct observations. An AHHMS, installed on 4 nursing units in a sequential manner, determined hand hygiene performance rates, expressed as the number of hand hygiene events performed upon entering and exiting patient rooms divided by the number of room entries and exits. Additional strategies implemented to improve hand hygiene included goal setting, hospital leadership support, feeding AHHMS data back to healthcare personnel, and use of Toyota Kata performance improvement methods. HAIs were defined using National Healthcare Safety Network criteria. Hand hygiene compliance rates generated by direct observation were substantially higher than performance rates generated by the AHHMS. Installation of the AHHMS without supplementary activities did not yield sustained improvement in hand hygiene performance rates. Implementing several supplementary strategies resulted in a statistically significant 85% increase in hand hygiene performance rates (P &lt; .0001). The incidence density of non-Clostridioies difficile HAIs decreased by 56% (P = .0841), while C. difficile infections increased by 60% (P = .0533) driven by 2 of the 4 study units. Implementation of an AHHMS, when combined with several supplementary strategies as part of a multimodal program, resulted in significantly improved hand hygiene performance rates. Reductions in non-C. difficile HAIs occurred but were not statistically significant.

Understanding nurses’ workflow: Batching care and potential opportunities for transmission of infectious organisms, a pilot study

Caring for patients in contact precautions can be challenging. In this pilot study, we sought to understand, using qualitative and visual methods, how nurses provide care for patients in contact precaution rooms and to identify potential breakdowns in practice that could increase risk of disease transmission. Qualitative data were collected while shadowing 4 nurses on 2 medical/surgical units at a university medical center between September and October 2016. Observers documented nurses' movements in handwritten fieldnotes. Fieldnote data were analyzed using a descriptive approach with visual depiction to map care delivery in precaution and non-precaution rooms. Nurses moved between non-precaution rooms, completing 1-4 tasks per room entry, over the course of several brief room entries and exits. In contrast, nurses rarely entered contact precaution rooms to complete only a few tasks, generally completing ≥10 tasks per room entry. Although hand hygiene on room entry/exit was consistently performed, a breakdown in practice occurred in precaution rooms as nurses tended to move between tasks and contact with the environment without performing hand hygiene. Differences in how nurses structure their work in contact precaution rooms may contribute to risk of infectious disease transmission. Understanding and addressing the challenges specific to how nurses work is a critical part of infection prevention in today's hospital environment.

Nursing Empowerment Intervention Reduces Inpatient Sleep Disruptions.

According to this study: An interprofessional intervention combining nursing education and empowerment to reduce sleep interruptions in hospitals led to fewer nighttime room entries and improved patient experience.The authors note that creating a sleep-friendly environment likely depends on the unit-based nurses championing this cause.

Characterizing pediatric inpatient sleep duration and disruptions

ObjectiveTo contextualize inpatient sleep duration and disruptions in a general pediatric hospital ward by comparing in-hospital and at-home sleep durations to recommended guidelines and to objectively measure nighttime room entries. MethodsCaregivers of patients four weeks – 18 years of age reported patient sleep duration and disruptions in anonymous surveys. Average at-home and in-hospital sleep durations were compared to National Sleep Foundation recommendations. Objective nighttime traffic was evaluated as the average number of room entries between 11:00pm and 7:00am using GOJO brand hand-hygiene room entry data. ResultsAmong 246 patients, patients slept less in the hospital than at home with newborn and infant cohorts experiencing 7- and 4-h sleep deficits respectively (Newborn: 787 ± 318 min at home vs. 354 ± 211 min in hospital, p < 0.001; Infants: 703 ± 203 min at home vs. 412 ± 152 min in hospital, p < 0.01). Newborn children also experienced >2 h sleep deficits at home when compared to NSF recommendations (Newborns: 787 ± 318 min at home vs. 930 min recommended, p < 0.05). Objective nighttime traffic measures revealed that hospitalized children experienced 7.3 room entries/night (7.3 ± 0.25 entries). Nighttime traffic was significantly correlated with caregiver-reported nighttime awakenings (Spearman Rank Correlation Coefficient: 0.83, p < 0.001). ConclusionHospitalization is a missed opportunity to improve sleep both in the hospital and at home.

Quality Improvement Initiative to Improve Sleep in Pediatric HSCT Patients and Caregivers

Background Sleep is an essential biological function vital for physiological rest, healing and emotional well-being. Sleep disruption, defined as interruptions or alterations to the normal sleeping patterns, is commonly seen in patients and caregivers with lengthy hospital stays such as patients undergoing hematopoietic stem cell transplant (HSCT). Sleep disruption in the caregivers of hospitalized patients can lead to increased stress and fatigue, decrease quality of life and ultimately affect the caregiver ability to support their loved one. Methods Through a longitudinal observational cohort study, the quality and quantity of sleep in pediatric patients undergoing HSCT and their caregivers was studied; we identified a high level of sleep disturbance utilizing actigraphy and recounted poor sleep through qualitative assessments. We then performed a cross sectional focus group analysis of patients, caregivers and medical staff to identify the factors associated with poor sleep. The global aim of our quality improvement initiative was to improve sleep quality in HSCT patients and caregivers. The smart aim of our project was to decrease nighttime noise from 46 decibels (dB) (mean baseline data) to 38dB (WHO recommends night outside noise of less than 40dB) in a 6 month period and increase sleep efficacy from a mean of 60 % (combined patient and caregiver) to 90% in the following 6 month period. We worked on achieving this goal through an overnight nighttime sleep hygiene bundle to decrease sleep disruption along with reduction of the hallway nighttime noise (9pm-7am). Results The most common factors associated with sleep disruption were noisy room entries, overnight trash pulls, loud hallway noise and noisy hospital staff. A simplified failure mode analysis identified four main key drivers; reliable nighttime awareness system, quiet nighttime nursing system, unobtrusive nighttime cleaning process and nighttime awareness maintenance system. Several PDSA (plan-do-study-act) interventions for each key driver took place and were adapted. The overnight mean dB decreased to 42dB (9% reduction). Overnight noise spikes above 60dB have decreased from a mean of 271 spikes to a mean of 151 spikes (44% reduction). Percentage of sleep efficacy results and follow up of quantitative and qualitative sleep assessments of patients and caregivers will be available by February 2019. Conclusions With a quality improvement initiative, we identified factors that negatively impact sleep and performed interventions that successfully mitigate these factors, leading to improved quality of sleep in HSCT patients and their caregivers.

Time from neuraxial anesthesia placement to delivery is inversely proportional to umbilical arterial cord pH at scheduled cesarean delivery

Neuraxial block-related hypotension and maternal obesity contribute to uterine hypoperfusion and decreased umbilical arterial pH at cesarean delivery. Between the time of anesthesia placement and delivery, the fetus may be exposed to a hypoperfused uterine environment without surgeon awareness of fetal compromise. We sought to evaluate neonatal umbilical arterial pH according to predelivery time intervals at scheduled term cesarean. We performed a retrospective cohort study of cesarean deliveries between September 2014 and February 2017. Singleton gestations undergoing scheduled cesarean delivery under spinal anesthesia between 37 and 41 weeks with a reassuring preoperative nonstress test were included. Time intervals between operative room entry, spinal anesthesia placement, skin incision, uterine incision, and delivery were calculated. The primary outcome was umbilical arterial pH. Demographic data, maternal blood pressures, predelivery time intervals, and delivery outcomes were analyzed according to umbilical arterial pH intervals of <7.0, 7.01-7.10, 7.11-7.20, 7.21-7.30, and >7.30. Umbilical cord gas analytes and neonatal outcomes were analyzed by spinal to delivery time. Stepwise linear regression was performed to identify predictors of decreasing umbilical arterial pH. Receiver-operator characteristic curves were calculated for spinal to delivery time and umbilical arterial pH <7.0 and 7.1. Among 527 included participants, median umbilical arterial pH was 7.27 [interquartile range, 7.23-7.29] and body mass index was 35 kg/m2 [interquartile range, 30-41]. Both maternal body mass index and hypotensive episodes increased with decreasing umbilical arterial pH (P <.001, P ≤ .02). All predelivery time intervals (operative room to delivery, spinal to skin, spinal to delivery, and uterine incision to delivery) increased as umbilical arterial pH interval decreased (P < .05 for all). In a stepwise linear regression, maternal body mass index, noncephalic presentation, spinal start to delivery interval, uterine incision to delivery interval, and maximum reduction in blood pressure from baseline were predictive of decreasing umbilical arterial pH after controlling for confounding variables (F [5,442]= 17.7, P= .0001], adjusted R2 of 0.157. When evaluated by spinal to delivery time, both umbilical arterial and venous pH and partial pressure of carbon dioxide decreased (P < .001 for all), but base deficit and neonatal outcomes were similar (P ≥ .7 for all). There were 2 cases of hypoxic-ischemic encephalopathy (0.38%). A receiver-operating characteristic curve demonstrated that a spinal start to delivery time greater than 27 minutes was associated with an umbilical arterial pH <7.1 (area under the curve, 0.74, 100% sensitivity, 21% specificity), and an interval greater than 30 minutes was associated with an umbilical arterial pH <7.0 (area under the curve, 0.80, 100% sensitivity, 33% specificity). Longer spinal-to-delivery and uterine incision-to-delivery time intervals were associated with decreasing umbilical arterial pH at scheduled term cesarean delivery. Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.