Sterile Gown Research Articles

Central line-associated bloodstream infections in the intensive care unit: importance of the care bundle.

BackgroundThe importance and efficacy of a care bundle for preventing central line-associated bloodstream infections (CLABSIs) and infectious complications related to placing a central venous catheter (CVC) in patients in the intensive care unit (ICU).MethodsA care bundle was implemented from July 2013 to June 2014 in a medical ICU and surgical ICU. Data were divided into three periods: the prior period (July 2012–June 2013), the intervention period (July 2013–June 2014; first and second periods), and the post-intervention period (July 2014–December 2014; third period). A care bundle consisting of optimal hand hygiene, skin antisepsis with chlorhexidine (2%) allowing the skin to dry, maximal barrier precautions for inserting a catheter (sterile gloves, gown, mask, and drapes), choice of optimal insertion site, prompt catheter removal, and daily evaluation of the need for the CVC was introduced.ResultsThe catheterization duration was longer and femoral access was more frequently observed in patients with CLABSIs. CLABSI rates decreased with use of the care bundle. The CLABSI rate in the medical ICU was 6.20/1,000 catheter days during the prior period, 3.88/1,000 catheter days during the intervention period, and 1.05/1,000 catheter days during the third period. The CLABSI rate in the surgical ICU was 8.27/1,000, 4.60/1,000, and 3.73/1,000 catheter days during these three periods, respectively.ConclusionsThe choice of an optimal catheter insertion site, use of all barrier precautions, and removal of catheters when they are no longer needed are essential to decrease the CLABSI rate.

Hand (and orthopaedic) surgery in primitive war conditions

Old Chinese and Egyptian physicians used some chemical methods for the treatment of wounds and injuries. Although the beneficial effect of passing surgical instruments through flame was well known to ancient civilizations, the heat as a preservative method in medical industry, was first introduced in 1809 in France. Joseph Lister (1827–1912) believed that it was microbes carried in the air that caused diseases to be spread in wards. Sterile gowns and caps were used by Gustav Neuber. Surgical masks were applied in 1897 by Mikulicz, while rubber gloves were advised by William Halstead in 1890. For the last two and half years, Syria has suffered from the worst kind of war. So far more than 125 thousand civilians are dead and more than four hundred thousand injured. A lot of severe different casualties resulted, which are severely above the capacity of the local hospitals, especially since some hospitals were occupied by some fighting sides and used for military purposes. Some houses changed into field hospitals, where there is no degree of sterilization at all. As I am an orthopedic surgeon, I found myself going back to practice a primitive form of sterilization. We applied smoking and boiling the metal surgical instruments. Other non-metal instruments were used without sterilization. Some surgical procedures, such as amputations, were performed with bare hands, as there are no surgical gloves. Bone saws were sterilized by flaming. The percentage of infection is very high due to a lack in antibiotics as well. The aim of this paper is to shed light on the primitive methods of sterilization inside some hospitals in Syria, where the war is still flaming.

Potential infection risk from thyroid radiation protection.

Thyroid shields that are worn for personal radiation protection in the operating room are often exposed above the sterile gown and are likely a bacterial source of wound infections. We would like to determine what bacteria may be present on the portion of the thyroid shield, which is facing the operative table. Community thyroid shields were collected from around the operative rooms. The shields were then cultured on the side, which faces the patient and operative table. The shields where then cleaned with a readily available cleaner and again cultured to evaluate the reduction of bacterial load. Samples were cultured on nonselective media for 72 hours. Thirty-two total thyroid shields were cultured before and after cleaning. Before cleaning, 81% of thyroid shields grew out at least 1 type of bacteria with 90% being coagulase negative staphylococcus. Postcleaning culturable contamination was reduced by 70% (P < 0.05). The thyroid shield that is often visible above the neckline is contaminated with strains of bacteria that are commonly implicated in postoperative infections. Cleaning the thyroid shield with readily available cleaners can significantly reduce the bacterial burden as detectable by culture. Based on the primary research question, this article is a basic science article.

Burn Center Barrier Protocols During Dressing Change: A National Survey.

Infection control is a critical component of post-burn care with prevention of infection serving as a major cause of decreasing morbidity and mortality. One potential deterrent for infection is barrier protection during dressing changes; however, no evidence-based standard has been established among burn centers. The purpose of this study is to describe the current barrier techniques of American burn centers. A 24-question survey was sent to 121 burn center nurse managers within the United States. The survey was comprised of yes or no questions with comment sections available for further detail. Questions were constructed to gain insight into the variation and commonality that may exist between burn center barrier protocols. Forty-one out of 121 centers (34%) responded. Centers reported the use of head covers, masks, gowns, and gloves during admission of a new burn (71%, 82%, 95%, and 100% respectively); daily dressing changes (64%, 80%, 97%, and 100% respectively); postoperative dressing changes (64%, masks 80%, 97%, and 100% respectively); and dressing changes of a nonburn (66%, 82%, 97%, and 100% respectively). Burn centers reported their use of sterile gloves and gowns during typical burn dressing changes as occurring 20% and 10% of the time, respectively. Estimates for costs of these garments annually ranged from $0 to $250,000. A calculation performed for this study demonstrated that barrier garments used for dressing changes nationwide is approximately $2.43 million. We demonstrated the immense cost, to an institution and nationwide, of barrier garments used solely for dressing changes.

Performance of aseptic technique during neuraxial analgesia for labor before and after the publication of international guidelines on aseptic technique

BackgroundAseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap).MethodsThe sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects.Results135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups.ConclusionSelf-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.

Clinical guidelines on central venous catheterisation

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

The effect of gowning on labor epidural catheter colonization rate: a randomized controlled trial.

The need to gown for labor epidural catheter insertion is controversial. The American Society of Regional Anesthesia and Pain Medicine has identified a lack of randomized controlled trials investigating this issue. The purpose of this study was to examine the effect of gowning on colonization rates following epidural catheter insertion for labor analgesia. Following research ethics board approval and informed written consent, parturients were randomized to undergo epidural analgesia with the anesthesiologist either ungowned or wearing a sterile gown. Cultures were obtained from each of the operator forearms, the work area under the insertion site, and from the epidural catheter tip as well as from the catheter segment adjacent to the insertion site. The primary outcome was growth of any microbial organisms from the cultured sites. Two hundred fourteen patients completed the study. There were no significant differences in catheter-tip colonization rates between the ungowned and gowned groups (9.2% vs 7.6%, respectively). The most common microorganism that was cultured was coagulase-negative Staphylococcus. The use of gowns in the current study did not affect catheter colonization rate. Overall, there was a relatively high incidence of catheter-tip colonization in both groups, which underscores the need for strict aseptic technique.

The Use of Protocols in Obstetrics and Gynecology

There was, is, and there always will be a clamor for a protocol-based approach to treat acute conditions in Obstetrics and Gynecology. Conditions like post-partum hemorrhage, rupture of the uterus, abruptio placenta, ectopic pregnancy, and gestational trophoblastic neoplasm come to mind readily. At times, severe differences can arise when protocols of different “schools of thought” are sought to be debated, and rightly so. Questions then arise and with it some doubts. Does labor have to be “programmed?” Should epidural analgesia be administered only when the patient is in active labor? Can protocols be designed broadly for the condition and specifically altered for each individual? Should doctors be “forced” to follow protocols? Why protocols anyway? Well, protocols are intended to allow for a systematic approach to a condition, to make sure serious mistakes and variations are not made in treatment, and to ensure that correct investigations are asked for, a contemporary well-documented method of treatment is instituted, and cost effectiveness maintained. Litigation may be prevented as well. A surgical safety checklist developed by Haynes et al. [1] for the WHO is an example of a protocol that can be useful before, during, and after surgery. Protocols or checklists can and should be used when there is some leeway for a procedural approach; however, in cases of a dire emergency, resorting to such an approach may be costly in term of loss of precious time, and in such cases learned memory and a robust “common sense” approach may be best suited. Pronovost et al. [2] described a protocol to reduce infections when introducing central venous catheters due to which the median infection rate at a typical ICU dropped from 2.7 per 1,000 to zero in 3 months. The protocol consisted of seemingly a simple approach of washing hands with soap; cleaning the patient’s skin with chlorhexidine; putting sterile drapes over the whole patient; wearing sterile hat, mask, gown, and gloves; and putting a sterile dressing over the catheter site. A simple solution for a complex problem. Protocols exist for the management of eclampsia, yet after the initiation of investigations and initial treatment, the condition of the patient and any existing complications that present, e.g., renal failure, disseminated intravascular coagulation, may indicate a delay for delivery; in other cases, labor may be induced or a cesarean section may be proceeded with promptly. Similarly, in cases of obstetric hemorrhage protocols, the use of packed red blood cells, fresh frozen plasma, and cryoprecipitate in certain ratios may be advocated, yet the anesthetist/intensivist managing a particular case may ultimately decide upon how the massive transfusion protocol needs to be administered. However, institution protocols and drills go a long way to ensure that a critical obstetric case is treated competently regardless of the individual in charge at that point in time. Maintaining a well-researched and documented protocol or a checklist for the management of labor is almost mandatory. This could include recording via the history and initial findings, the raising of “red flags”—previous cesarean section, diabetes, placenta previa, pregnancy-induced hypertension—the maintenance of a partogram, the correct use of oxytocics, a recording of intrapartum monitoring when deemed necessary, and a well-timed intervention to end labor. There are several established protocols for the use of oxytocin and any of these could be followed with good results. However, a protocol of hand washing, the use of sterile gowns, and a clean environment to maintain hygiene when delivery is conducted in the labor room is almost mandatory to prevent post-partum morbidity. Protocols in the management of preterm labor could include documentation of contractions by cardiotocography, obtaining a high vaginal swab, a baseline ECG when tocolytics are considered, and the stoppage of treatment when uterine contractions are controlled. Likewise, the use of steroids in such cases is also dictated by several established protocols. An ideal protocol that can be adopted universally is non-existent. Protocols can and should vary marginally depending on local resources and work ethic. However, some standardized methodology has to be adopted in every institution or nursing home so that the essentials are kept in sight and the endpoints of treatment are achieved. Protocols have to be reviewed and altered whenever necessary to maintain a “contemporary” value to treatment. No archaic treatment based on “experience” or anecdotal evidence will be tolerated by anyone anymore.

P70 Management of pleural effusions: Are healthcare professionals adequately trained?

Introduction and ObjectivesManagement of pleural effusions is evolving with the introduction of a Best Practice Tariff for unilateral effusions and increasing use of thoracic ultrasound. However, transitions have been slow...

Implementing AORN Recommended Practices for Sterile Technique

Using sterile technique helps prevent the surgical environment from becoming contaminated and thus can help reduce the incidence of surgical site infection. The AORN “Recommended practices for sterile technique” provides guidance for setting up, maintaining, and monitoring a sterile field. Topics include the use of surgical attire and personal protective equipment; appropriate selection and evaluation of surgical gowns, gloves, and drape products for each procedure; use of sterile technique to don sterile gowns and gloves; appropriate methods for establishing and monitoring a sterile field; and techniques to ensure that items such as surgical instruments that may be contaminated are not used. Breaks in sterile technique should be corrected immediately unless the actions necessary would endanger the patient. If remedial actions must be delayed, they should be undertaken as soon as possible. Adhering to best practices for sterile technique requires remaining up to date with new approaches and incorporating these into quality initiatives.

Quantifying bacterial transfer from patients to staff during burns dressing and bed changes: Implications for infection control

Routine nursing activities such as dressing/bed changes increase bacterial dispersal from burns patients, potentially contaminating healthcare workers (HCW) carrying out these tasks. HCW thus become vectors for transmission of nosocomial infection between patients. The suspected relationship between %total body surface area (%TBSA) of burn and levels of bacterial release has never been fully established. Bacterial contamination of HCW was assessed by contact plate samples (n=20) from initially sterile gowns worn by the HCW during burns patient dressing/bed changes. Analysis of 24 gowns was undertaken and examined for relationships between %TBSA, time taken for activity, and contamination received by the HCW. Relationships between size of burn and levels of HCW contamination, and time taken for the dressing/bed change and levels of HCW contamination were best described by exponential models. Burn size correlated more strongly (R(2)=0.82, p<0.001) than time taken (R(2)=0.52, p<0.001), with levels of contamination received by the HCW. Contamination doubled with every 6-9% TBSA increase in burn size. Burn size was used to create a model to predict bacterial contamination received by a HCW carrying out bed/dressing changes. This may help with the creation of burn-specific guidelines on protective clothing worn by HCW caring for burns patients.

Treatment for Lupus, First in 50 Years, Offers Modest Benefits, Hope to Patients

by weighing the risk of infection against mechanical complicationssuchaspneumothoraxorsubclavianarterypuncture; avoiding use of the femoral vein for central venous access in adults. •Washing hands with soap and water or alcohol-based rubs before and after palpating insertion sites as well as inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Wearing sterile gloves to insert arterial, central, or midline catheters. •Using maximal sterile barrier precautions—cap, mask, sterile gown, sterile gloves, and sterile full-body drape— wheninsertingcentralvenouscatheters, peripherally insertedcentralcatheters,or guidewire exchange. •Preparing patients’ clean skin with a chlorhexidine preparation of greater than 0.5% with alcohol before inserting central venous or peripheral arterial catheters, and during dressing changes. Later this year, US hospitals will have totrackandreportcentral line–associated bloodstreaminfectionsthatoccurintheir intensivecareunits if theywant toget an annual2%payment increase fromMedicare.Thedatasubsequentlywillbeavailable to the public on the government’s Hospital Compare Web site, http://www .hospitalcompare.hhs.gov.

Transitions in Care

I arrive at the hospital in the early morning and soon afterward my colleague hands me two sheets of crisp white paper listing her patients. After her long night on-call, she is ready to relinquish her patients to my care. I spend a few minutes with her, scanning this index of unfamiliar names while she emphasizes details relating to her sickest patients. Alongside the rows of names are tidy “to do” and “to know” columns where personal details, critical test results and response plans for worst case scenarios have been reduced to acronyms and abbreviations. I’m convinced that these two impersonal pages contain all I will need to know to care for these patients over the grueling shift ahead—responses for every contingency. Often the only contact I have with my colleague’s patients are their names and diagnoses on these sign-out sheets, when a nurse passes along a routine request or gives me a quick update. On occasion, I remain at a patient’s bedside, agonizing over a critical decision. Some encounters expose the lingering uncertainty inherent in caring for little known patients, yet other interactions reveal confidence, born out of budding experience. I cautiously interpret the hemorrhagic stroke patient’s head CT for the family that just arrived in town after driving hundreds of miles. Did they have any idea what I was explaining to them? I absently okay the bisacodyl suppository for the constipated patient in the midst of a hectic emergency room admission. I no longer reach for my pocket guide when prescribing such common medications. I hesitantly pronounce the young woman’s death while her husband tearfully accepts that her 10-year battle with breast cancer has ended. Was I sensitive to the new widower in the midst of a chaotic night? I urgently assess the man with severe thrombocytopenia who just fell out of bed and hit his head. Could we have done more to prevent his fall? I quickly check the hyponatremic patient’s sodium level, then make a slight adjustment to her intravenous fluids. I continue to become more comfortable with such routines of patient care. I reflexively order blood cultures and a chest radiograph for the febrile patient, distracted by the piles of paperwork on my desk. Should I have taken more time to evaluate him? I smoothly place a central line, the thick sterile gown and mask concealing beads of sweat, as the septic patient becomes progressively hypotensive. With each procedure I enhance my poise to act under stress. Many hours pass before I finally see the shadow of distant mountains outlined by the approaching dawn. The chatter of nurses at shift change and the aroma of breakfast wafting from heavy food carts rolling down the hall mean that my relief is finally arriving. I glance over the now well-worn sign-out document, marked with hurried notations and smudged with tea stains. The night’s interactions—some challenging, some easily forgettable and a few leaving a lasting impression, have transformed sterile data into living, breathing individuals. Reflecting on the night, I consider how I, too, was transformed. Forced to rely on my growing clinical acumen, I perceive that I am settling into my role as a physician. Decisions that once seemed pedantic appear increasingly straightforward, and conversations that previously felt halted become progressively more natural. As my shift ends, I prepare my sign-out document, creating new rows and columns while deleting others. With the exchange of a few words and this fresh sheet of paper, I relay updated patient information to the next team member. Exhausted, I snap on my helmet and bicycle toward home. Wheels spin beneath me, the spokes casting a hypnotic shadow on the pavement. I envision my colleague proceeding from patient to patient, sign-out in hand. For him, as with me, each encounter will animate the lifeless sign-out sheet as the cycle begins again.

Heightened Infection-Control Practices are Associated with Significantly Lower Infection Rates in Office-Based Mohs Surgery

Reported infection rates for Mohs micrographic surgery (MMS) range from less than 1% to 3.5%. To determine whether lower infection rates are possible for MMS with a consistently applied infection-control regimen. A series of 832 consecutive patients with 950 tumors undergoing MMS formed the cohort for a retrospective study of infections before and after a program of heightened infection-control practices at a single-surgeon academic Mohs practice. The sterility upgrade included jewelry restrictions, alcohol hand scrub before stages and reconstruction, sterile gloves and (during reconstruction) sterile gowns for staff, and sterile towels and dressings for patients during Mohs stages. Infection rate was 2.5% (9 infections/365 tumors) before the sterility upgrade and 0.9% (5 infections/585 tumors) after, a statistically significant difference (p=.04). MMS already has low rates of infection, but this study shows that rigorous infection-control practices can significantly affect infection rates. The authors have indicated no significant interest with commercial supporters.

Regional anaesthesia practice for total knee arthroplasty: French national survey – 2008

Background and objective Improved pain management techniques and rehabilitation programs have significantly modified outcome for total knee arthroplasty (TKA). Objective The aim of the survey was to describe the French practice patterns in regional anaesthesia for TKA. Methods Twenty-item questionnaires were distributed to units with significant orthopaedic activity across France. The content referred to the type of orthopaedic activity; anaesthetic and analgesic management; preoperative patient information; technical aspects describing regional anaesthesia and postoperative analgesia. Results Response rate was 54%. Combined general anaesthesia and perineural catheter was the most frequently used anaesthetic technique. Most of respondents used multimodal analgesia (including femoral nerve catheter by 80%). Written hygiene protocols were rarely available. Sterile gowns were seldom worn. Among antiseptic agents, povidone iodine was most often used. Sedative agents were systematically used by 36% of respondents. Ropivacaine was the preferred local anaesthetic agent. Finally, adjuvants were rarely used. In most cases (58%) the femoral block was performed before induction of general anaesthesia. The catheter was commonly threaded to a length between 5 and 8 cm. The correct position of the catheter tip was verified clinically by majority of respondents. Local anaesthetics were administered by continuous infusion, continuous infusion plus boluses and boluses alone in 44, 36 and 8% of cases. Catheter duration was 48 and 72 h in 45 and 33% of the units and was independent of pain scores. Conclusion This national survey showed practices in accordance with recent guidelines as well as persistent challenges in regional anaesthesia for TKA.

Évaluation des pratiques de gestion des cathéters veineux centraux dans les réanimations chirurgicales universitaires françaises

Introduction Recommendations on insertion and maintenance of central venous catheters (CVC) in intensive care unit (ICU) patients were updated in 2002. The aim of this study was to estimate their knowledge and/or application by physicians in French university hospital ICUs. Methods Two forms were sent to 124 professors of anaesthesia and intensive care encouraging them to participate to the survey. The first one was completed by the physician in charge of each unit and concerned the structure and activity of the unit in 2006. The second one was filled by each junior or senior physician working in the units and asked for experience, CVC insertion modalities and knowledge of CVC care protocols. Results Forty-one (75 %) university hospitals with at least one adult surgical ICU took part to the study. A questionnaire was filled by 124 senior (75 % of the staff) and 53 junior (43 % of the staff) physicians inserting an average of 10 CVC per month (range, 1–35). A written protocol for CVC insertion was known by 127 (72 %) of them. CVC insertion was done while wearing sterile gown (97 %), cap (100 %) and surgical mask (100 %) and using large sterile draps (96 %). The antiseptic solution used for cutaneous antisepsis was povidone iodine in aqueous (36 %) or alcoholic solution (40 %), or an alcoholic solution of chlorhexidine (24 %) applied one (9 %), two (64 %) or three (27 %) times before insertion. A 4-times disinfection sequence (washing, rinsing, drying and disinfection) was performed by 161 (91 %) physicians. Ultrasound-guided insertion was realized by only eight (5 %) operators. CVCs were made of polyurethane (84 %), usually multi-lumens (> 96 %) and rarely tunnelised (14 %). Only two physicians (1 %) sometimes use catheters coated with antibiotics or antiseptics. The site for catheter insertion was mostly the sub-clavian (47 %) or internal jugular vein (34 %), and rarely the femoral vein (20 %). CVCs were secured with a thread (99 %) and covered with a semi-permeable dressing (76 %). Concerning CVCs maintenance, 91 % of physicians acknowledged the existence of a written protocol in the unit. Dressings were changed every day (10 %), every two days (49 %), every three days (29 %) or every four days or more (12 %) by using the same antiseptic solution and semi-permeable transparent dressing in 78 % of cases. Venous lines changes were done during dressing maintenance (48 %), every day in case of administration of lipids (32 %) or just after administration of blood products via the catheter (32 %). Routine change of CVC was rarely recommended (11 %). Conclusion The high number of answers allows setting of a precise state of CVCs insertion practices in adult surgical ICUs. Recommendations for central venous catheter insertion and maintenance are not still known and\\or applied.

Critical Care Medicine

The year of 2009∼2010 brought a number of concepts and new ideas were evaluated with promising results. However, some studies that challenged many beliefs. In acute respiratory distress syndrome (ARDS), recent clinical studies took into consideration of pathophysiologic changes of respiratory system compliance. Meta-analysis of positive end-expiratory pressure trials showed survival benefit of high positive end-expiratory pressure in ARDS. Until now, prone positioning did not show survival benefit in patients with ARDS. Extracorporeal membrane oxygenation (ECMO) based management improved survival in patien ts with severe ARDS. ECMO can be a management option in severe ARDS. Sedation is a standard practice in critically ill patients needing mechanical ventilation. However, Danish group reported less sedation of critically ill patients receiving mechanical ventilation was associated with an increase in days without ventilation. Although this single center study has some limitations, the overall results are promising. Use of maximal sterile barrier precautions (mask, sterile gown, sterile gloves, and large sterile drapes) with chlorhexidine-impregnated dressing reduced central venous catheter related infection. Selective oropharyngeal decontamination (application of topical antibiotics in the oropharynx) reduced the mortality rate of an intensive care unit (ICU) population. Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial reported intensive glucose control increased mortality among adults in the ICU. Some of the results of above papers are promising. However, some ideas may need for more frequent individual assessment and increase the workload of ICU staffs. Before implementation of new practice in ICU, we should take into consideration of individual hospital situation including human and material resources.

Owens &amp; Minor, Inc.

AbstractSpecialist Equipment Supplies (MIC: SIC: 5047 NAIC: 423450)Owens &amp; Minor is a distributor of medical and surgical supplies to the acute‐care market, a healthcare supply chain management company and a national direct‐to‐consumer supplier of testing and monitoring supplies for diabetics. As of Dec 31 2007, Co. distributed 180,000 finished medical and surgical products produced by over 1,200 suppliers to about 4,100 healthcare provider customers from 45 distribution centers. Most of Co.'s sales consist of consumable goods such as disposable gloves, dressings, endoscopic products, intravenous products, needles and syringes, sterile procedure trays, surgical products and gowns, urological products and wound closure products.

Ethics: Ethics in Healthcare Organizations: Struggling with New Questions

Citation: Sorrell, J., (August 20, 2008) Column: Ethics in Healthcare Organizations: Struggling with New Questions OJIN: The Online Journal of Issues in Nursing, Vol. 13, No. 3. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/EthicsandNewQuestions.aspx is a pause to wonder, to question, to step back, to notice. (Moules, 2006, p. 7.) In 2006, researchers at Johns Hopkins University published results of a program designed to prevent specific types of hospital infections in intensive care units. The program involved a simple, five-step checklist to remind physicians that before implementing specific procedures, such as inserting central lines into patients, they should carry out routine precautions, for example washing their hands and wearing a sterile gown and gloves. After three months of using the checklist, the rate of bloodstream infections from the central lines was decreased by two-thirds. Researchers estimated that in the 18-month period following implementation of the checklist, the program saved more than 1,500 lives and nearly $200,000,000 (Gawande, 2007). In spite of these amazing results, the Office for Human Research Protections (OHRP) in Michigan, where the checklist program had been implemented by Johns Hopkins University researchers, halted the program. Further, Johns Hopkins was required to discontinue its plans to extend the program to hospitals in New Jersey and Rhode Island. Why was this decision made? The Office for Human Research Protections ruled that federal monitoring and written informed consent from patients should be required for the study in the same way that these would be required for the research (Gawande, 2007). This scenario raises interesting, ironic, and difficult ethical questions for healthcare professionals. With increasing evidence of unnecessary surgery, inappropriate use of medications, inadequate preventive measures, avoidable exacerbations of chronic conditions, and other errors and waste, initiatives to improve of care have become a major force in shaping healthcare. These diverse initiatives share a common goal of generating knowledge that will guide improvements in healthcare (Casarett, Karlawish, & Sugarman, 2000). Some of the most effective approaches have evolved from methods pioneered in manufacturing: pursuing high by systematically implementing changes, and monitoring the effects of those changes to guide ongoing improvement. This general approach has come to be called quality (Johnson, Vermeulen, & Smith, 2006). Previously, organizational efforts that focused on improvement of healthcare had been exempt from scientific research regulations (Gawande, 2007). Increasingly, however, organizational efforts are focusing on more scientific approaches to studying enhancement of in healthcare. How will future decisions be made to ensure that vital improvement initiatives are implemented within appropriate guidelines focused on patient safety? Ethical issues arise in improvement because attempts to improve care for some patients may inadvertently cause harm or may benefit some at the expense of others; these ethical concerns mirror those in which patients are used as subjects in medical research (Casarett, Karlawish, & Sugarman, 2000). Gawande (2007) notes that although the decision of Michigan's Office for Human Research Protections in response to the improvement checklist initiative was questionable and even dangerous, there was a certain logic to it: A checklist is an alteration in medical care similar to an experimental drug. It is unethical to use an experimental drug in people without federal monitoring and explicit written permission from each patient. Therefore, the ruling stated, it is unethical to do the same with a checklist. In fact, the agency concluded that a checklist may require even more stringent oversight because collecting data might bring risk to not only patients, but also healthcare providers, whose failure to follow basic infection-prevention procedures might be exposed. …

Owens &amp; Minor, Inc.

AbstractSpecialist Equipment Supplies (MIC: SIC: 5047 NAIC: 423450)Owens &amp; Minor is a distributor of medical and surgical supplies to the acute‐care market, a healthcare supply chain management company and a national direct‐to‐consumer supplier of testing and monitoring supplies for diabetics. As of Dec 31 2007, Co. distributed 180,000 finished medical and surgical products produced by over 1,200 suppliers to about 4,100 healthcare provider customers from 45 distribution centers. Most of Co.'s sales consist of consumable goods such as disposable gloves, dressings, endoscopic products, intravenous products, needles and syringes, sterile procedure trays, surgical products and gowns, urological products and wound closure products.