Teaching Hospital In Taiwan Research Articles

Self‐efficacy, self‐care behavior, anxiety, and depression in Taiwanese with type 2 diabetes: A cross‐sectional survey

The relationships between self-efficacy, self-care behavior, anxiety, and depression for Taiwanese individuals with type 2 diabetes were determined in this study. Depression and anxiety are common symptoms that can contribute toward adverse medical outcomes. A descriptive, cross-sectional, correlational design was used. The sample comprised 201 patients with type 2 diabetes from diabetes outpatient clinics at three teaching hospitals in Taiwan. The results of this study revealed that people with diabetes who had received diabetes health education, regularly made clinical visits, underwent treatment, and did not smoke demonstrated a high self-efficacy score (P < 0.05). Self-efficacy among people with diabetes positively correlated with illness duration (P < 0.05), treatment (P < 0.01), and self-care behavior (P < 0.01). Self-efficacy among people with diabetes negatively correlated with anxiety and depression (P < 0.01). Self-efficacy can be a predictor of anxiety and depression (P < 0.01). This study revealed that enhancing self-efficacy levels might reduce anxiety and depression. Self-efficacy-enhancing programs should be held regularly in clinical practices. Conducting psychological research on diabetes drives policy and healthcare system change.

P147: Assessing the thoroughness of hand hygiene: “To see is to believe”

Many staff challenged infection control personnel (ICP) regarding the rationale of hand rubbing time. Furthermore, few if any recommendation described how to evaluate correct hand hygiene (HH) technique. Here we descried the impact of a stress-free, “to see is to believe” program on proper HH technique conduced in May 2012 at a 2200-bed teaching hospital in Taiwan.

Prevalence of carbapenemase-producing Enterobacteriaceae and its impact on clinical outcomes at a teaching hospital in Taiwan

Among 15,174 non-duplicated Enterobacteriaceae isolates, the prevalence of carbapenem-nonsusceptible Enterobacteriaceae (CNSE) was about 2.5% at a teaching hospital in Taiwan during 2010. Among 117 available isolates of CNSE, 8.6% carried genes encoding carbapenemases. Tigecycline and colistin were the most active agents against carbapenemase-producing and non-producing isolates. Patients infected with CNSE had an all-cause in-hospital mortality of 37.3%, and mortality was similar for infections from carbapenemase producers and non-producers (14-day mortality rates: 22.2% and 21.5%; 30-day mortality rates: 22.2% and 32.3%, respectively). Continuous surveillance of CNSE is recommended in Taiwan.

A Web-Based Multidrug-Resistant Organisms Surveillance and Outbreak Detection System with Rule-Based Classification and Clustering

BackgroundThe emergence and spread of multidrug-resistant organisms (MDROs) are causing a global crisis. Combating antimicrobial resistance requires prevention of transmission of resistant organisms and improved use of antimicrobials.ObjectivesTo develop a Web-based information system for automatic integration, analysis, and interpretation of the antimicrobial susceptibility of all clinical isolates that incorporates rule-based classification and cluster analysis of MDROs and implements control chart analysis to facilitate outbreak detection.MethodsElectronic microbiological data from a 2200-bed teaching hospital in Taiwan were classified according to predefined criteria of MDROs. The numbers of organisms, patients, and incident patients in each MDRO pattern were presented graphically to describe spatial and time information in a Web-based user interface. Hierarchical clustering with 7 upper control limits (UCL) was used to detect suspicious outbreaks. The system’s performance in outbreak detection was evaluated based on vancomycin-resistant enterococcal outbreaks determined by a hospital-wide prospective active surveillance database compiled by infection control personnel.ResultsThe optimal UCL for MDRO outbreak detection was the upper 90% confidence interval (CI) using germ criterion with clustering (area under ROC curve (AUC) 0.93, 95% CI 0.91 to 0.95), upper 85% CI using patient criterion (AUC 0.87, 95% CI 0.80 to 0.93), and one standard deviation using incident patient criterion (AUC 0.84, 95% CI 0.75 to 0.92). The performance indicators of each UCL were statistically significantly higher with clustering than those without clustering in germ criterion (P < .001), patient criterion (P = .04), and incident patient criterion (P < .001). ConclusionThis system automatically identifies MDROs and accurately detects suspicious outbreaks of MDROs based on the antimicrobial susceptibility of all clinical isolates.

Comparison of epidemiology and treatment outcome of patients with candidemia at a teaching hospital in Northern Taiwan, in 2002 and 2010

The incidence of candidemia varied between hospitals and different study periods. Few, if any, studies provide the reasons. This hospital-based population study aimed to describe and compare the patient population hospitalized in 2002 and 2010 and determine the disease-specific incidences of candidemia and evaluate the impact of time to initiate antifungal therapy on 30-day mortality. All patients hospitalized at a 2300-bed teaching hospital in Taiwan in 2002 and 2010 were analyzed for the distribution of age, sex, and type of underlying diseases (maximum of six diagnoses). All patients with blood isolates that were collected in 2002 and 2010 and yielded Candida species were included for analysis of the demographic and clinical characteristics, distribution of Candida species, length of hospital stay before candidemia, stay in the intensive care units at onset of candidemia, time of initiating systemic antifungal agent, antifungal regimen, and 30-day crude mortality. In 2010, the hospitalized patients were older (p<0.001), had a higher Charlson Comorbidity Index (p<0.001), and more underlying disease/status, including chronic pulmonary diseases, moderate-to-severe renal diseases, leukemia, lymphoma, and gastrointestinal malignancies (p<0.001) than those seen in 2002. Multivariate analysis identified the following host factors were associated with the occurrence of candidemia in 2010: neonate (adjust odds ratio [OR], 3.67), 45-64 year (OR, 2.18) and the elderly (OR 2.64), compared with young adult (20-44 year); patients with moderate-to-severe renal diseases (OR, 8.08), leukemia (OR, 4.58) and lymphoma (OR 3.98) and gastrointestinal malignancies (OR 2.80). The incidence density of candidemia was 0.34 and 0.41 per 1000 patient-days in 2002 and 2010, respectively (p=0.04). The majority of characteristics of patients with candidemia and disease-specific incidences of candidemia did not differ between 2002 and 2010. Despite more patients in 2010 receiving antifungal therapy on the same day or 1 day after onset (27.5% vs. 41.2%, respectively, p=0.002), the 30-day mortality remained high (45.9% in 2002 and 44.4% in 2010). Moreover, time to initiate antifungal therapy had no impact on 30-day mortality. This hospital-based population study demonstrated that the incidence density of candidemia was high and increased in 2010 compared with 2002, which was at least in part due to the increase in the proportion of patients at a higher risk of candidemia. Although antifungal therapy was initiated earlier in 2010, the 30-day mortality remained high.

An exploratory study of complaints handling and nature

Different countries have different complaints handling systems. This study reveals general pathways to handling complaints that provide an overview at the case hospital as well as a general complaints handling picture in Taiwan. It explores hospital complaints and how hospital staff handle them. A large teaching hospital in Taiwan was purposefully chosen as a case study. Data were collected through in-depth interviews, document analysis and interrogating a 3-year complaints archive. The study found that dissatisfaction with 'humaneness' and 'care/treatment' commonly causes the case hospital patients to complain. Understanding complaint patterns, therefore, can help hospital managers improve organizational performance, which shows that certain service provision needs to be prioritized if hospital staff intend to improve service quality.

Dissemination of multidrug-resistant Acinetobacter baumannii carrying BlaOxA-23 from hospitals in central Taiwan

Imipenem-resistant Acinetobacter baumannii (IRAB) poses a great threat to healthcare systems. Production of carbapenem-hydrolyzing class D β-lactamases (CHDLs) is the major mechanism for imipenem resistance. In this study, we found a high prevalence of IRAB carrying a gene encoding CHDL, bla(OxA-23), in central Taiwan and elucidated the molecular characteristics and possible mechanisms of the spread of these isolates. During 2007, we collected 291 nonrepetitive A baumannii isolates from 10 teaching hospitals in Taiwan. The antimicrobial susceptibility of the isolates was determined by agar dilution or Etest. The genes encoding carbapenemase and related structure were detected by polymerase chain reaction mapping and sequencing, and the clonal relationship of the isolates was analyzed by pulsed-field gel electrophoresis. Plasmid localization of bla(OxA-23) was determined by extraction of plasmid with commercial kit and Southern blot analysis. Among 142 IRAB isolates, 30 harbored the bla(OxA-23). The prevalence of IRAB with bla(OxA-23) was highest in central Taiwan compared to other areas [24.8% (27/109) vs. 1.6% (3/182); p < 0.001]. These IRAB with bla(OxA-23) were also resistant to other antimicrobial agents, except colistin. The PCR methods showed the presence of bla(OxA-51) in all isolates. We could exclude clonal spreading due to the diversity of the pulsotype. The bla(OxA-23) gene was detected in the plasmids of 6 isolates. Tn2006 was present in 22 (73.3%) isolates, and Tn2008, in 6 other isolates (26.7%). Two strains had bla(oxa-23)-ΔATPase but lacked upstream ISAba1. The high prevalence of bla(OxA-23)-harboring IRAB in central Taiwan might be attributed to the transposition event of Tn2006.

Predictors of In-hospital Mortality in Oldest-Old Patients in Taiwan

Elderly adults are at a higher risk of complications during their hospital stay and have a higher in-hospital mortality rate. The aim of this study was to analyze the risk factors associated with mortality in the oldest-old patients admitted to a large teaching hospital in Taiwan. All study participants, aged more than 75 years, were recruited from the unselected acutely ill patients admitted to our hospital between March and July 2009. A total of 3945 admissions were included. Out of these, 2037 (51.6%) patients were female and the average age was 81.8 (±5.4) years. The overall in-hospital mortality rate was 8.2% (9.9% in medical wards; 3.7% in surgical wards). The main predictors for in-hospital mortality in medical wards were advanced age >80 years [odds ratio (OR), 1.83 (1.25–2.68)], plasma glucose at admission >160 or <80 mg/dL [OR, 1.97 (1.36–2.85)], alanine aminotransferase >80 U/L [OR, 2.78 (1.68–4.58)], creatinine >1.5 mg/dL [OR, 2.91 (2.06–4.12)], white cell count >12 × 10 3 or <3 × 10 3 /μL [OR, 2.59 (1.84–3.65)], and abnormal blood pressure >180 or <90 mmHg [OR, 2.29 (1.31–3.99)]. Abnormal levels of hemoglobin (<9 g/dL), white cell count, and being transferred from the emergency room were significantly related to in-hospital mortality in surgical wards. Our findings suggest that particular attention should be paid to patients with an older age, those with abnormal levels of routine admission tests, or those being referred from an emergency room, which indicates critical health conditions, and higher in-hospital mortality.

A Drug Utility Analysis of the Withdrawal of the Propoxyphene–acetaminophen Combination from a Teaching Hospital in Taiwan

Purpose In March 2011, Taiwan's Food and Drug Administration announced license withdrawal of propoxyphene-containing products in response to the finding of propoxyphene-related fatal cardiotoxicity. This study was conducted to review the usage pattern of propoxyphene and acetaminophen combination dosage form (PA) and to assess the clinical impact in association to the withdrawal. Methods This retrospective observational study was conducted in an 800-bed regional teaching hospital in northern Taiwan accredited by the Joint Institutional Review Board (JIRB). Study participants were outpatients older than 18 years for whom PA was prescribed between September 2010 and March 2011. Data collection was done through review of medical charts and electronic medical records from the health informatics system. Our primary outcomes were the usage pattern of PA and the efficacy of alternative analgesic agents used in replacement before and after the withdrawal of PA as an analgesic agent for pain management. Data analysis was done using descriptive statistics and Wilcoxon signed-rank test. Results PA was mainly prescribed for pain control in patients with diseases of the musculoskeletal system and connective tissue (60.8%, n = 463) and neoplasms (16.0%, n = 122). Of the 761 included study participants, most of them were short-term users (82.1%; n = 625) and 17.9% ( n = 136) were chronic users of PA. Dosages prescribed were within the recommended dosing range. No cardiovascular events were reported due to PA. The most frequently prescribed alternative analgesic agents in PA replacement were nonsteroidal antiinflammatory drugs (NSAIDs) (38.7%; n = 63), acetaminophen (22.1%; n = 36), and nonopioid transdermal analgesic agents (14.7%; n = 24) in short-term users. For chronic users, the most frequently prescribed analgesic agent was acetaminophen (35.2%; n = 25), followed by NSAIDs (31.0%; n = 22) and tramadol (11.3%; n = 8). There was no significant difference between the mean numerical rating score with prescription of PA and prescription of alternative analgesic agents in replacement of PA for pain management. Conclusion PA was mainly prescribed for the management of mild to moderate musculoskeletal- and neoplasm-associated pain. Acetaminophen and NSAIDs were used most often in replacement of PA. There was no significant clinical effect associated with formulary withdrawal of PA because it was mainly prescribed for short-term use and other comparable alternative agents were available.

Wide spread of Tn2006 in an AbaR4-type resistance island among carbapenem-resistant Acinetobacter baumannii clinical isolates in Taiwan

Carbapenem resistance in Acinetobacter baumannii is a global problem. The purpose of this study was to elucidate current resistance mechanisms of imipenem-resistant A. baumannii (IRAB) in Taiwan and their correlation with patient outcomes. Acinetobacter baumannii clinical isolates from two teaching hospitals in Taiwan were collected in 2009 and were examined by Etest for determination of the minimum inhibitory concentrations (MICs) of imipenem, ceftazidime and ceftriaxone. Primers specific for carbapenemase genes and upstream regions were designed for PCR amplification. Bacterial isolates were genotyped by pulsed-field gel electrophoresis (PFGE). Clinical presentations of patients were analysed retrospectively. Upstream insertion sequence ISAba1 was found in 34 isolates that carried blaOXA-23, including 28 with transposon Tn2006 (ISAba1–blaOXA-23–ISAba1) in an AbaR4-type resistance island and 6 with Tn2008 (ISAba1–blaOXA-23), as well as in 8 isolates carrying ISAba1–blaOXA-51-like. All of these isolates expressed full resistance to imipenem (MIC>32mg/L). Forty-one different PFGE genotypes were found among 62 isolates. Tn2006 was found in 19 genotypes (46.3%), which is more common than ISAba1–blaOXA-51-like (12.2%) (P=0.001). Prior use of carbapenems or extended-spectrum cephalosporins for ≥5 days was the only independent risk factor significantly associated with IRAB infection (odds ratio=361.175). Higher mortality was significantly associated with infection caused by IRAB and ISAba1–blaOXA-23-carrying strains compared with infection caused by imipenem-susceptible A. baumannii and ISAba1–blaOXA-51-like-carrying strains (P=0.009 and 0.027, respectively). Tn2006 is currently the most common imipenem resistance determinant, which showed a higher ability to spread among A. baumannii and was associated with a higher mortality in IRAB-infected patients.

Syphilis and neurosyphilis in human immunodeficiency virus-infected patients: A retrospective study at a teaching hospital in Taiwan

Some studies have reported that the risk factors for neurosyphilis in patients with human immunodeficiency virus (HIV) and syphilis co-infection, include CD4 cell counts ≤350cells/μL and rapid plasma reagin (RPR) titer ≥1:32. However, neurosyphils can develop even in patients with CD4 cell counts >350cells/μL or RPR titer <1:32. In this study, we evaluated the outcome of syphilis to treatment in HIV-infected patients, and analysed the predictors of neurosyphilis in this population. We retrospectively reviewed medical records of HIV-infected patients with syphilis who visited the China Medical University Hospital between January 2000 and December 2009. Neurosyphilis was defined by white blood cell (WBC) counts >20cells/μL in the cerebrospinal fluid (CSF) sample or elevated Venereal Disease Research Laboratory (VDRL) titers of the CSF samples. Treatment failure was defined as less than 4-fold decrease in the serum RPR titer at or beyond 12 months post-treatment in case of early syphilis, and, at or beyond 24 months in case of late syphilis. One hundred and twenty-one HIV-infected patients (average age, 32 years) with syphilis were included in this study. Of 63 patients who had follow-up of serologic responses, 30 (47.6%) failed to respond to treatment. CD4 cell counts ≤200cells/μL was the indicator for treatment failure (P=.029). Lumbar puncture was performed in 65 patients, and 14 patients were diagnosed with neurosyphilis. At the time of lumbar puncture, 31 and 19 of the 65 patients showed CD4 cell counts of >350cells/μL and RPR of <1:32, respectively. An HIV viral load (VL) ≥10000copies/mL was found to be associated with the development of neurosyphilis (P=.016). In HIV-infected patients with syphilis, RPR titer should be evaluated more frequently when CD4 count ≤200cell/μL is associated with treatment failure. Lumbar puncture for the diagnosis of neurosyphilis should be considered in patients with HIV and syphilis co-infection, even in patients with CD4 cell counts >350cells/μL, and particularly when the HIV VL ≥10000copies/mL.

Abstract 2656: Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients

Abstract Background There is no literature for stratification of permanent implantable venous ports (Port-A) related bloodstream infection (BSI) in solid cancer patients. We conduct this study to characterize the risk factors of BSI associated with the use of Port-A (PABSI) in solid cancer patients. Methods The study is done in a teaching hospital in Taiwan. Solid cancer patients who were implanted with a Port-A for systemic anti-cancer therapies were prospectively followed for the occurrence of PABSI, defined as BSI without other identifiable infection foci. Patients with PABSI during the follow-up period constitute the case cohort (N = 58) and 174 patients were randomly selected from those without BSI as the control cohort. PABSI risk score was developed by Cox proportional hazards model. Results 416 patients were registered (Table 1). Eighty-eight PABSI episodes occurred in 58 patients, with an incidence of 1.05 per 1000 catheter-days. All but one patient had stage 4 cancer. Independent predictors of PABSI occurrence included neutropenia (HR = 3.86, 95% CI = 1.75-8.50), total parental nutrition (TPN) (HR = 3.51, 95% CI = 1.86-6.63), chronic steroid use (HR = 7.01, 95% CI = 2.78-17.65), invasive procedure (HR = 3.00, 95% CI = 1.29-6.98), postoperative antibiotics (HR = 2.61, 95% CI = 1.43-4.75), and preoperative antibiotics (HR = 0.38, 95% CI = 0.17-0.83). A PABSI risk score, with a cut-off value of 0 (sensitivity 88.5%, specificity 64.3%), was defined for stage 4 cancer patients as follows: neutropenia, +1.350; TPN, +1.256; chronic steroid use, +1.947; preoperative antibiotics, –0.970; postoperative antibiotics, +0.959; and invasive procedure, +1.098. The median PABSI-free survival was 4.47 months for patients with score β0 but not reached for patients with score &amp;lt; 0 (p &amp;lt; 0.0001). Conclusions The PABSI risk score can help define high-risk groups in solid cancer patients and may help design future preventive strategies. Presence of any risk factor would render patients as high risk. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2656. doi:1538-7445.AM2012-2656

Impact of Appropriate Antimicrobial Therapy on Mortality Associated With Acinetobacter baumannii Bacteremia: Relation to Severity of Infection

The efficacy of antimicrobial therapy for Acinetobacter baumannii bacteremia has been difficult to establish because of confounding by underlying diseases, severity of infection, and differences in the pathogenicity of Acinetobacter species. This retrospective study was conducted to evaluate the effect of appropriate antimicrobial therapy on 14-day mortality after adjustment for multiple risk factors. The population consisted of 252 patients with monomicrobial A. baumannii bacteremia admitted to a large teaching hospital in Taiwan. The isolates were identified to species level using reference molecular methods. Predictors of 14-day mortality were determined by logistic regression analysis. The influence of severity of infection, determined by Acute Physiology and Chronic Health Evaluation (APACHE) II score, on the impact of appropriate use of antimicrobials on 14-day mortality was assessed by including an interaction term. The overall 14-day mortality rate was 29.8% (75 of 252 patients). The unadjusted mortality rate for appropriate antimicrobial therapy was 13.2% (12 of 91 patients). Appropriate therapy was independently associated with reduced mortality (odds ratio [OR], 0.22; 95% confidence interval [CI], .01-.50; P < .001), and the effect was influenced by APACHE II score (OR for interaction term, 0.90; 95% CI, .82-.98; P= .02). A subgroup analysis revealed that the benefit of appropriate therapy was limited to patients with high APACHE II scores (OR for patients with scores >25 and ≤ 35, 0.16 [95% CI, .07-.37]; OR for those with scores >35, 0.06; 95% CI, .01-.25). Appropriate antimicrobial therapy significantly reduced 14-day mortality for A. baumannii bacteremia in severely ill patients.

In vitro susceptibilities of clinical isolates of ertapenem-non-susceptible Enterobacteriaceae to cefotaxime, ceftazidime, cefepime and aztreonam

To investigate the in vitro susceptibility of ertapenem-non-susceptible Enterobacteriaceae (ENSE) isolates to cefotaxime, ceftazidime, cefepime and aztreonam. Clinical isolates of ENSE tested in this study were obtained from 10 major teaching hospitals in Taiwan during the period January 2008 to October 2010. MICs of ertapenem, cefotaxime, ceftazidime, cefepime and aztreonam were determined by the agar dilution method and were interpreted based on 2011 MIC interpretive criteria recommended by the CLSI and EUCAST. A total of 412 non-duplicate ENSE isolates (with ertapenem MIC values ≥ 0.5 mg/L) were tested. These comprised 72 isolates of Escherichia coli [28 (38.9%) were extended-spectrum β-lactamase (ESBL)-producing isolates], 167 isolates of Klebsiella pneumoniae [74 (44.3%) were ESBL-producing isolates], 115 isolates of Enterobacter cloacae, 13 isolates of Enterobacter aerogenes, 20 isolates of Citrobacter freundii and 25 isolates of Serratia marcescens. According to 2011 CLSI (EUCAST) MIC interpretive breakpoints for Enterobacteriaceae, 64% (31%) of all ENSE isolates, 45.8% (16.7%) of E. coli isolates, 53% (29.3%) of K. pneumoniae isolates and 86.1% (35.7%) of E. cloacae isolates were susceptible to cefepime. As for ESBL-producing ENSE isolates, 25% and 14.3% of E. coli isolates and 36.5% and 10.8% of K. pneumoniae isolates were susceptible to cefepime based on CLSI and EUCAST criteria, respectively. Cefepime exerts in vitro antimicrobial activity against a significant portion of clinical isolates of ENSE, although there are discrepancies between results obtained using the CLSI-2011 and EUCAST-2011 guidelines.

Congenital Webs of the Gastrointestinal Tract: 20 Years of Experience From a Pediatric Care Teaching Hospital in Taiwan

To classify and evaluate the clinical spectrum of congenital webs in the gastrointestinal (GI) tract, including clinical courses and related factors. A retrospective chart review was performed on 37 patients with congenital GI webs at a pediatric care teaching hospital in north Taiwan. All of the related parameters were collected and analyzed. Twelve patients had gastric webs, 22 had duodenal webs, and three had jejunal webs. The mean time to diagnosis was 1576 days for gastric webs, 116 days for duodenal and 230 days for jejunal webs. There was a statistically significant difference between the gastric and duodenal groups (p=0.001). The major symptom was vomiting (78%). Patients with duodenal webs had a high association with congenital anomalies (50%). The major anomalies included cardiac (27%) and GI anomalies (18%). Endoscopy was performed in 10 gastric cases, and all of them were noted to have positive findings, including a fixed nonfolded stenotic ring following a second gastric chamber and a real pylorus. All of the patients received surgery except for three with gastric webs, and no mortality was noted. The mean postoperative days of tolerated feeding was 6 for those with gastric webs, 10 for those with duodenal and 11 for those with jejunal webs. The clinical course of gastrointestinal webs may be chronic or obscure. A delay from onset of symptoms to treatment may exist, especially in gastric webs. We suggest that prompt endoscopic confirmation and surgical intervention for these lesions, when suspected due to clinical and radiologic abnormalities, will decrease the morbidity of unexplained recurrent symptoms or signs of GI obstruction in these patients.

Circadian variation of acute myocardial infarction in young people

AimsThe aim was to investigate the circadian and weekly variation in Chinese young patients with acute myocardial infarction (AMI). MethodsThis was a 10-year retrospective cohort study. We studied patients (>18 to <45 years of age) with a first attack of AMI from the emergency departments of 3 university teaching hospitals in Taiwan from January 1, 2001, to December 31, 2010. We analyzed patients in the standard circadian fashion using 6-hour intervals (00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-24:00). We also did an analysis by day of week. ResultsThe database had 505 patients with AMI with complete data. The percentage of total AMIs that occurred in the 6-hour intervals were as follows: 00:01 to 06:00, 30.9%; 06:01 to 12:00, 23.4%; 12:01 to 18:00, 25.9%; and 18:01 to 24:00, 19.8%. The percentage of AMIs between 00:01 and 06:00 was significant higher compared with that in the other three 6-hour intervals (df = 3, χ2 = 91.7, P < .001). However, there was no significant weekly variation for these patients in the present study. ConclusionsThere was a significant circadian variation with a peak from 00:01 to 06:00 in Chinese young patients with AMI. However, there was no significant weekly variation in these patients. The circadian periodicity may create new possibilities for disease prevention and medication prescription.

Mediating Role of Daily Physical Activity on Quality of Life in Patients With Heart Failure

An understanding of the contribution of daily physical activity and functional status to quality of life in patients with heart failure has the potential to enable patients to achieve better outcomes. Nevertheless, research that examines the relationship between these 3 variables in heart failure patients in Taiwan is lacking. Therefore, the purpose of this study was to close this gap by exploring the relationship among daily physical activity, functional status, and quality of life in this population. This study used a descriptive, cross-sectional, correlational design. A convenience sample of 108 heart failure patients was recruited, from November 2009 to September 2010, from 4 teaching hospitals in Taiwan. The data were collected by demographic questionnaire, New York Heart Association classification (functional status), Daily Physical Activity Status Index (daily physical activity), and Minnesota Living With Heart Failure Questionnaire (quality of life). Pearson correlations, hierarchical logistic regression, and the Sobel test were conducted to determine the relationship between functional status, daily physical activity, and quality of life. Propensity score analysis was used to adjust the inequality of the underlying diseases that the patients had and ensure the mediating effect. A significant mediating effect of daily physical activity on the relationship between functional status and quality of life was found. Multidisciplinary healthcare providers should work together to develop an intervention focused on enhancing daily physical activity and to evaluate the effectiveness of promoting quality of life for patients living with heart failure.

Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections.

BackgroundLimited data describe the sustained impact of hand hygiene programs (HHPs) implemented in teaching hospitals, where the burden of healthcare-associated infections (HAIs) is high. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs.Methods and FindingsA 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Compliance was measured by direct observation and the use of hand rub products. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. The economic impact was estimated based on a case-control study in Taiwan. We observed 8,420 opportunities for hand hygiene during the study period. Compliance improved from 43.3% in April 2004 to 95.6% in 2007 (p<.001), and was closely correlated with increased consumption of the alcohol-based hand rub (r = 0.9399). The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate.ConclusionsImplementation of a HHP reduces preventable HAIs and is cost effective.

Factors Affecting the Unplanned Peripheral Reinsertion in Pediatric Patients From a Teaching Hospital in Taiwan

The purpose of this study was to investigate the factors affecting the unplanned peripheral intravenous reinsertion in pediatric inpatients at a teaching hospital in Taiwan. Researchers recruited 206 pediatric inpatients and their caretakers for the study and used multivariate regression in calculating their results. The results showed the following: whether pediatric patients received drugs (P < .001), whether the appropriate height of the drops was adhered to (P = .053), and whether the adjustment of the drip rate was done by the clients or caretakers themselves (P = .046) were significant determinants of unplanned peripheral intravenous reinsertions. It may be worthwhile to incorporate the findings regarding factors affecting the unplanned peripheral intravenous reinsertion into pediatric nurses' educational programs.

A System for Using Patient Complaints as a Trigger to Improve Quality

This study aims to explore how hospital organizations can use complaints to drive quality improvement. A teaching hospital in Taiwan was purposefully selected as a case study. Data were collected from a variety of sources, including interview with key managers and social workers, questionnaire survey of managers (n = 53), interview with government organizations (n = 4) and nongovernment organizations (n = 3), document collection and review, and the Critical Incident Technique using a questionnaire and nonparticipant observation (n = 59). This study revealed that the case hospital attempted to resolve complaints on a case-by-case basis. But it did not act on these complaints as a collective group to identify systemic problems and deficiencies. This approach provides single-loop learning, which may be sufficient to handle the problem on hand but is not enough to prevent such problems occurring again in the future. This study suggests some implications in regard to a best practice system for using complaints to improve quality.