Turkish Hospitals Research Articles

Evaluation of Device Associated Infection Rates in Intensive Care Units of Pamukkale University Hospital

Intensive care units (ICUs) are unfortunately the epicenters of nosocomial infections. The aim of the study was to investigate device associated infection rates in a small Turkish hospital. Device utilization ratios and device associated infection rates were calculated according to definitions of the Centers for Disease Control (CDC). During a period of 24 months 1,387 patients were surveyed in our ICUs. A total of 287 device associated infections were detected. In our study ventilator associated pneumonia was the most frequent nosocomial infection with a rate of 59.7 per 1,000 ventilator days. The most frequent pathogen of device associated infection was Candida spp. High rates of device associated infections in a small Turkish hospital clearly indicate the urgent need of the implementation of infection control guidelines.

Implementing management tools in Turkish public hospitals: the impact of culture, politics and role status

AbstractThe government of Turkey has attempted to substantially improve the management of its public hospitals. However, an analysis of the performance of the quality certified hospitals finds only minor improvements. This study seeks to explain these disappointing results by interviewing 46 hospital managers and employees about the successes and failures of the management reform effort. The interviews suggest that traditional Turkish organisational culture often hinders attempts to decrease hierarchy, but, more positively, it also encourages the use of frontline teams and group rewards. Moreover, Turkey's hybrid system of allowing public doctors to maintain private practices has provided doctors with both the resources and the incentives to fight management reform efforts. Finally, organisational decentralisation in Turkey has evoked fierce political opposition, ironically even from many pro‐modernising forces that fear it could increase the power of Islamic fundamentalists. Turkey's experience suggests a number of broader points about management reform in non‐western societies. It suggests that decentralisation can often impede, rather than strengthen the other aspects of management reform; that a hybrid market organisation is often harder to move toward market efficiencies than a purely governmental one; and that national cultures should help guide the order in which reform tools are implemented. Copyright © 2008 John Wiley & Sons, Ltd.

Nosocomial outbreak of vancomycin-resistant Enterococcus faecium in a paediatric unit at a Turkish university hospital

Despite growing concern about vancomycin-resistant enterococci (VRE) as nosocomial pathogens, especially in the USA, they have been rarely isolated in Turkish hospitals. After initial description in 2001 of unrelated VRE isolates, we report now the molecular characterization of a nosocomial outbreak at the Akdeniz University Hospital, Antalya, Turkey. VRE isolates were from either clinical or rectal swab specimens. Identification, susceptibility testing and molecular characterization were performed according to standard techniques. Virulence genes (encoding aggregation substance, gelatinase, cytolysin, enterococcal surface protein and hyaluronidase) were sought by PCR. Thirty-six VRE were isolated from 10 patients between June and October 2005 in the Department of Paediatrics. Six patients were only carriers, two had urinary tract infections and two had bloodstream infections. All isolates were Enterococcus faecium, of vanA genotype and belonged either to a main pulsotype (A) or to three minor pulsotypes (B, C and D). The epidemic strain A, found in eight patients, expressed high-level glycopeptide resistance (MIC of vancomycin 256 mg/L and MIC of teicoplanin 64 mg/L) and was of multilocus sequence typing sequence type (ST) 31, whereas the minor strain D, found in two patients, expressed heterogeneous glycopeptide resistance (MIC of vancomycin 8 to 256 mg/L) and was ST18. Strains B and C were only found in single patients either with strain A or alone. The two epidemic strains A and D were esp gene-positive. Their vanA genes were located on transposons similar to Tn1546, except for deletion of the transposition genes and the presence of IS1542, inserted upstream of the vanA operon, and IS1216, inserted at the 3' end of the vanX gene. VRE outbreak was contained by early identification and implementation of measures for patient isolation and of stringent hand and environmental disinfection policies. This work underlines the emergence in Turkey of epidemic VRE clones that belong to the clonal complex-17 (CC-17) and that are esp-positive.

Research on knowledge sources used in nursing practices

This paper reports a questionnaire-based investigation into the knowledge sources used by nurses in two Turkish university hospitals, and whether these knowledge sources were related to sociodemographic variables. 78.5% of the nurses said that practice should be based on evidence and 75.9% stated that this evidence should come from research. 80.7% stated that evidence-based practice was useful. However, evidence that was not based on research constituted the first three most frequently used sources of knowledge. Sources of evidence-based on research were detected as being in the 4th, 5th, 6th, 8th, and 10th positions regarding the frequency of use. The nurses expressed a belief that nursing practices should be based on evidence, but did not reflect this belief in their behavior.

EXTENDED-SPECTRUM BETA-LACTAMASES IN CEFTAZIDIME-RESISTANT ESCHERICHIA COLI AND KLEBSIELLA PNEUMONIAE ISOLATES IN TURKISH HOSPITALS

Purpose: To study the prevalence of TEM-, SHV- and GES-type β-lactamases among Escherichia coli and Klebsiella pneumoniae strains having ceftazidime MICs higher than 2 mg/L. Methods: A total of 63 E. coli and 41 K. pneumoniae isolated from five different university hospitals were studied for the existence of TEM-, SHV- and GES-type β-lactamases. Susceptibility tests were carried out according to the criteria of National Committee for Clinical Laboratory Standards. MICs were obtained by agar dilution method. Existence of extended-spectrum β-lactamases (ESBLs) were assessed by double-disc synergy test (DDST). Existence of the above-mentioned β-lactamase genes were studied both by PCR with specific oligonucleotide primers and isoelectric focusing methods. Results: None of the isolates were carbapenem-resistant. DDSTs were positive in 50 (79.3%) and 33 (80.5%) of E. coli and K. pneumoniae, respectively. TEM gene was detected in 41 (65.1%) and 19 (46.3%), whereas SHV gene in 18 (28.6%) and 20 (48.8%) of E. coli and K. pneumoniae strains, respectively. GES genes were not detected. Conclusions: TEM and SHV genes are highly prevalent among ESBL-producing E. coli and K. pneumoniae, whereas GES-type ESBLs are absent and found not to be responsible of ceftazidime resistance in Turkish hospitals.

The spectrum of diseases causing fever of unknown origin in Turkey: a multicenter study

The purpose of this trial was to determine the spectrum of diseases with fever of unknown origin (FUO) in Turkey. A prospective multicenter study of 154 patients with FUO in twelve Turkish tertiary-care hospitals was conducted. The mean age of the patients was 42+/-17 years (range 17-75). Fifty-three (34.4%) had infectious diseases (ID), 47 (30.5%) had non-infectious inflammatory diseases (NIID), 22 (14.3%) had malignant diseases (MD), and eight (5.2%) had miscellaneous diseases (Mi). In 24 (15.6%) of the cases, the reason for high fever could not be determined despite intensive efforts. The most common ID etiologies were tuberculosis (13.6%) and cytomegalovirus (CMV) infection (3.2%). Adult Still's disease was the most common NIID (13.6%) and hematological malignancy was the most common MD (7.8%). In patients with NIID, the mean duration of reaching a definite diagnosis (37+/-23 days) was significantly longer compared to the patients with ID (25+/-12 days) (p=0.007). In patients with MD, the mean duration of fever (51+/-35 days) was longer compared to patients with ID (37+/-38 days) (p=0.052). Although infection remains the most common cause of FUO, with the highest percentage for tuberculosis, non-infectious etiologies seem to have increased when compared with previous studies.

Tumor marker requests in a general teaching Turkish hospital

Serum tumor markers may be requested inappropriately by clinicians. In this retrospective study, we aimed to investigate the appropriateness of TM requests in our hospital. Patients in the study were identified from the TM requests for 3 months between June-August 2004, using the laboratory database. A total of 2249 patients (1351 men, 898 women) were included in the study and there were 6570 TM requests. The number of requests were 1050 (16%) for Carbohydrate Antigen 19-9, 993 (15.1%) for Cancer Antigen 125, 941 (14.3%) for Prostate Specific Antigen, 921 (14%) for free PSA, 925 (14.1%) for Cancer Antigen 15-3, 788 (12%) for Alphafetoprotein, 730 (11.1%) for Carcinoembryonic Antigen and 222 (3.4%) for AFP/Human Chorionic Gonadotrophin. Our findings support the idea that for the evidence-based use of TM requests the education of clinical staff is required. Clear clinical guidelines including recommendations about the appropriate use of TM can be useful for this education process. Careful audit studies are also useful to determine the impact of these guidelines on the practice of evidence-based laboratory medicine.

Nurses' Use of Physical Restraints in Four Turkish Hospitals

(a) Determine the frequency and types of physical restraints used by nurses in intensive care units, emergency departments, and neurosurgery wards; (b) understand nurses' attitudes toward physical restraint; and (c) identify complications in physically restrained patients. This descriptive, cross-sectional study was carried out on 254 nurses working in intensive care units, emergency departments, and neurosurgery wards in four Turkish hospitals where physical restraints were used. The whole population was studied without any sampling, and data were collected via semistructured interviews from July 20 to September 6, 2005. Nurses used either wrist, ankle, or whole body restraints at various levels. Those nurses who worked in surgical intensive care units and emergency departments and had in-service training used more physical restraint than did others. Only a third of nurses decided on physical restraint together with physicians and three-fourths tried alternative methods. Nurses reported edema and cyanosis on wrist and arm regions, pressure ulcers on various regions, and aspiration and breathing difficulties in relation to physical restraint. Moreover, they reported 9 deaths of patients in chest restraints. Reduction in the frequency of caregiving was related to complications. Actions to reduce use of and complications from physical restraints should include attention to nurse staffing and education about use of restraints.

Device-associated hospital-acquired infection rates in Turkish intensive care units. Findings of the International Nosocomial Infection Control Consortium (INICC)

We conducted a prospective study of targeted surveillance of healthcare-associated infections (HAIs) in 13 intensive care units (ICUs) from 12 Turkish hospitals, all members of the International Nosocomial Infection Control Consortium (INICC). The definitions of the US Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (NNISS) were applied. During the three-year study, 3288 patients for accumulated duration of 37 631 days acquired 1277 device-associated infections (DAI), an overall rate of 38.3% or 33.9 DAIs per 1000 ICU-days. Ventilator-associated pneumonia (VAP) (47.4% of all DAI, 26.5 cases per 1000 ventilator-days) gave the highest risk, followed by central venous catheter (CVC)-related bloodstream infections (30.4% of all DAI, 17.6 cases per 1000 catheter-days) and catheter-associated urinary tract infections (22.1% of all DAI, 8.3 cases per 1000 catheter-days). Overall 89.2% of all Staphylococcus aureus infections were caused by methicillin-resistant strains, 48.2% of the Enterobacteriaceae isolates were resistant to ceftriaxone, 52.0% to ceftazidime, and 33.2% to piperacilin-tazobactam; 51.1% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.7% to ceftazidime, 38.7% to imipenem, and 30.0% to piperacilin-tazobactam; 1.9% of Enterococcus sp. isolates were resistant to vancomycin. This is the first multi-centre study showing DAI in Turkish ICUs. DAI rates in the ICUs of Turkey are higher than reports from industrialized countries.

Extended-spectrum beta-lactamases in ceftazidime-resistant <i>Escherichia coli </i>and <i>Klebsiella pneumoniae </i>isolates in Turkish hospitals

To study the prevalence of TEM-, SHV- and GES-type beta -lactamases among Escherichia coli and Klebsiella pneumoniae strains having ceftazidime MICs higher than 2 mg/L. A total of 63 E. coli and 41 K. pneumoniae isolated from five different university hospitals were studied for the existence of TEM-, SHV- and GES-type beta -lactamases. Susceptibility tests were carried out according to the criteria of National Committee for Clinical Laboratory Standards. MICs were obtained by agar dilution method. Existence of extended-spectrum beta -lactamases (ESBLs) were assessed by double-disc synergy test (DDST). Existence of the above-mentioned beta -lactamase genes were studied both by PCR with specific oligonucleotide primers and isoelectric focusing methods. None of the isolates were carbapenem-resistant. DDSTs were positive in 50 (79.3%) and 33 (80.5%) of E. coli and K. pneumoniae , respectively. TEM gene was detected in 41 (65.1%) and 19 (46.3%), whereas SHV gene in 18 (28.6%) and 20 (48.8%) of E. coli and K. pneumoniae strains, respectively. GES genes were not detected. TEM and SHV genes are highly prevalent among ESBL-producing E. coli and K. pneumoniae , whereas GES-type ESBLs are absent and found not to be responsible of ceftazidime resistance in Turkish hospitals.

How Responsive Turkish Health Care System Is to Its Citizens: The Views of Hospital Managers

With this paper it was tried to give a broad perspective about the responsiveness level of Turkish health care system, and how Turkish health care system meets the expectations of its citizens. For achieving the main purpose of this study a sample of hospital managers (n = 172) was selected, and the responsiveness questionnaire developed by WHO was administered. If the responsiveness level of Turkish health care system is measured on the basis of the Turkish hospital managers' views in the sample by using the weights reported in the World Health Report 2000, responsiveness level is calculated as 6.14, and Turkey's place should be 35 rather than 93 among 191 countries. The findings showed that Turkish health care system met confidentiality expectations of Turkish citizens better than other expectations for other aspects of responsiveness. In light of the main results of this study we conclude that the economic status, demographic structure, culture, and some other regional and country-specific factors should be taken into account by calculating and especially ranking the countries according to responsiveness level of their health care systems, and each country should carry out this kind of studies by using the views of their own key informants or preferably citizens, if possible.

Long working hours increase the risk of sharp and needlestick injury in nurses: the need for new policy implication

This paper reports a study to determine the sharp and needlestick injury incidence in nurses working at a university hospital and the contributing factors. Although it is generally felt that working in the healthcare sector is clean and without risk, healthcare staff and especially physicians and nurses who generally work very long hours are actually exposed to various occupational risks. Sharps and needlestick injuries are important problems for healthcare workers as they increase the risk of spread of infection. A self-administered questionnaire was completed in October 2005 by 449 of the 516 nurses working at a Turkish hospital (response rate 87.0%). The percentage of nurses experiencing a sharp or needlestick injury during their professional life was 79.7%. The incidence of exposure to sharp or needlestick injury in the last year was 68.4%. The factors increasing the rate of sharp and needlestick injury were: age 24 years and less, <or=4 years of nursing experience, working in surgical or intensive care units and working for more than 8 hours per day (P < 0.05). The findings indicate which groups of staff should be targeted for educational programmes. Consideration also needs to be given to the unwanted effects of working long shifts, where tiredness may contribute to the number of needlestick injuries.

Comparison of Computing Capability and Information System Abilities of State Hospitals Owned by Ministry of Labor and Social Security and Ministry of Health

The main purpose of this study is to give an idea to the readers about how big and important the computing and information problems that hospital managers as well as policy makers will face with after collecting the Ministry of Labor and Social Security (MoLSS) and Ministry of Health (MoH) hospitals under single structure in Turkey by comparing the current level of computing capability of hospitals owned by two ministries. The data used in this study were obtained from 729 hospitals that belong to both ministries by using a data collection tool. The results indicate that there have been considerable differences among the hospitals owned by the two ministries in terms of human resources and information systems. The hospital managers and decision makers making their decisions based on the data produced by current hospital information system (HIS) would more likely face very important difficulties after merging MoH and MoLSS hospitals in Turkey. It is also possible to claim that the level and adequacy of computing abilities and devices do not allow the managers of public hospitals to use computer technology effectively in their information management practices. Lack of technical information, undeveloped information culture, inappropriate management styles, and being inexperienced are the main reasons of why HIS does not run properly and effectively in Turkish hospitals.

High prevalence of OXA-51-type class D -lactamases among ceftazidime-resistant clinical isolates of Acinetobacter spp.: co-existence with OXA-58 in multiple centres

This study was designed to demonstrate the prevalence of the newly discovered carbapenem-hydrolysing class D enzymes, OXA-51-type and OXA-58, among clinical isolates of Acinetobacter spp. A total of 72 isolates from six centres were studied. Isolates were screened by PCR with specific primers for bla(OXA-51-type) and bla(OXA-58). PCR products were sequence-analysed. Plasmids were digested with EcoRV and genomic DNAs were digested with PvuII. Hybridization experiments were done with digoxigenin-labelled specific probes. Macro-restriction analysis was done on SmaI-digested genomic DNAs. A total of 56 (77.8%) isolates were positive for bla(OXA-51-type) genes. Sequence analysis of the products from 23 selected isolates revealed the occurrence of multiple alleles in all contributing centres. The bla(OXA-58) gene was detected among 10 isolates from five centres. All were also positive for bla(OXA-51-type) genes. Among the bla(OXA-58)-positive isolates, two from the same centre were positive for a novel OXA-51 allele (OXA-86). Southern hybridization of plasmids and of genomic DNAs suggested that bla(OXA-51-type) genes are located on chromosomes whereas bla(OXA-58) genes are plasmid borne in these 10 isolates. Plasmid profiles and pulsed-field gel electrophoresis patterns indicated the spread of the bla(OXA-58) gene among multiple clones. The bla(OXA-51-type) and bla(OXA-58) co-carrier strains were mostly associated with a pandrug-resistant phenotype. This study indicated that bla(OXA-58)-bearing plasmids are readily spreading among multiple clones of the bla(OXA-51-type)-bearing clinical isolates of Acinetobacter spp. Since these isolates are highly resistant to antibiotics this finding indicates the existence of a significant problem in Turkish hospitals.

Scalding in Turkish children: Comparison of burns caused by hot water and hot milk

Introduction Our aim in this study was to compare the clinical differences and etiologic risk factors for hot water and hot milk scald burns in Turkish children. Methods The retrospective study examined the cases of 140 children aged 0.1–7 years who had scald burns treated in three burn units of a Turkish hospital network between March 2000 and December 2004. The patients were categorized in two groups: hot water burns or hot milk burns. Results Ninety-five (67.9%) patients had hot water burns and 45 (47.1%) had hot milk burns. The proportion of patients with hot milk burns who lived in rural areas was significantly higher than the corresponding proportion for the hot water cases (75.6% versus 52.6%, respectively; p < 0.01). In 20 (44%) of the hot milk cases, the burn was caused by milk being boiled in large pots outdoors for cheese production. The other 25 hot milk cases were caused by milk being boiled in the kitchen. The mean (±S.D.) percentage total body surface area burned in the hot milk cases was higher than that in the hot water cases (33.6 ± 2.24% versus 21.42 ± 1.43%, respectively; p < 0.001), and the corresponding mean percentages of TBSA with full-thickness burns were 9.2 ± 2.52% versus 3.13 ± 0.83%, respectively; ( p = 0.083). The mean percentages of TBSA with second-degree burns showed the same trend (29.0 ± 12.39% versus 18.8 ± 1.47%, respectively; p < 0.001) higher percentage of the children with hot milk burns required antibiotics (78% versus 52.8%, respectively; p < 0.006). Seven (7.4%) of the hot water burn patients and 15 (33.3%) of the hot milk burn patients died during the study period ( p = 0.025; overall mortality rate 15.7%). Conclusion Children scalded with hot milk tend to have more extensive burns, and thus have higher mortality, than those scalded with hot water. To create effective programs for preventing scald injuries in Turkey and elsewhere, it is essential to consider ethnic and cultural issues based on these characteristics. Simple precautions should be explained and methods of using liquids such as hot milk should be researched in different geographic locations in order to formulate good prevention strategies.

Maternal outcome in HELLP syndrome requiring intensive care management in a Turkish hospital

Despite the development of tertiary care facilities, intensive care and advanced blood banking techniques, pregnancy-related hypertensive disorders are the main cause of maternal mortality in most countries. Our purpose was to determine maternal outcome in pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count) that required intensive care management. Retrospective study at Department of Obstetrics and Gynecology, and Department of Anesthesiology and Reanimation, Karadeniz Technical University, Trabzon, Turkey. 37 patients with HELLP syndrome admitted to the obstetric intensive care unit were analyzed retrospectively from 1992 to 2004. All patients were hypertensive, with mean Glasgow coma score (GCS) of 11 +/- 3.96. Mean gestational age at delivery was 32 +/- 4.09 weeks. Delivery was vaginally in nine and by cesarean section in 27 patients. General anesthesia was used in 12 and spinal anesthesia in 25 patients. Maternal morbidity included acute renal failure (11%), disseminated intravascular coagulation (5%), acute lung edema (3%), severe ascites (11%), pleural effusion (3%), adult respiratory distress syndrome (11%), abruptio placenta (11%), cerebral edema (8%) and cerebral hemorrhage (40%). All patients required transfusions using blood products. There were 11 maternal deaths (30%). Because of high maternal mortality and morbidity found among patients with HELLP syndrome, standard antenatal follow-up protocols should be applied, so as to obtain early diagnosis and improve the speed of transfer to obstetric departments with expertise in this field.

A fuzzy preference-ranking model for a quality evaluation of hospital web sites

This article presents a quality evaluation model for measuring the performance of hospital Web sites. The model is developed on the basis of a conceptual framework, which consists of seven major e-service quality dimensions, including tangibles, reliability, responsiveness, confidence, empathy, quality of information, and integration of communication issues of Web sites. The dimensions and their associated attributes are first obtained from published articles in the health care and information technology literature and then adapted according to the suggestions of related domain experts. Two multicriteria decision-making methods are used in the evaluation procedure. Determined Web site evaluation dimensions and their relevant attributes are weighted using the Analytic Hierarchy Process (AHP) method. Vagueness in some stages of the evaluation required the incorporation of fuzzy numbers in the assessment process. Both fuzzy and crisp data are then synthesized using the fuzzy PROMETHEE (Preference Ranking Organization Method for Enrichment Evaluation) ranking method. The model is applied initially to measure the performance of the Web sites of Turkish hospitals. This study should be of interest to health care and technology practitioners and researchers, as the findings shed light on the further development of performance measurements for hospital Web sites. © 2006 Wiley Periodicals, Inc. Int J Int Syst 21: 1181–1197, 2006.

Benign Prostatic Hyperplasia: Cost and Effectiveness of Three Alternative Surgical Treatment Methods Used in a Turkish Hospital

The purpose of this study was to compare three alternative surgical therapies for Benign prostatic hyperplasia (BPH) in terms of their cost and effectiveness in a general hospital setting in Turkey. BPH is an important potential burden on health care resources in developing countries like Turkey, not only because of the increasing incidence of the disease, but also because of the differences in cost and effectiveness that exist among the various available treatment technologies. In this study, three alternative surgical treatments for BPH, namely open prostatectomy, transurethral resection of the prostate (TURP), and laser prostatectomy were compared in terms of their cost and effectiveness. Effectiveness was measured through the use of the International Prostate Symptom Score (IPSS) before the operation and at 3 months after. Laser prostatectomy was found to be the most costly and least effective way of treating BPH. This conclusion was valid both in terms of cost per prostate symptom score and cost per improvement of quality of life index. This study shows how a rough estimate can be made of the potential burdens that alternative treatment methods would impose on a country's health budget.

PER-1 is still widespread in Turkish hospitals among Pseudomonas aeruginosa and Acinetobacter spp.

PER-1 type β-lactamases were screened among ceftazidime-resistant clinical isolates of Acinetobacter spp. and Pseudomonas aeruginosa. A total of 176 non-repetitive isolates (84 Acinetobacter spp. and 92 P. aeruginosa) were collected during a three month surveillance period. Isolates were obtained from seven intensive care units of seven university hospitals. All strains were screened for bla PER-1 alleles by PCR. Of the strains, 31% and 55.4% of Acinetobacter spp. and P. aeruginosa were positive for bla PER-1 type genes, respectively.

Prevalence and characteristics of nosocomial infections in a Turkish university hospital

The purpose of this study is to estimate the prevalence of nosocomial infections in a university hospital, as well as determining the groups at high risk of such infections. Two surveys based on a modification of the British National Survey protocol for nosocomial infection were conducted in July and December 1998. In the first survey, hospital infections were found in 41 (13.4%) of the patients, and in the second survey in 34 (10.9%). The study showed that the risk of nosocomial infection was associated with being in the intensive care unit, undergoing surgery, and invasive procedures. Prevalence data are consistent with results reported in many other regions of the world. These findings provide the principal information for future surveillance in association with prevention programs in Turkish hospitals.