Tag Archives: Health services

Best article for 2018 – #blogoff

Jon Otter and I have been having a ‘blog off’, with the aim of presenting the best infection control paper for 2018 (to date). Below, I put my case forward. You can read Jon’s post here. After you read both blogs and listen to points made via Twitter, we encourage you to vote (for the article I present!). Follow more on Twitter (@1healthau) and #mitchellvsotter via this link. Results will be presented during my social media talk on Monday 1st October (& via Twitter). You can vote using this link: https://www.surveymonkey.com/r/SL23H6K

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My (Brett Mitchell’s) choice of article

Choosing the best article is always fraught with danger. There are so many great infection control articles in 2018, but for this blog, I have chosen something that impacts everyone working in infection control – contact precautions (CP).  The article – Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis by Bearman et al.

There are three main reasons, why I believe this article is noteworthy:

  1. Advancement of knowledge in a difficult area
  2. Sets foundation for additional studies
  3. The implications for changing practice around contact precautions are profound

What is the article about?

In this single centre quasi experimental study, seven horizontal infection control interventions were evaluated. One of these, was the discontinuation of CP for patients with MRSA and VRE. During the study period, using interrupted time-series analysis, infection rates for MRSA and VRE decreased, in addition to device associated HAIs – following discontinuation of CP. Importantly, compliance with CP was monitored prior to cessation, 94% compliance with CPs hospital wide, from nearly 2700 observations. The authors conclude with the suggestions that the discontinuation of CP for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. MRSA HAI decreased by 1.3 per 100,000 bed days and VRE HAI decreased by 7.5/100,000 bed days. Not statistically significant, but clinically relevant in the context of no increase or difference.

Advancement of knowledge

Evidence supporting the use of CPs is largely based on observational studies, theory and expert opinion. Undertaking RCTs in infection control is challenging and not always possible, not the least on the topic of evaluating the impact of stopping CPs.  We have seen other work which has tested the value of universal glove and gown use, but limited work on ceasing CPs. This study takes a big step forward, using a robust design. It adds to a small but growing body of evidence investigating the universal application of CP for patients with any MRO.

Sets foundation

Another important aspect of this study, is that it sets the foundation for more work. It appears that no harm was caused as a result of ceasing CPs. This evidence is critical when attempting to seek funds for future studies, convincing a hospital to attempt something similar and obtaining ethical approvals. It was ‘gutsy’ to undertake a study that ceased CP, but the pragmatic and clever approach of bundling this with other horizontal infection control initiative made this palatable, as well as being able to unpick the relative effect of ceasing CP, using interrupted time series. In so doing, the authors have taken this controversial topic forward and established platform for multi-site sites (plus or minus randomisation).

For the record, I am not suggesting we should change practice around CPs yet, nor I am suggesting CP do not work in the prevention transmission of certain organisms. Rather, I am saying we should be open to the idea and support work that helps answer this question one way or another.

Implications

Imagine the implications if CPs were not required for patients with certain organisms. As quoted in a recent paper by Prof Nick GravesBecause you exist in a world of scarce resources, the choices you make have economic consequences”. The implications regarding CPs are significant and include the (reduction) in cost of personal protection equipment to the increased availability of single rooms as a starting point. In addition, think about the time invested in

identifying patients with MROs, placing them in CPs, monitoring compliance and the associated education with staff. The freeing up of resources, where there are finite resources, is critically important and present new opportunities.

The authors are to be congratulated for tackling a vexed issue and opening the door to the next stage. We need more research in infection prevention and control, that tackles the ‘known unknowns’, so we can advance the science of the profession, have practice underpinned by strong evidence and provide optimal patient care. Where else to start, than with evidence around CPs?  Regardless of whether you are clinician, an infection control professional, policy maker or researcher, this article should be of interest to you. Let’s hope more studies can build on this in the near future.

If you are in agreement, don’t forget to vote for this article here

 

Reducing urinary catheter use

One of the ways  to reduce the risk of catheter associated urinary tract infection (CAUTI) is to reduce catheter duration. Evidence has shown the value of stop orders and reminders (to remove the catheter ASAP) at reducing the incidence of CAUTI.

We have finished a RCT  in an Australian hospital, exploring the effect of an electronic reminder, attached to a catheter bag, on reducing catheter duration. We also surveyed nurses and undertook a focus group.

I’m looking forward to presenting results at the IPS conference in Glasgow and ACIPC later in the year in Australia. 

 

Researchers: Mitchell, BG., Fasugba, O., Russo, P., Cheng, A., Northcote, M. (Hannah Rosebrock, Research Officer).

Funding: This study was supported by an Commonwealth government commercialisation grant.

References

Meddings, J., Rogers, M. A., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual saf, 23(4), 277-289.

The Cerberus of science – dealing with ethics committees

We asked a colleage, Hannah Rosebrock, to write a blog for us, thank you Hannah.

In Greek mythology, Cerberus guards the gate of the underworld to prevent the dead from leaving. In social and clinical science, this role is fulfilled by ethics committees who stand as guardian between researchers and Cerberusparticipants and prevent the latter to be exploited by the former for the sake of science. The role of the Cerberus is a necessary one – although not very flattering, Cerberus is depicted as a three-headed beast. In the context of ethics committees, its three heads are called bureaucracy, officialdom and inefficiency.

According to the National Health and Medical Research Council (NHMRC) there are more than 200 HRECs operating in organisations and institutions throughout Australia (find a list of human Research Ethics Committees registered with NHMRC here). Although all HRECs base their decisions on the same principles deprived from the same National Statement on Ethical Conduct in Human Research, every HREC has its own application procedures, forms and processes. Further, gaining approval from one ethics committee is no vouch for approval from another ethics committee.

This lack of standardisation specifically affects multi-site projects which led to the founding of the National Mutual Acceptance Scheme (NMA) in 2013. Under the NMA scheme, multi-site research projects do not have to gain ethics approval from every site the project is conducted at but only once, from a NMA certified HREC. As of August 2017 the scope of the NMA scheme covers all human research conducted at a public health organisation in Queensland, New South Wales, the Australian Capital Territory, Victoria, South Australia, and – the latest addition to the scheme – Western Australia. Note: Northern Territory, Tasmania, and private health organisations are not included in the NMA scheme. Still, you might be tempted to think, that the NMA scheme has de-bureaucratised the ethics application process, and to some extent, this is true. There is certainly less duplication (if you don’t count private health organisations, Northern Territory and Tasmania). However, researchers are still fighting with a lack of standardisation, as every state has multiple NMA certified HRECs[1] and application procedures vary between and within states. This multitude in ethics committees, applications processes and forms, seems unnecessarily confusing, given that they are all assessed and certified by the same body (the NHMRC) for their compliance with the same criteria based on the same National Statement of Responsible Conduct in Human Research.

Independent of the HREC approval, researchers have to seek approval from the relevant Research Governance office (RGO) for each site the project is conducted at. There is no such thing as a mutual acceptance scheme for research governance approval, every site has its own assessing criteria for determining the site’s suitability for conducting a given research project. This adds to the generally labour-some and tedious process of gaining ethics approval.  In terms, this uses resources, and most commonly tax payer funded resources. In one Australian study, the cost of obtaining ethics and relevant approvals was $348,000 or 38% of study budget.

Applications for HREC approval are often no less than 63 pages; applications for Research Governance approval encompass about 23 pages – exclusive the extensive supporting documentation required, which can be up to another 150+ pages. Applications to both, HREC and RGO’s vary, with some still requiring submission in hardcopy by snail-mail, (additionally to email, USB and online forms) and will only be assessed, once received in hardcopy. This method is unnecessarily prone to error. To simplify, you must take steps away, rather than adding additional steps. The entire process is so focussed on detail that researchers, as well as assessing HREC and RGO officials can’t see the wood for the trees anymore. So much information is requested that even low-risk research projects that involve none to minimal involvement with participants, and thus hardly justify the use of the term ‘participants’, seem to turn into a second Stanford prison experiment throughout the process.

 

[1] Queensland has 7 NMA certified HRECs, New South Wales has 11, Victoria has 7, South Australia has 5 and Western Australia has 3 (Australian Capital Territory has 1). Find a full list here.