Severe community-acquired pneumonia: timely management measures in the first 24 hours

Phua, J. et al. Critical Care. Published online: 28 August 2016

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.

These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

CC flow chart

While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

Frota, P.O. et al. American Journal of Infection Control. Published online: 24 August 2016

Highlights

  • The interventions immediately improved the effectiveness of cleaning.
  • These improvements disappeared after four months of interventions.
  • Microfiber cloths did not impact any increase in cleaning effectiveness.
  • Continuous education and feedback on cleaning practices appear to be warranted.
  • This policy should be adapted to the particularities of each health care setting.

Abstract

Background: Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

Methods: This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions—feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

Results: We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

Conclusions: The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

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A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care

Beam, C. et al. Journal of Emergency Nursing. Published online: 21 July 2016

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Concern about antibiotic overuse has become heightened as bacterial resistance to antibiotics continues to increase. Patients experiencing respiratory symptoms frequently present to urgent/emergent care settings such as fast-track emergency care departments and primary care retail settings with the expectation that they will be prescribed antibiotics.
The Centers for Disease Control and Prevention (CDC) reports that approximately 2 million people will become ill with bacteria that are resistant to at least one antibiotic, approximately 23,000 people die as a direct result of these infections, and many others die as a result of complications related to antibiotic-resistant infections.
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A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care

Beam, C. et al. Journal of Emergency Nursing. Published online: July 21 2016

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Image shows digitally colorized electron micograph of influenza virions 

Concern about antibiotic overuse has become heightened as bacterial resistance to antibiotics continues to increase. Patients experiencing respiratory symptoms frequently present to urgent/emergent care settings such as fast-track emergency care departments and primary care retail settings with the expectation that they will be prescribed antibiotics.

The Centers for Disease Control and Prevention (CDC) reports that approximately 2 million people will become ill with bacteria that are resistant to at least one antibiotic, approximately 23,000 people die as a direct result of these infections, and many others die as a result of complications related to antibiotic-resistant infections.

Read the abstract here

The influence of contaminated urine cultures in inpatient and emergency department settings

Klausing, B.T. et al. American Journal of Infection Control. Published online: 13 June 2016

Highlights

  • Urine culture contamination results in substantial impact to patients.
  • Morbidity includes unnecessary testing and antibiotic exposure.
  • Reducing urine culture contamination is an important quality intervention.

We retrospectively evaluated 131 patients with contaminated urine cultures during a 12-month period. Sixty-four patients (48.8%) experienced 139 potential complications related to these specimens. The most common complication was inappropriate antibiotic administration (noted in 58 patients [44.3%]). Contaminated urine cultures led to additional diagnostic evaluation and unnecessary antibiotic use.

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Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department

Arntz, P.R.H. et al. American Journal of Infection Control. Published online: 6 May 2016

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Highlights:

  • A total of 1,007 opportunities for handrubs were recorded in the emergency department. Hand hygiene (HH) compliance increased significantly (P < .001) after the first intervention week to 40.5% (95% confidence interval [CI], 33%-48%) and stabilized (P = .075) after the second intervention week to 49.5% (95% CI, 43%-56%).
  • The total number of alcohol dispensers was increased from 25 to 55. Within every 5-m radius in the emergency department an alcohol dispenser was placed. Existing alcohol-based handrub was switched for a different brand for its proven skin friendliness.
  • Profession-specific analysis revealed a significant increase over the phases of the study in both subgroups, the physicians and nurses.
  • Regarding the frequency of hand hygiene indications, indication 4 (hand hygiene after touching a patient) composed most indications (31.6%). The increase of compliance applied for all indications; the highest and lowest relative improvements appeared to be indication 3, after contact with body fluids (700% of baseline), and indication 4, after patient contact (136% of baseline), respectively.
  • During the baseline observations, the effect of the time of day (day vs evening and week vs weekend) and the type of patient (surgical patients vs patients with infection vs others without infection) showed no significant effect on hand hygiene compliance.

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Keep It Clean: A Visual Approach to Reinforce Hand Hygiene Compliance in the Emergency Department.

Abstract Although hand hygiene strategies significantly reduce health care-associated infections, multiple studies have documented that hand hygiene is the most overlooked and poorly performed infection control intervention.

METHODS: Emergency nurses and technicians (n = 95) in a 41-bed emergency department in eastern Virginia completed pretests and posttests, an education module, and two experiential learning activities reinforcing hand hygiene and infection control protocols.

RESULTS: Posttest scores were significantly higher than pretest scores (t (108) = -6.928, P = .048). Hand hygiene compliance rates improved at the conclusion of the project and 3 months after the study (F (2, 15) = 9.89, P = .002).

IMPLICATIONS FOR PRACTICE: Interfaces with staff as they completed the interactive exercise, as well as anecdotal notes collected during the study, identified key times when compliance suffered and offered opportunities to further improve hand hygiene and, ultimately, patient safety.

Reference: Keep It Clean: A Visual Approach to Reinforce Hand Hygiene Compliance in the Emergency Department. Wiles LL, Roberts C, Schmidt K. J Emerg Nurs. 2015 Jan 19.