Hand-hygiene behaviour, attitudes and beliefs in first year clinical medical students.
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Cross Infection↗
Biomedical subjects
S P Stone
Publications and source records attributed to S P Stone.
Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature.
OBJECTIVE: To evaluate the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients. DESIGN: Systematic review of published articles. DATA SOURCES: Medline, Embase, CINAHL, Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), and citation lists (1966-2000). REVIEW METHODS: Articles reporting MRSA related outcomes and describing an isolation policy were selected. No quality restrictions were imposed on studies using isolation wards or nurse cohorting. Other studies were included if they were prospective or employed planned comparisons of retrospective data. RESULTS: 46 studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA. CONCLUSION: Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.
Cross Infection↗
Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes.
Methicillin-resistant Staphylococcus aureus (MRSA) represents a serious threat to the health of hospitalized patients. Attempts to reduce the spread of MRSA have largely depended on hospital hygiene and patient isolation. These measures have met with mixed success: although some countries have almost eliminated MRSA or remained largely free of the organism, others have seen substantial increases despite rigorous control policies. We use a mathematical model to show how these increases can be explained by considering both hospital and community reservoirs of MRSA colonization. We show how the timing of the intervention, the level of resource provision, and chance combine to determine whether control measures succeed or fail. We find that even control measures able to repeatedly prevent sustained outbreaks in the short-term can result in long-term control failure resulting from gradual increases in the community reservoir. If resources do not scale with MRSA prevalence, isolation policies can fail "catastrophically."
Community-Acquired Infections↗
The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK.
Methicillin-resistant Staphylococcus aureus (MRSA) predominantly affects those over 65 years old. There may be a substantial pool of older people with MRSA in the community. We studied the prevalence in one London general practice, screening 258 older people living in their own home. MRSA (E-MRSA 15) was found in two participants (0.78%). Past history of MRSA was the only significant risk factor. The results of this and other studies suggest that national guidelines recommending early discharge for MRSA carriers have not resulted in widespread community acquisition amongst elderly people living in their own home. Community antibiotic policies for skin and soft-tissue infection do not require amendment. Patients with previous MRSA should be isolated and screened on admission especially to high-risk units.
Age Distribution↗
Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling.
OBJECTIVE: To review the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital in-patients. To develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA. DATA SOURCES: MEDLINE, EMBASE, CINAHL, The Cochrane Library and SIGLE (1966-2000). Hand-searching key journals. No language restrictions. REVIEW METHODS: Key data were extracted from articles reporting MRSA-related outcomes and describing an isolation policy in a hospital with epidemic or endemic MRSA. No quality restrictions were imposed on studies using isolation wards (IW) or nurse cohorting (NC). Other studies were included if they were prospective or employed planned comparisons of retrospective data. Stochastic and deterministic models investigated long-term transmission dynamics, studying the effect of a fixed capacity IW, producing economic evaluations using local cost data. RESULTS: A total of 46 studies were accepted: 18 IWs, 9 NC, 19 other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures which included patient isolation were effective in controlling MRSA. In two others IW use failed to prevent endemic MRSA. There was no robust economic evaluation. Models showed that improving the detection rate or ensuring adequate isolation capacity reduced endemic levels, with substantial savings achievable. CONCLUSIONS: Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well-designed studies allow the role of isolation measures alone to be assessed. Nonetheless, there is evidence that concerted efforts that include isolation can reduce MRSA even when endemic. Little evidence was found to suggest that current isolation measures recommended in the UK are ineffective, and these should continue to be applied until further research establishes otherwise. The studies with the strongest evidence, together with the results of the modelling, provide testable hypotheses for future research. Guidelines to facilitate design of future research are produced.
Cost-Benefit Analysis↗
Controlling infection in British nursing homes. It is time for a national strategy.
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Aged↗
Hand hygiene--the case for evidence-based education.
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Cross Infection↗
Unusual, innovative, and long-forgotten remedies.
A compendium of uncommon dermatologic treatments, both medical and surgical, are presented. This article is based on a survey of the members of the Noah Worcester Dermatologic Society with subsequent additions, including treatment pearls from the Internet and other contributions from practicing dermatologists, as well as some published material. Most of the therapies discussed in this article are based on anecdotal information.
Humans↗
'Now please wash your hands': the handwashing behaviour of final MBBS candidates.
The Handwashing Liaison Group has pointed out that "The failure of healthcare workers to decontaminate their hands reflects fundamentals of attitudes, beliefs and behaviours". Doctors are known to be poor at handwashing. This poor compliance may have its roots in a failure to learn this behaviour at medical college, where the influence of consultants and other role models may be critical. The handwashing behaviour of modern day medical students has not been previously studied. The Final MBBS Objective Structured Clinical Examination (OSCE) reflects learnt behaviours and attitudes of final year medical students 'absorbed' from role models within their training. We observed the handwashing behaviour of 187 candidates during the 1998 Final MBBS OSCE, at one clinical station, neurological examination of the lower limbs. Only 8.5% of candidates washed their hands after patient contact, although this figure rose to 18.3% with the aid of handwashing signs. These findings suggest that handwashing should become an educational priority. As student learning is highly focused by assessment (in-course or examination), we sug-gest that compliance with handwashing be built into undergraduate and Teaching Quality assessments with, for example, 'Hygiene marks' incorporated into OSCE or observed long case checklists. This study re-emphasizes the need for good clinical practice whenever teaching medical students.
Attitude of Health Personnel↗
Predicting outcome in acute stroke.
The natural history of acute stroke is well defined. Predicting outcome in individuals, however, remains difficult, because prognostic studies examining associations between clinical signs or syndromes and outcome differ in patient selection, timing and choice of neurological assessments and outcome measures. Accuracy has been disappointing. Osler in 1892 stated that the 'course of the disease ... is dependent on the situation and extent of the lesion'. Until recently, it has not been possible to examine the stroke prognosis, using Osler's approach, with any great accuracy. The advent of diffusion weighted magnetic resonance imaging (DWI), which is highly sensitive to the pathophysiological changes underlying stroke, offers this possibility as it measures the site and extent of irreversible infarction. This review summarises the results of syndrome or sign-based predictive studies and shows how DWI may explain different outcomes in patients with identical neurological presentations, according to the 'situation and extent of the lesion'.
Acute Disease↗
Soil, seed and climate: developing a strategy for prevention and management of infections in UK nursing homes.
Most studies of nursing home (NH) infections come from the USA and very few from the UK. USA studies lead us to anticipate a rate of 7 infections per 1000 patient days with a point prevalence as high as 16% in UK NH residents. Pneumonia, skin and urine infections would be the most frequent, followed by enteric infection and bacteraemia. Colonization with resistant organisms is increasing in UK NH residents (e.g., MRSA in 4-17%). Surveillance studies are needed in UK NHs to report incidence of infection, residents' characteristics, existence of and adherence to above standards and policies. Trials of effectiveness of different infection control programmes and of NH vs hospital management are required. Management of infection may be a useful marker of quality of care in NHs and therefore of interest to health and local authorities.
Aged↗
The effect of an enhanced infection-control policy on the incidence of Clostridium difficile infection and methicillin-resistant Staphyloccocus aureus colonization in acute elderly medical patients.
BACKGROUND: Clostridium difficile (CD) infection and methicillin-resistant Staphylococcus aureus (MRSA) colonization are increasingly common in elderly patients, are associated with cephalosporin or prolonged aminopenicillin courses and can be transmitted by direct contact. Management is by side-room isolation. Ward closure may be required to control outbreaks. METHODS: following prolonged bed closures due to CD and MRSA in an acute age-related geriatric service, an enhanced infection control policy was introduced-emphasis on handwashing, cephalosporin restriction, 7-day time limits on antibiotics and feedback of infection rates. The effect of this policy was evaluated by investigating 2,467 consecutive admissions in the 9 months before and after its introduction. RESULTS: CD infection fell from 36/1,075 admissions (3.35 per 100) to 27/1,392 (1.94 per 100; P < 0.05). MRSA incidence fell from 3.95 per 100 to 1.94 (P < 0.01) whilst that in the rest of the hospital continued to fluctuate. Cephalosporin use fell (and aminopenicillin and trimethoprim use rose) by a factor of three. Unoccupied bed days fell from 1,164 (12.6%) to 513 (5.1%) over the winter, an increase in bed availability of 4.95 a day. CONCLUSIONS: introduction of the policy was associated with significant reductions in CD infection and unoccupied bed-days and helped maintain a lower incidence of MRSA. It is not clear which elements of the policy most influenced outcome. A multi-centre study is needed to determine whether our findings are generally applicable.
Aged↗
Unilateral neglect: a common but heterogeneous syndrome.
The neglect syndrome is a cluster of neurologic symptoms commonly found after right hemisphere damage. This study investigates the degree of association between the main components in a representative sample of 69 patients at 2 to 3 days poststroke. Despite evidence of statistically significant associations between components, many dissociations were found, indicating that neglect is a highly heterogeneous condition.
Aged↗
Managing methicillin-resistant Staphylococcus aureus in hospital: the balance of risk.
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Anti-Bacterial Agents↗
Pharyngeal sensation and gag reflex in healthy subjects.
The gag reflex is often used in the assessment of swallowing, yet its absence does not predict aspiration in acute stroke. Disordered pharyngeal sensation has been found to be a sensitive predictor. The occurrence of gag reflex and pharyngeal sensation in healthy people is unknown. We studied these tests in 140 healthy subjects (half elderly and half young). Gag reflex was absent in 37% of subjects whereas pharyngeal sensation was absent in only 1. The results largely explain the low predictive value of gag reflex in the assessment of aspiration in acute stroke. Testing pharyngeal sensation would be more likely to be useful in these circumstances.
Adult↗
Fluctuations in visual neglect after stroke?
Clinical experience suggests that the visual neglect in stroke patients fluctuates over short periods of time. This fluctuation has been variously attributed to fatigue, time of day, previous activities, patient learning and compensation. Such fluctuations have clinical implications for the assessment and rehabilitation of visual neglect but do date no formal study has evaluated the extent of such fluctuation over the course of a day. Twenty-two patients with an acute stroke and 19 patients with convalescent stroke were examined for visual neglect twice on the same day using the Visual Neglect Recovery Index (VNRI), a valid and sensitive measure of the severity of neglect, which could be used to select acute patients for trials of treatment of neglect. The inter-test reliability was extremely high. In contrast to past clinical accounts most patients failed to show significant fluctuation. Although preliminary, this finding suggests that a single assessment of visual neglect, using the VNRI, could help select patients for treatment trials.
Aged↗
The incidence of neglect phenomena and related disorders in patients with an acute right or left hemisphere stroke.
We studied 171 consecutive patients with an acute hemispheric stroke (69 right hemisphere, 102 left), at 2-3 days post-stroke. A standardized test battery, previously validated in patients with acute stroke, was used to detect a wide variety of neglect phenomena and related disorders. Visual neglect was found in 82% of assessable right hemisphere patients and 65% of left hemisphere patients. Hemi-inattention was found in 70% of right and 49% of left hemisphere strokes. Tactile extinction was found in 65% of right and 35% of left hemisphere patients; allaesthesia in 57% (right), and 11% (left); visual extinction in 23% (right) 2% (left). Anosognosia was found in 28% (right), and 5% (left); anosodiaphoria in 27% (right), and 2% (left); non-belonging in 36% (right) and 29% (left). Visual neglect occurred more commonly in left hemisphere stroke than previously reported. Although neglect phenomena and related disorders were associated with right hemisphere damage, it is possible that language difficulties obscured their presence in some patients with a left hemisphere stroke.
Adult↗
Selection of acute stroke patients for treatment of visual neglect.
Although visual neglect is a predictor of poor outcome after stroke, some patients regain independence, whilst others take up considerable rehabilitation resources. Intensive treatment of visual neglect is available and a knowledge of the predictive features in the recovery of these patients would be helpful in the early selection of patients for treatment. A study was therefore carried out to determine the prognosis of patients presenting with visual neglect at two to three days after stroke. Linear logistic regression showed that the initial degree of paralysis (measured by the Motricity Index), the severity of neglect (measured by the Visual Neglect Recovery Index) and the patient's age were the significant predictors of independence (Barthel score 20), mild dependence (Barthel 15-19), and moderate/severe dependence (Barthel 0-14) in surviving patients at three months and at six months. Regression equations correctly predicted 78% of outcomes, and had a sensitivity and specificity for "independence" of 84% and 90% respectively, and a sensitivity and specificity for "moderate/severe dependence" of 89% and 80%. It is suggested that these equations may be useful in selecting comparable groups of patients for randomised controlled trials of treatment of visual neglect.
Aged↗