Efficacy of a New Educational Tool to Improve Handrubbing Technique amongst Healthcare Workers: A Controlled,Before-After Study

Introduction

Hand hygiene is a key component of infection control in healthcare. WHO recommends that healthcare workers perform six specific poses during each hand hygiene action. SureWash (Glanta Ltd, Dublin, Ireland) is a novel device that uses video-measurement technology and immediate feedback to teach this technique. We assessed the impact of self-directed SureWash use on healthcare worker hand hygiene technique and evaluated the device''s diagnostic capacity.

Methods

A controlled before-after study: subjects in Group A were exposed to the SureWash for four weeks followed by Group B for 12 weeks. Each subject''s hand hygiene technique was assessed by blinded observers at baseline (T₀) and following intervention periods (T₁ and T₂). Primary outcome was performance of a complete hand hygiene action, requiring all six poses during an action lasting ≥20 seconds. The number of poses per hand hygiene action (maximum 6) was assessed in a post-hoc analysis. SureWash''s diagnostic capacity compared to human observers was assessed using ROC curve analysis.

Results

Thirty-four and 29 healthcare workers were recruited to groups A and B, respectively. No participants performed a complete action at baseline. At T₁, one Group A participant and no Group B participants performed a complete action. At baseline, the median number of poses performed per action was 2.0 and 1.0 in Groups A and B, respectively (p = 0.12). At T₁, the number of poses per action was greater in Group A (post-intervention) than Group B (control): median 3.8 and 2.0, respectively (p<0.001). In Group A, the number of poses performed twelve weeks post-intervention (median 3.0) remained higher than baseline (p<0.001). The area under the ROC curves for the 6 poses ranged from 0.59 to 0.88.

Discussion

While no impact on complete actions was demonstrated, SureWash significantly increased the number of poses per hand hygiene action and demonstrated good diagnostic capacity.     

Working Memory Training in Post-Secondary Students with ADHD: A Randomized Controlled Study

Objectives

To determine whether standard-length computerized training enhances working memory (WM), transfers to other cognitive domains and shows sustained effects, when controlling for motivation, engagement, and expectancy.

Methods

97 post-secondary students (59.8% female) aged 18–35 years with Attention-Deficit/Hyperactivity Disorder, were randomized into standard-length adaptive Cogmed WM training (CWMT; 45-min/session), a shortened-length adaptive version of CWMT (15 min/session) that controlled for motivation, engagement and expectancy of change, or into a no training group (waitlist-control group). All three groups received weekly telephone calls from trained coaches, who supervised the CWMT and were independent from the research team. All were evaluated before and 3 weeks post-training; those in the two CWMT groups were also assessed 3 months post-training. Untrained outcome measures of WM included the WAIS-IV Digit Span (auditory-verbal WM), CANTAB Spatial Span (visual-spatial WM) and WRAML Finger Windows (visual-spatial WM). Transfer-of-training effects included measures of short-term memory, cognitive speed, math and reading fluency, complex reasoning, and ADHD symptoms.

Results

Performance on 5/7 criterion measures indicated that shortened-length CWMT conferred as much benefit on WM performance as did standard-length training, with both CWMT groups improving more than the waitlist-control group. Only 2 of these findings remained robust after correcting for multiple comparisons. Follow-up analyses revealed that post-training improvements on WM performance were maintained for at least three months. There was no evidence of any transfer effects but the standard-length group showed improvement in task-specific strategy use.

Conclusions

This study failed to find robust evidence of benefits of standard-length CWMT for improving WM in college students with ADHD and the overall pattern of findings raise questions about the specificity of training effects.

Trial Registration

ClinicalTrials.gov NCT01657721     

Stress-Management Training for Essential Hypertension: A Controlled Study

Forty three patients with essential hypertension participated in a study on the effectiveness of stress-management training for essential hypertension. After 6–9 clinic and 48 self-measured readings of systolic and diastolic blood pressures (SBP and DBP), 22 patients were treated with a program based on education, relaxation, and problem-solving training; and another 21 patients were assigned to a waiting list control group. At post-treatment, mean reductions of clinic BP (17/13 mm Hg vs. 6.9/4.7 mm Hg for SBP/DBP), percentages of subjects who achieved at least a 5 mm Hg reduction (86/86% vs. 48/48% for SBP/DBP) and percentages of subjects who in addition achieved a normotensive level (59/68% vs. 29/14% for SBP/DBP) were significantly higher in the treated group than in the control group. Concerning self-measured BP, the effectiveness of the stress-management training was not so considerable (mean reductions of 3.6/2.4 mm Hg and percentages of subjects who achieved a 5 mm Hg reduction of 52/38% for SBP/DBP), but it was significant and maintained in a 4-month follow-up assessment (mean reductions of 4/2 mm Hg and percentages of subjects who achieved a 5 mm Hg reduction of 48/33% for SBP/DBP). It is suggested that stress-management training can be beneficial for treatment of essential hypertension.     

Immediate Outcome Indicators in Perioperative Care: A Controlled Intervention Study on Quality Improvement in Hospitals in Tanzania

Introduction

Outcome assessment is the standard for evaluating the quality of health services worldwide. In this study, outcome has been divided into immediate and final outcome. Aim was to compare an intervention hospital with a Continuous Quality Improvement approach to a control group using benchmark assessments of immediate outcome indicators in surgical care. Results were compared to final outcome indicators.

Method

Surgical care quality in six hospitals in Tanzania was assessed from 2006–2011, using the Hospital Performance Assessment Tool. Independent observers assessed structural, process and outcome quality using checklists based on evidence-based guidelines. The number of surgical key procedures over the benchmark of 80% was compared between the intervention hospital and the control group. Results were compared to Case Fatality Rates.

Results

In the intervention hospital, in 2006, two of nine key procedures reached the benchmark, one in 2009, and four in 2011. In the control group, one of nine key procedures reached the benchmark in 2006, one in 2009, and none in 2011. Case Fatality Rate for all in-patients in the intervention hospital was 5.5% (n = 12,530) in 2006, 3.5% (n = 21,114) in 2009 and 4.6% (n = 18,840) in 2011. In the control group it was 3.1% (n = 17,827) in 2006, 4.2% (n = 13,632) in 2009 and 3.8% (n = 17,059) in 2011.

Discussion

Results demonstrated that quality assurance improved performance levels in both groups. After the introduction of Continuous Quality Improvement, performance levels improved further in the intervention hospital while quality in the district hospital did not. Immediate outcome indicators appeared to be a better steering tool for quality improvement compared to final outcome indicators. Immediate outcome indicators revealed a need for improvement in pre- and postoperative care.

Conclusion

Quality assurance programs based on immediate outcome indicators can be effective if embedded in Continuous Quality Improvement. Nevertheless, final outcome indicators cannot be neglected.     

Effect of Autogenic Training on General Improvement in Patients with Irritable Bowel Syndrome: A Randomized Controlled Trial

Autogenic training (AT) is a useful and comprehensive relaxation technique. However, no studies have investigated the effects of AT on irritable bowel syndrome (IBS). In this study we tested the hypothesis that AT improves symptoms of IBS. Twenty-one patients with IBS were randomly assigned to AT (n = 11, 5 male, 6 female) or control therapy (n = 10, 5 male, 5 female). AT patients were trained intensively, while the control therapy consisted of discussions about patients’ meal habits and life styles. All patients answered a question related to adequate relief (AR) of IBS symptoms and four questionnaires: Self-induced IBS Questionnaire (SIBSQ), Self-reported Depression Scale (SDS), State-Trait Anxiety Inventory (STAI), and Medical Outcome Short Form 36 Health Survey (SF-36). The proportion of AR in the last AT session in the AT group (9/11, 81.8%) was significantly higher than that in the controls (3/10, 30.0%, Chi-square test, p = 0.048). Two subscales of the SF-36, i.e., social functioning and bodily pain, were significantly improved in the AT group (p < 0.05) as compared to the control group. Role emotional (p = 0.051) and general health (p = 0.068) showed a tendency for improvement in the AT group. AT may be useful in the treatment of IBS by enhancing self-control.     

Reconciliation in Captive Chimpanzees: A Reevaluation with Controlled Methods

Affiliative postconflict reunions—reconciliations—of former opponents were first demonstrated in the chimpanzees at the Arnhem Zoo. Since then methods have been considerably refined, and reconciliation has been demonstrated in a large number of primates and also some gregarious nonprimates. This study, conducted with a different captive group, is the first to use the revised methodology with chimpanzees. We analyzed a total of 297 agonistic conflicts with the PC–MC method: we observed focal individuals for 15 min after a conflict and during matched control observations the next day. The mean conciliatory tendency of the 16 chimpanzees was 41%, with a range in different age-sex classes of 58% (among adult females) to 19% (among adult vs. immature males). After conflicts, former opponents were selectively attracted to one another. Preferential contact with previous opponents persisted when activity level during matched controls was controlled for statistically. Opponents that were frequent grooming partners reconciled more frequently, but the frequency of agonistic support had no such effect. Our findings thus confirm the existence of reconciliation in chimpanzees, which show one of the highest conciliatory tendencies among primate species.     

基于精益管理对微创手术患者护理满意度影响分析

目的 分析精益管理应用于微创手术患者对护理满意度的影响。 方法 　选择2012年1—12月530例入住我院行微创治疗的患者作为管理前组,同时应用精益管理理念和方法选择2013年1—12月400例同类患者作为管理后组,比较两组患者对护理满意度差异。结果 管理后组明显优于管理后前组(P <0.05)。结论　精益管理有效改善了护理服务的质量,提高了微创手术患者对护理服务的满意度,同时促进了护理人员综合能力的提高,减少医疗设备的完好率,保证了手术的顺利完成。     

Feasibility and Impact of Doctor-Nurse Task Delegation in Preventive Child Health Care in the Netherlands,a Controlled Before-After Study

BackgroundIn the Netherlands a need is felt for more flexible Child Health Care services, both efficient and tailored to needs. We set up a study on impact and feasibility of task delegation to child health care nurses performing all regular checkups on children aged 2 months to 4 years. Abnormal findings were discussed with the attending child health care doctor. This article describes impact and feasibility of this task delegation from four viewpoints: competences of nurses; percentage of children assigned to the nurse; change in abnormal findings and referrals; experiences of professionals and parents.MethodsTwo experiment teams and two control teams were compared before and after starting task delegation. Nurses in the experiment teams were trained to carry out regular checkups on healthy children. Assignment to the experiment schedule was a joint decision by doctor and nurse. Nursing competences were measured by means of questionnaires. Percentage of children assigned to the nurse and screening results of eyes, heart, hips, growth and development were extracted from the electronic health record. Difference in change was compared between experiment and control teams. Mann-Whitney tests and logistic generalized estimating equations were used to test for significance. Experiences of professionals and parents were evaluated through focus group interviews, which were subjected to a qualitative analysis.ResultsNurses in the experiment regions showed improvement in medical screening skills. No difference in change was perceived in general nursing competences. In the experiment group, 69% of all children were assigned to the nurse. There were no significant differences in change in the percentages of abnormal findings or referrals in the experiment teams compared to the control teams, except for hips. Interviews showed that both doctors and nurses thought positively of the new working method, yet made some recommendations for improvements. Parents felt well-informed and experienced an equal level of proficiency but less continuity in person.ConclusionThis experiment shows that task delegation from doctor to nurse in preventive child health care is feasible. It is important to pay attention to the acceptation process of professionals during implementation. More investigation is needed in order to assess effectiveness and efficacy of task delegation.     

Quality of Life after Gastric Bypass Surgery: A Cross-Sectional Study

Objective: Numerous reports document significant weight loss after gastric bypass; however, there is little objective data on postsurgical changes in health-related quality of life (HRQL). Research Methods and Procedures: This study examined HRQL in four groups of patients: presurgery (T1), several weeks postsurgery (T2), 6 months postsurgery (T3), and 1 year postsurgery (T4). Subjects were given three HRQL measures: the short form 36 (SF-36), the Impact of Weight on Quality of Life-Lite Questionnaire (IWQOL-Lite), and the Bariatric Analysis and Reporting Outcome System (BAROS). Subjects also completed the Beck Depression Inventory (BDI) and the Rosenberg Self-Esteem Scale (RSE). Results: There were no significant differences among the groups on demographics or presurgical body mass index. Results showed significant differences between T1 and T2 on several SF-36 and IWQOL-Lite subscales, as well as the RSE and BDI. Significant differences were found on all measures between T2 and T3. Significant differences were found on all subscales of the IWQOL-Lite, but no subscales of the SF-36, the RSE, or the BDI between T3 and T4. Discussion: This study is the first to objectively document these differences in several objective measures of HRQL, depression, and self-esteem after gastric bypass in a large sample. It is notable that many differences are apparent within several weeks after surgery. Furthermore, results indicate that the IWQOL-Lite may be more sensitive than the SF-36 to the changes of quality of life that gastric bypass patients report.     

Impact of STROBE Statement Publication on Quality of Observational Study Reporting: Interrupted Time Series versus Before-After Analysis

Background

In uncontrolled before-after studies, CONSORT was shown to improve the reporting of randomised trials. Before-after studies ignore underlying secular trends and may overestimate the impact of interventions. Our aim was to assess the impact of the 2007 STROBE statement publication on the quality of observational study reporting, using both uncontrolled before-after analyses and interrupted time series.

Methods

For this quasi-experimental study, original articles reporting cohort, case-control, and cross-sectional studies published between 2004 and 2010 in the four dermatological journals having the highest 5-year impact factors (≥4) were selected. We compared the proportions of STROBE items (STROBE score) adequately reported in each article during three periods, two pre STROBE period (2004–2005 and 2006–2007) and one post STROBE period (2008–2010). Segmented regression analysis of interrupted time series was also performed.

Results

Of the 456 included articles, 187 (41%) reported cohort studies, 166 (36.4%) cross-sectional studies, and 103 (22.6%) case-control studies. The median STROBE score was 57% (range, 18%–98%). Before-after analysis evidenced significant STROBE score increases between the two pre-STROBE periods and between the earliest pre-STROBE period and the post-STROBE period (median score_2004–05 48% versus median score_2008–10 58%, p<0.001) but not between the immediate pre-STROBE period and the post-STROBE period (median score_2006–07 58% versus median score_2008–10 58%, p = 0.42). In the pre STROBE period, the six-monthly mean STROBE score increased significantly, by 1.19% per six-month period (absolute increase 95%CI, 0.26% to 2.11%, p = 0.016). By segmented analysis, no significant changes in STROBE score trends occurred (−0.40%; 95%CI, −2.20 to 1.41; p = 0.64) in the post STROBE statement publication.

Interpretation

The quality of reports increased over time but was not affected by STROBE. Our findings raise concerns about the relevance of uncontrolled before-after analysis for estimating the impact of guidelines.     

对手术室准时开台实施精益管理的探索

??????? 目的 对手术室准时开台实施精益管理的研究,有效发挥手术室资源来探讨精益管理的可行性。方法 医院对手术室手术安排以及对手术医师、麻醉医师、手术护士实施面部指纹考勤等一系列的精益管理手段来促使手术室准时开台的实施。结果 通过对手术室准时开台实施精益管理,手术准时开台率由原来的42.12%上升至现在的92.60%,手术周转时间缩短,成效显著(P<0.01)。结论 精益管理能有效提高手术室准时开台,保障手术顺利进行。     

Continuous Quality Improvement in Daily Clinical Practice: A Proof of Concept Study

Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6–8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1–2; epoetin decreased from month 4. By months 16–18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were $22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost.     

Intraoperative Fluid Restriction in Pancreatic Surgery: A Double Blinded Randomised Controlled Trial

Background

Perioperative fluid restriction in a variety of operations has shown improvement of: complications, recovery of gastrointestinal function and length of stay (LOS). We investigated effects of crystalloid fluid restriction in pancreatic surgery. Our hypothesis: enhanced recovery of gastrointestinal function.

Methods

In this double-blinded randomized trial, patients scheduled to undergo pancreatoduodenectomy (PD) were randomized: standard (S:10ml/kg/hr) or restricted (R:5ml/kg/hr) fluid protocols. Primary endpoint: gastric emptying scintigraphically assessed on postoperative day 7.

Results

In 66 randomized patients, complications and 6-year survival were analyzed. 54 patients were analyzed in intention to treat: 24 S-group and 30 R-group. 32 patients actually underwent a PD and 16 patients had a palliative gastrojejunostomy bypass operation in the full protocol analysis. The median gastric emptying time (T½) was 104 minutes (S-group, 95% confidence interval: 74–369) versus 159 minutes (R-group, 95% confidence interval: 61–204) (P = 0.893, NS). Delayed gastric emptying occurred in 10 patients in the S-group and in 13 patients in the R-group (45% and 50%, P = 0.779, NS). The primary outcome parameter, gastric emptying time, did not show a statistically significant difference between groups.

Conclusion

A fluid regimen of 10ml/kg/hr or 5ml/kg/hr during pancreatic surgery did not lead to statistically significant differences in gastric emptying. A larger study would be needed to draw definite conclusions about fluid restriction in pancreatic surgery.

Trial registration

ISRCTN62621488     

加速康复外科在医疗质量改进中的作用与推广策略

从加速康复外科的概念与内涵出发,阐述了加速康复外科在医疗质量改进中的作用,指出这一理念有利于提升医疗服务品质、节约医疗卫生资源、促进医患关系和谐。同时,剖析了加速康复外科推广应用中存在的障碍,并结合医院实践探讨了加速康复外科推广应用的策略,对于探索以新理念新技术提升医疗服务质量有十分重要的借鉴意义。     

PXL01 in Sodium Hyaluronate for Improvement of Hand Recovery after Flexor Tendon Repair Surgery: Randomized Controlled Trial

Background

Postoperative adhesions constitute a substantial clinical problem in hand surgery. Fexor tendon injury and repair result in adhesion formation around the tendon, which restricts the gliding function of the tendon, leading to decreased digit mobility and impaired hand recovery. This study evaluated the efficacy and safety of the peptide PXL01 in preventing adhesions, and correspondingly improving hand function, in flexor tendon repair surgery.

Methods

This prospective, randomised, double-blind trial included 138 patients admitted for flexor tendon repair surgery. PXL01 in carrier sodium hyaluronate or placebo was administered around the repaired tendon. Efficacy was assessed by total active motion of the injured finger, tip-to-crease distance, sensory function, tenolysis rate and grip strength, and safety parameters were followed, for 12 months post-surgery.

Results

The most pronounced difference between the treatment groups was observed at 6 months post-surgery. At this timepoint, the total active motion of the distal finger joint was improved in the PXL01 group (60 vs. 41 degrees for PXL01 vs. placebo group, p = 0.016 in PPAS). The proportion of patients with excellent/good digit mobility was higher in the PXL01 group (61% vs. 38%, p = 0.0499 in PPAS). Consistently, the PXL01 group presented improved tip-to-crease distance (5.0 vs. 15.5 mm for PXL01 vs. placebo group, p = 0.048 in PPAS). Sensory evaluation showed that more patients in the PXL01 group felt the thinnest monofilaments (FAS: 74% vs. 35%, p = 0.021; PPAS: 76% vs. 35%, p = 0.016). At 12 months post-surgery, more patients in the placebo group were considered to benefit from tenolysis (30% vs. 12%, p = 0.086 in PPAS). The treatment was safe, well tolerated, and did not increase the rate of tendon rupture.

Conclusions

Treatment with PXL01 in sodium hyaluronate improves hand recovery after flexor tendon repair surgery. Further clinical trials are warranted to determine the most efficient dose and health economic benefits.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01022242","term_id":"NCT01022242"}}NCT01022242; EU Clinical Trials 2009-012703-25.     

Resistance versus Balance Training to Improve Postural Control in Parkinson's Disease: A Randomized Rater Blinded Controlled Study

Background

Reduced muscle strength is an independent risk factor for falls and related to postural instability in individuals with Parkinson’s disease. The ability of resistance training to improve postural control still remains unclear.

Objective

To compare resistance training with balance training to improve postural control in people with Parkinson’s disease.

Methods

40 patients with idiopathic Parkinson’s disease (Hoehn&Yahr: 2.5–3.0) were randomly assigned into resistance or balance training (2x/week for 7 weeks). Assessments were performed at baseline, 8- and 12-weeks follow-up: primary outcome: Fullerton Advanced Balance (FAB) scale; secondary outcomes: center of mass analysis during surface perturbations, Timed-up-and-go-test, Unified Parkinson’s Disease Rating Scale, Clinical Global Impression, gait analysis, maximal isometric leg strength, PDQ-39, Beck Depression Inventory. Clinical tests were videotaped and analysed by a second rater, blind to group allocation and assessment time.

Results

32 participants (resistance training: n = 17, balance training: n = 15; 8 drop-outs) were analyzed at 8-weeks follow-up. No significant difference was found in the FAB scale when comparing the effects of the two training types (p = 0.14; effect size (Cohen’s d) = -0.59). Participants from the resistance training group, but not from the balance training group significantly improved on the FAB scale (resistance training: +2.4 points, Cohen’s d = -0.46; balance training: +0.3 points, Cohen’s d = -0.08). Within the resistance training group, improvements of the FAB scale were significantly correlated with improvements of rate of force development and stride time variability. No significant differences were found in the secondary outcome measures when comparing the training effects of both training types.

Conclusions

The difference between resistance and balance training to improve postural control in people with Parkinson’s disease was small and not significant with this sample size. There was weak evidence that freely coordinated resistance training might be more effective than balance training. Our results indicate a relationship between the enhancement of rate of force development and the improvement of postural control.

Trial Registration

ClinicalTrials.gov ID: NCT02253563