Browsing School, Graduate by Subject "Universal Precautions"
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The Effect of Contact Precautions on the Frequency of Hospital Adverse EventsBackground: Contact Precautions are an infection control approach where patients with antibiotic resistant bacteria are isolated and disposable gloves and gowns are donned prior to room entry. Some studies suggest Contact Precautions may increase the occurrence of hospital adverse events. However, few studies have examined the effect of Contact Precautions on adverse events using a standard definition and accounting for the effect of severity of illness. We assessed whether Contact Precautions exposure was associated with patient adverse events in both ICU and non-ICU settings. Methods: The relationship between universal use of Contact Precautions (universal glove and gown use for all patient contact, regardless of colonization) and adverse events in the intensive care unit (ICU) was studied using medical record review of 1800 randomly sampled patients equally distributed over a 20 ICU cluster randomized trial. To reduce the influence of severity of illness, eligible patients could not be colonized or infected with antibiotic resistant bacteria. Within a non-ICU setting, a prospective cohort of 296 patients at the University of Maryland Medical Center (UMMC) matched on initial 3 day length of stay and admission location was used to study the association between usual use of Contact Precautions and adverse events. Results: The study of 1800 randomly selected patients from a cluster randomized trial of universal glove and gown use found that the rates of adverse events among patients in universal glove and gown ICUs were not statistically different (IRR, 0.91; 95% CI, 0.59-1.42; p=0.68). The UMMC prospective cohort observed significantly fewer noninfectious adverse events among patients exposed to traditional Contact Precautions compared to unexposed patients (IRR, 0.70; 95% CI, 0.51-0.95; p=0.02). Conclusions: In ICUs where healthcare workers donned gloves and gowns for all patient contact, patients were no more likely to experience adverse events than in control ICUs. In non-ICU settings Contact Precautions were associated with fewer noninfectious adverse events. Concerns about adverse events resulting from either universal glove and gown use or traditional use of Contact Precautions were not supported.
The Impact of Contact Precautions on Depression, Anxiety, Delirium and Emotional States in General Hospital InpatientsBackground:Contact Precautions are an infection control intervention that isolate patients in a private room and require staff to wear gown and gloves. Studies have associated Contact Precautions with negative outcomes. Objectives: To evaluate psychological outcomes associated with the use of Contact Precautions, including delirium, depression, anxiety and mood states (sadness, worry, happiness, anger, confusion). This dissertation will clarify differences between incident and prevalent psychological outcomes associated with Contact Precautions Methods: The relationship between Contact Precautions and depression, anxiety and delirium were studied using two retrospective cohort studies and a prospective cohort study. The retrospective cohort studies examined delirium, depression and anxiety in patients on Contact Precautions. The prospective cohort study enrolled patients within 36 hours of admission to the hospital and followed them over the course of hospitalization to examine incident symptoms of depression, anxiety and mood states. Results: The first retrospective cohort study of 45,266 non-psychiatric admissions to University of Maryland Medical Center (UMMC) found delirium was more common in patients newly transferred to Contact Precautions than patients never admitted to Contact Precautions (OR: 1.53, 95% CI 1.37-1.70) or patients on Contact Precautions from a previous admission (OR 1.07, 95% CI 0.92-1.25). The second retrospective cohort study found increased prevalence of depression in 28,564 non-psychiatric, non-intensive care unit patients. (OR 1.4, 95% CI 1.2, 1.5) The prospective cohort study found Contact Precautions had more depressive symptoms on their first day of admission but Contact Precautions were not associated with incident symptoms of depression, anxiety or a change in mood states. Conclusions: Contact Precautions are associated with increased delirium and depression, but do not appear to cause incident depression, anxiety or delirium in relation to duration on Contact Precautions. Although Contact Precautions may mark a population at higher risk for depression or delirium, they do not appear to cause them.
Role of Persistent Environmental Contamination and Universal Glove and Gown Use in the Acquisition of Extended Spectrum Beta-Lactamase-Producing Enterobacteriaceae in Intensive Care Unit PatientsBackground: Extended-spectrum beta-lactamase (ESBL)-producing Gram-negative rods (GNR) are emerging pathogens that are associated with considerable morbidity, mortality and costs among hospitalized patients. The association between persistent environmental contamination and acquisition of ESBL-GNR and the effectiveness of universal glove and gown in reducing the transmission of ESBL-GNR among Intensive care unit (ICU) patients has not been well established. Objectives: The objectives of this dissertation are to evaluate the role of persistent environmental contamination using prior room occupant as a proxy in the acquisition of ESBL-GNR and to evaluate the effectiveness of universal glove and gown use in reducing the incidence of ESBL-GNR in ICU patients. Methods: A retrospective cohort study and a quasi-experimental study were conducted using patient data obtained from the central data repository and by laboratory analysis. Peri-anal surveillance cultures were collected from all patients on ICU admission, weekly and at ICU discharge and clinical cultures were collected as medically indicated. Inclusion criteria were ICU length of stay >48 hours and a peri-anal surveillance culture negative for ESBL-GNR on ICU admission. Multivariable logistic regression and segmented linear regression were used to analyze the data. Results: The first study of 18,175 admissions to the University of Maryland Medical Center (UMMC) medical ICU (MICU) and surgical ICU (SICU) between September 1, 2001 and June 30, 2009 showed that prior room occupants' ESBL-Klebsiella and E. coli positive status is not associated with acquiring ESBL- Klebsiella and E. coli after adjusting for potential confounders (Adjusted Odds Ratio (AOR) = 1.39, 95% Confidence Interval (CI) = 0.94 - 2.08). The second study of 6,089 admissions to the MICU between July 1, 2005 and June 30, 2009 showed that universal glove and gown did not reduce acquisition of ESBL-GNR immediately (p =0.48) or long term (p =0.34). Conclusions: Our study results suggest that environmental contamination may not play a significant role in the acquisition of ESBL-GNR at UMMC. Universal glove and gown was not effective at reducing the acquisition of ESBL-GNR immediately and long term at UMMC.