572647 research-article2015

BJI0010.1177/1757177415572647Journal of Infection PreventionWigglesworth and Xuereb

Journal of

Infection Prevention

Commentary

Journal of Infection Prevention 2015, Vol. 16(2) 89­–91 DOI: 10.1177/1757177415572647 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav jip.sagepub.com

Journal Watch Neil Wigglesworth1 and Debbie Xuereb2

The journal watch feature is provided as a service to our readers. The intention is to highlight new research and other developments in infection prevention and control and related fields, published elsewhere. A brief description of each article and its main findings is given here; readers are encouraged to refer to the full published article for the details of the work. The editorial management group would welcome feedback and recommendations for articles to feature in this column; for comments and recommendations please contact [email protected] or editor@ ips.uk.net My guest co-author for the January 2015 Journal Watch seems to have enjoyed the experience enough to come back for more; I hope this encourages others to do the same. Anyone interested should contact me or the editor as above. Once again this issue brings a mixture of reviews and original studies, no particular theme but rather a breadth that reflects the diversity of infection prevention and control practice and related fields. From the everyday to the more obscure, we hope there’s something to interest every reader. The first article in this issue reminds us of the risks presented to our healthcare facilities and population by emerging pathogens and Middle East respiratory syndrome Coronavirus (MERS-CoV) in particular: Maltezou HC and Tsiodras S (2014) Middle East respiratory syndrome Coronavirus: Implications for health care facilities. American Journal of Infection Control 42: 1261–1265. The authors have summarised the current understanding of this emerging pathogen in this helpful narrative review. This is a developing situation so new information may have superseded some of the content, but the review covers the period from the first identification of the virus in September 2012 to June 2014. At the time of writing the risk from MERS-CoV appears to have been a little forgotten by the infection prevention community, because of all the Ebola Virus Disease (EVD) preparedness work currently taking place. Once the EVD outbreak in West Africa is brought under control, attention may well return to MERS-CoV. The article covers the epidemiology and clinical aspects of MERS-CoV including its probable zoonotic origins in bats and particularly camels, and notes that the human and

camel viruses are genetically indistinguishable. A key point is that, although sporadic zoonotic transmissions have occurred and are occurring, person-to-person transmission and, in particular, hospital-acquired cases, are an important element in the epidemiology of this disease. It is of some comfort to read that, to date, there is no evidence of a pandemic potential and that there has been no genetic change in the virus that might influence such a possibility. The review describes the clinical symptoms and mortality associated with the virus. It is interesting to note that this description is not dissimilar to early and progressing EVD (for example, fever, myalgia, diarrhoea and vomiting). The guidance for infection prevention and control is aimed at the United States so practitioners in the UK and Ireland will need to cross-check with local guidance, but the principles are the same; droplet precautions plus airborne for aerosol generating procedures (AGP). In addition, as in the UK, a respirator is being advocated for routine care (FFP3 in the UK) because of our limited understanding of this relatively new disease. There is a slightly curious comment in the paper; having said that the MERS-CoV positivity rate in healthcare worker (HCW) contacts has been 1.12% (admittedly lower than that in family contacts of 3.4%), the authors state that the ‘recommended infection control measures are adequate thus far’ – I disagree! The next article is a single study from Canada, chosen as it adds more to the ongoing debate about the efficacy of increased single room capacity in the prevention of healthcare-associated infections (HCAI): Ellison J, Southern D, Holton D et al. (2014) Hospital ward design and prevention of hospital acquired infections: A prospective clinical trial. Canadian Journal of Infectious Diseases & Medical Microbiology 25: 265–270. Reading this article is something of an exercise of hope over experience as the results are ultimately a

1Public 2Mater

Health Wales, UK Dei Hospital, Malta

Corresponding author: Neil Wigglesworth, Public Health Wales, Cardiff, CF10 3NW, UK. Email: [email protected]

90 little disappointing; nevertheless it is worth reading as an exercise in just how difficult it is to generate high quality evidence in this area. The authors should be commended for two reasons, first for conceiving and attempting a prospective trial with contemporary controls and an attempted degree of randomisation; and second for publishing their ‘negative’ results as should be the case for all trials to avoid publication bias. The basis for this trial was the opening of a refurbished ward with a high proportion of single rooms with en suite facilities. The rates of certain infections in this ward were compared with rates in control wards that had a high proportion of four-bed rooms. After applying some reasonable exclusion criteria, patients being admitted to the general medicine service were housed in either the new ward (intervention) or one of the existing wards (control). The intention was to do this with an element of randomisation, but this depended on empty beds being available on both intervention and control wards; perhaps this was rather wishful thinking. The patients enrolled in the study were monitored for the development of new infections or colonisation with Meticillin-resistant Staphylococcus aureus (MRSA), Vancomycin (glycopeptide)-resistant enterococci (V(G)RE) or Clostridium difficile and the results compared between intervention and control. The results are interesting and probably serve to continue the debate about single rooms more than resolve it. First of all the attempt at a degree of randomisation failed, the bed occupancy was such that patients were admitted to where a bed was available. This is reflected in some differences in baseline data between the two groups (see the article for details). The headline result is that there was no significant difference between the rates of ‘events’ (acquisition of any of the three outcomes), between the two settings. This result has been found before and the authors refer to this in their discussion; thus the debate goes on. There are some important limitations to this finding; in particular, the authors report that the design of the new ward was subverted very quickly with the addition of extra beds into ‘single rooms’! Also because the new ward had a high proportion of single rooms, it became a de-facto isolation unit. Two final points, the final study appears to be underpowered based on their own power calculation and the data collection was completed in 2010, a very long time before the article was published. There is no explanation given for this. From the quantitative to the qualitative, the next study, from Infection Control and Hospital Epidemiology, looks to explain the hand hygiene behaviours of doctors: Squires JE, Linklater S, Grimshaw JM et al. (2014) Understanding practice: factors that influence physician hand hygiene compliance. Infection Control and Hospital Epidemiology 35: 1511–1520. This qualitative study, carried out in a large Canadian hospital, sought to look deeper at the reasons why doctors have low hand hygiene compliance rates. As the authors point

Journal of Infection Prevention 16(2) out, this topic has been often investigated among the nursing profession, but less so among doctors. A better understanding of the barriers and enablers of hand hygiene allows infection prevention teams to develop targeted interventions with more pronounced and sustainable effects. In this study, the researchers used a behavioural theory approach – the Theoretical Domains Framework – to construct semistructured interviews carried out with 42 doctors working in medicine and surgery specialties. This comprehensive framework groups together constructs from 33 behaviour change theories, to facilitate their use in implementation research. According to the researchers, this is the first study utilising this framework to identify the determinants of physician hand hygiene compliance. The authors give a detailed description of the study methodology and this helps improve the reader’s confidence in the results. Nine of the 14 theoretical domains were identified as relevant to doctors’ hand hygiene compliance, ranging from individual knowledge and skills to organisational and social influences. Although generally this study reinforces several of those factors already known to be important determinants in influencing hand hygiene behaviours such as availability of hand hygiene resources, work load and knowledge it also highlights other areas to be considered, such as role modelling, positive deviance and also patient involvement. This study reports that although doctors had adequate knowledge of proper hand hygiene technique, they think there is not enough evidence to prove that hand hygiene is effective in preventing healthcare-associated infections. In contrast with findings from similar research among nurses, doctors stated that for them hand hygiene required a conscious decision rather than being a routine and automatic process ingrained in daily practice. Thus reminders in the work place are essential component of hand hygiene interventions. Interestingly, participants also mentioned that their hand hygiene behaviour was influenced both by their colleagues (as has been reported in other research) and also by patients’ expectations. This could indicate that patients are becoming more active participants in their care; indeed several hand hygiene campaigns encourage patients to ask about their healthcare workers’ hand hygiene practice. The findings from this study strengthen the notion that interventions to influence doctors’ hand hygiene behaviours need to be multifaceted. This research is a must-read for anyone seeking to understand the factors influencing doctors’ hand hygiene behaviours in their local context. This piece of work also possibly sets the groundwork for an international multicentre study on understanding the barriers and enablers influencing doctors’ hand hygiene behaviours within different contexts and cultures. The penultimate paper describes a randomised control trial that tries to establish if patient stories have a measureable impact on the behaviours of healthcare workers; Jha V, Buckley H, Gabe R et al. (2015) Patients as teachers: a randomized controlled trial on the use of personal

Wigglesworth and Xuereb stories of harm to raise awareness of patient safety for doctors in training. BMJ Quality and Safety 24: 21–30. Last year’s Francis and Berwick reports highlighted the need for training of healthcare professionals on patient safety. One of the methods used to teach safety issues is the use of patient stories. Patient narratives help ‘communicate meaning’ by evoking an emotional response among learners and hopefully improve attitudes to safety as they show the true impact on the patients and their families’ lives. Infection prevention initiatives have often utilised patient stories to highlight the impact of HCAIs on patients and engage learners. This ambitious randomised control trial (RCT) sought to verify whether the use of patient stories during safety training, actually helps improve healthcare professionals’ behaviours in the clinical context. A total of 283 doctors in their first year of foundation training participated in the study and were randomly assigned into two groups. In the intervention group, participants received teaching facilitated by patients while those in the control arm, received standard faculty-delivered patient safety teaching. The intervention consisted of a presentation by a patient followed by a facilitated discussion between learners and patients with emphasis on analysis of inadequate care and its consequences. Researchers studied participants’ attitudes as an outcome measure since it has been reported that emotions and attitudes influence behaviour directly or indirectly. Two questionnaires addressing patient safety attitudes, mood and emotional engagement were given out to participants before, during and after starting the sessions. The doctors who participated in patient based learning seemed to give more importance to communication with patients and colleagues than doctors in the control group. On the other hand, those who received standard patient safety training seemed to appreciate more the necessity of challenging senior colleagues to prevent errors and of speaking up and honesty after an error has occurred. Still, the study failed to provide any conclusion whether engaging healthcare workers about safety through patient stories will actually translate into improved behaviours in the clinical context. In spite of this conclusion, one cannot dismiss the utility of patient stories. Several issues identified in the study could not be analysed further with the methodology adopted in this study. For example, the researchers noted that the patient stories seemed to trigger both positive and negative attitudes among doctors and could not further explore how this could impact behaviours in the clinical context. Although the authors claim that their study proves that RCTs can be successfully implemented in education research, it seems that topics such as this are more amenable to a qualitative approach. In spite of the allure of RCTs within the medical field it must be

91 acknowledged that not all questions can be best answered through strictly quantitative approaches and better conclusions and understanding can be obtained through qualitative approaches. Continuing the occasional series of ‘and finally’ slightly unusual articles, the last paper in this issue of Journal Watch is a basic primer in mathematical modelling of infection prevention and control. Don’t panic, it’s an optional extra: Doan TN, Kong CM, Kirkpatrick CMJ, et al. (2014) Optimizing hospital infection control: the role of mathematical modelling. Infection Control and Hospital Epidemiology 35: 1521–1530. Many infection prevention practitioners may look at this article and think ‘not for me’, but I would argue that to at least understand the potential applications of mathematical modelling to infection prevention and control (IPC) is useful. To that end this paper gives the reader an essential primer and covers all the basics of the subject. Mathematical modelling allows a researcher to consider issues that are difficult or impossible to test in real-life situations. To give an extreme example, in a model the researcher can ask the hypothetical question ‘what if nobody washed their hands ever?’ – not something that would ever be ethically acceptable in a clinical situation. Of course most models are designed to test more realistic scenarios, e.g. the impact of isolation or increasing (or decreasing) staff/patient ratios; indeed the authors point out that many of the findings from modelling will need to be tested in clinical practice subsequently. The paper explains the essential components of any model for IPC; for example, a patient may be considered to be in a number of states from being susceptible to an infection, through exposure (with or without a latency period), infectious to others and recovered (or removed from the situation, i.e. discharged or died). Taking these states as the basis for modelling, the authors explain the range of models from the most simple to the really quite complicated. Along the way some concepts, such as the basic reproduction number R0, are explained. There is some mathematics (mainly algebra) in the article but you don’t need to understand, or even read, the equations to get some value from reading it. The authors then move on to review the uses of modelling to date in the area of IPC, covering areas such as hand hygiene, staffing levels, screening, antibiotic restrictions and environmental contamination. Don’t be afraid of the maths; this is an interesting read. This issue has shown just a sample of the diversity of infection prevention and control practice, art and science. As always, suggestions for inclusion are very welcome, what article has made an impression on you and your colleagues?

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