bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reducing healthcare-associated infections by improving compliance to aseptic non-touch technique in intravenous line maintenance: a quality improvement approach
Authors: Shettigar Savithri , Somasekhara Aradhya Abhishek , Ramappa Srinath , Reddy Venugopal , Venkatagiri Praveen 
Published: August 2021

BackgroundLack of standardisation and failure to maintain aseptic techniques during procedures contributes to healthcare-associated infections (HCAI). Although numerous procedures are performed in neonatal intensive care units (NICU), handling peripheral intravenous lines is one of the simple and common procedures performed daily. Despite evidence-based care bundle approach variability is higher, and compliance to asepsis is less in routine clinical practice. In this study, we aimed to standardise and improve compliance with Aseptic non-technique (ANTT) in intravenous line maintenance of neonates admitted to NICU to reduce HCAI by 50% over 6 months.MethodsAll nurses were subjects of assessment for compliance with intravenous line maintenance. All admitted neonates with intravenous lines were subjects for the HCAI data collection. At baseline, the current practices for intravenous line maintenance were observed on a generic ANTT audit proforma. Pictorial standard operating procedure (SOP) was developed based on ANTT. Implementation and sustenance were ensured by Plan-Do-Study-Act cycles. Audit data on compliance to ANTT and trends of HCAI rates were displayed using run charts monthly. Qualitative experience from the nursing staff was also recorded.ResultsSignificant improvement was seen in compliance to various components—use of the aseptic field (0% to 100%), closed ports (0% to 100%), key part contamination reduction (80% to 0%), and intravenous hub scrubbing (0% to 72%). SOP of intravenous line maintenance based on ANTT could be implemented and sustained throughout for 9 months. There was a reduction of HCAI from 26 per 1000 patient days to 8 per 1000 patient days. Qualitative experience showed the main determinant of compliance to scrub the hub was the neonate’s sickness level.ConclusionsUsing a quality improvement model of improvement, ANTT in intravenous line maintenance was implemented stepwise. Improving compliance with ANTT principles in intravenous line maintenance reduced HCAI. Scrub the hub requires longer sustained efforts to become part of the practice.
Increasing adherence to plotting e-partograph: a quality improvement project in a rural maternity hospital in India
Authors: Jain Shuchi , Kumar Pramod , Jain Manish , Bathla Megha , Joshi Shiv , Srivastava Sushil , Singh Mahtab , Sudke Ajit , Datta Vikram , Shivkumar Poonam 
Published: August 2021

Abnormal prolonged labour and its effects are important contributors to maternal and perinatal mortality and morbidity worldwide. E-partograph is a modern tool for real-time computerised recording of labour data which improves maternal and neonatal outcome. The aim was to improve the rates of e-partograph plotting in all eligible women in the labour room from existing 30% to achieve 90% in 6 months through a quality improvement (QI) process.A team of nurses, obstetricians, postgraduates and a data entry operator did a root cause analysis to identify the possible reasons for the drop in e-partograph plotting to 30%. The team used process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address the issues identified.The interventions included training labour room staff, identification of eligible women and providing an additional computer and internet facility for plotting and assigning responsibility of plotting e-partographs. We implemented these interventions in five PDSA cycles and observed outcomes by using control charts. A set of process, output and outcome indicators were used to track if the changes made were leading to improvement.The rate of e-partograph plotting increased from 30% to 93% over the study period of 6 months from August 2018 to January 2019. The result has been sustained since the last PDSA cycle. The maternal outcome included a decrease in obstructed and prolonged labour with its associated complications from 6.2% to 2.4%. The neonatal outcomes included a decrease in admissions in the neonatal intensive care unit for birth asphyxia from 8% to 3.4%. It can thus be concluded that a QI approach can help in improving adherence to e-partography plotting resulting in improved maternal health services in a rural maternity hospital in India.
Checklist to aid young physicians managing obstetric emergencies in rural India: a quality improvement initiative
Authors: Puntambekar Varad , Sharma Aparna K , Yadav Kapil , Kumar Rakesh 
Published: August 2021

BackgroundThe decision to admit or refer a patient presenting with an obstetric emergency is extremely crucial. In rural India, such decisions are usually made by young physicians who are less experienced and often miss relevant data points required for appropriate decision making. In our setting, before the quality improvement (QI) initiative, this information was recorded on loose blank sheets (first information sheets (FIS)) where an initial clinical history, physical examination and investigations were recorded. The mean FIS completeness, at baseline, was 73.95% (1–5 January 2020) with none of the FIS being fully complete. Our objective was to increase the FIS completeness to >90% and to increase the number of FIS that were fully complete over a 9-month period.MethodsWith the help of a prioritisation matrix, the QI team decided to tackle the problem of incomplete FIS. The team then used fishbone analysis and identified that the main causes of incomplete FIS were that the interns did not know what to document and would often forget some data points. Change ideas to improve FIS completeness were implemented using Plan-Do-Study-Act (PDSA) cycles, and ultimately, a checklist (referred to as antenatal care (ANC) checklist) was implemented. The study was divided into six phases, and after every phase, a few FIS were conveniently sampled for completeness.ResultsFIS completeness improved to 86.34% (p<0.001) in the post implementation phase (1 Feb to 31 August 2020), and in this phase, 69.72% of the FIS were documented using the ANC checklist. The data points that saw the maximum improvement were relating to the physical examination.ConclusionThe use of ANC checklist increased FIS completeness. Interns with no prior clinical and QI experience can effectively lead and participate in QI initiatives. The ANC checklist is a scalable concept across similar healthcare settings in rural India.
Implementing a three-hourly feeding schedule in stable preterm infants to decrease maternal fatigue
Authors: Aradhya Abhishek S , Kaur Inderjot , Gupta Rima , Kaur Sonaljot , Shrimanth Yamasandi Siddegowda , Masih Parveen Darshan , Kumar Praveen 
Published: August 2021

BackgroundA three-hourly feeding schedule has been shown to be as safe as a two-hourly schedule in preterm neonates. It saves nursing time and may be less tiring for the mothers. However, tradition and apprehensions have prevented its wider acceptance. We used a quality improvement approach to implement a three-hourly feeding schedule in stable preterm infants >32 weeks postmenstrual age (PMA) in our unit through a series of plan–do–study–act (PDSA) cycles.MethodsAll preterm neonates >32 weeks PMA, who were on full enteral feeds and without any respiratory support were eligible. The key quantitative outcome was maternal fatigue score. Safety was assessed in terms of episodes of hypoglycaemia and feed intolerance. Qualitative experiences from nursing staff were captured. The volume of expressed breastmilk and requirement of formula feeds were also recorded. After recording baseline data on a two-hourly feeding schedule, four PDSA cycles were sequentially completed over 21 weeks. The results of each PDSA cycle informed the change strategy for the next cycle.ResultsIn the baseline phase, five neonates on a two-hourly schedule were studied. In PDSA cycles I, II, III and IV, a cumulative of 122 neonates were studied on a three-hourly schedule. There was a significant decrease in median maternal fatigue score (13 (IQR 8–23) to 3 (IQR 1–6); p=0.01)). Only one neonate had feed intolerance, while two had mild asymptomatic transient hypoglycaemia. Six (5%) neonates were shifted to two-hourly feeds temporarily due to transient reasons. Nursing staff felt mothers could devote more time to Kangaroo mother care. The volume of expressed breastmilk and requirement of formula feeds were not different from the three-hourly schedule.ConclusionsIt was possible to change the traditional two-hourly feeding schedule to three-hourly in stable preterm infants using a quality improvement approach, while objectively documenting its safety and benefits.
Advancing emergency airway management by reducing intubation time at a high-volume academic emergency department
Authors: Gopinath Bharath , Sachdeva Seema , Kumar Akshay , Kumar Gaurav 
Published: August 2021

BackgroundAirway management is a life-saving procedure in the emergency department (ED). Hypoxia during rapid sequence intubation (RSI) is associated with high morbidity and mortality.AimTo decrease the median time of intubation (time from administration of paralytic agent to the successful passage of endotracheal tube) by 40% from baseline 300 s in patients undergoing RSI in the ED.MethodsA multidisciplinary quality improvement team worked to improve the airway management. The bottle necks identified using process mapping and fish bone analysis were lack of formal training of residents and nursing officers, and communication gap between residents and nursing officers. Change ideas focused on training residents in laryngoscopy and intubation and nursing officers in facilitating airway management by preparation of drugs and equipment; on-site awareness of logistical issues to the residents and nursing officers, introducing airway drug checklist and ensuring availability of difficult airway equipment.ResultsAfter implementation of change ideas there was a significant reduction in intubation time. At the end of first Plan-Do-Study-Act (PDSA) cycle median intubation time was 165 s (IQR 125 s). By the end of last PDSA cycle, median intubation time reduced to 157 s (IQR 66 s). A shift was obtained on the run chart with a new median time of 141.5 s from mid-PDSA 1. The 8-week data after the end of PDSA 3 showed sustainability with median time of 126 s (IQR 42 s).ConclusionA well organised team effort, simple change ideas such as structured training of residents and nursing officers, introduction of airway drug checklist and improved communication can decrease the intubation time in a chaotic ED.
Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons
Authors: Datta Vikram , Srivastava Sushil , Garde Rahul , Mehta Rajesh , Livesley Nigel , Sawleshwarkar Kedar , Pemde Harish , Patnaik Suprabha K , Sooden Ankur , Singh Mahtab , John Susy Sarah , Pradeep Jeena , Vig Anupa , Kumar Achala , Singh Vivek , Bhatia Vandana , Garg Bishan Singh , Baswal Dinesh 
Published: August 2021

BackgroundInadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020.MethodsA total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the ‘translating research in practice’ framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites.ResultsThree implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region.ConclusionThe development of an implementation framework for POCQI is an essential requirement for the initiative’s successful country-wide scale. The implementation plan should be flexible to the healthcare system’s needs, target population and the implementing agency’s capacity and amenable to multiple iterative changes.
Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study
Authors: Baril Laurence , Nguyen Elisabeth , Dufresne-Santerre Lauralee , Émond Virginie , Émond Marcel , Berthelot Simon , Gagnon Ann-Pier , Nadeau Alexandra , Carmichael Pierre-Hugues , Mercier Eric 
Published: August 2021

BackgroundThis study aimed to assess the level of pain induced by common interventions performed in older adults consulting to the ED.MethodsWe conducted a prospective multicentre observational cohort study in two academic EDs (Quebec City, Canada) between June 2018 and December 2019. A convenience sample of well-oriented and haemodynamically stable older adults (≥65 years old) who underwent at least two interventions during their ED stay was recruited. The level of pain was assessed using an 11-point Numerous Rating Scale (NRS) and is presented using median and IQR or categorised as no pain (0), mild (1–3), moderate (4–6) or severe pain (7–10).ResultsA total of 318 patients were included. The mean age was 77.8±8.0 years old and 54.4% were female . The number of pain assessments per intervention ranged between 22 (urinary catheterisation) and 240 (intravenous catheter). All imaging investigations (X-rays, CT and bedside ultrasound) were associated with a median level of pain of 0. The median level of pain for other interventions was as follows: blood samplings (n=231, NRS 1 (IQR 0–3)), intravenous catheters (n=240, NRS 2 (IQR 0–4)), urinary catheterisations (n=22, NRS 4.5 (IQR 2–6)), cervical collars (n=50, NRS 5 (IQR 0–8)) and immobilisation mattresses (n=34, NRS 5 (IQR 0–8)). Urinary catheterisations (63.8%), cervical collars (56.0%) and immobilisation mattresses (52.9%) frequently induced moderate or severe pain.ConclusionsMost interventions administered to older adults in the ED are associated with no or low pain intensity. However, urinary catheterisation and spinal motion restriction devices are frequently associated with moderate or severe pain.
Suppressor CD4+T cells expressing HLA-G are expanded in the peripheral blood from patients with acute decompensation of cirrhosis
Authors: Khamri Wafa , Gudd Cathrin , Liu Tong , Nathwani Rooshi , Krasniqi Marigona , Azam Sofia , Barbera Thomas , Trovato Francesca M , Possamai Lucia , Triantafyllou Evangelos , Seoane Rocio Castro , Lebosse Fanny , Singanayagam Arjuna , Kumar Naveenta , Bernsmeier Christine , Mukherjee Sujit , McPhail Mark , Weston Chris J , Antoniades Charalambos Gustav , Thursz Mark R 
Published: August 2021

ObjectiveIdentifying components of immuneparesis, a hallmark of chronic liver failure, is crucial for our understanding of complications in cirrhosis. Various suppressor CD4+T cells have been established as potent inhibitors of systemic immune activation. Here, we establish the presence, regulation and mechanism of action of a suppressive CD4+T cell subset expressing human leucocyte antigen G (HLA-G) in patients with acute decompensation of cirrhosis (AD).DesignFlow cytometry was used to determine the proportion and immunophenotype of CD4+HLA-G+T cells from peripheral blood of 20 healthy controls (HCs) and 98 patients with cirrhosis (28 with stable cirrhosis (SC), 20 with chronic decompensated cirrhosis (CD) and 50 with AD). Transcriptional and functional signatures of cell-sorted CD4+HLA-G+cells were delineated by NanoString technology and suppression assays, respectively. The role of immunosuppressive cytokine interleukin (IL)-35 in inducing this population was investigated through in vitro blockade experiments. Immunohistochemistry (IHC) and cultures of primary human Kupffer cells (KCs) were performed to assess cellular sources of IL-35. HLA-G-mediated T cell suppression was explored using neutralising antibodies targeting co-inhibitory pathways.ResultsPatients with AD were distinguished by an expansion of a CD4+HLA-G+CTLA-4+IL-35+immunosuppressive population associated with disease severity, clinical course of AD, infectious complications and poor outcome. Transcriptomic analyses excluded the possibility that these were thymic-derived regulatory T cells. IHC analyses and in vitro cultures demonstrate that KCs represent a potent source of IL-35 which can induce the observed HLA-G+phenotype. These exert cytotoxic T lymphocyte antigen-4-mediated impaired responses in T cells paralleled by an HLA-G-driven downregulation of T helper 17-related cytokines.ConclusionWe have identified a cytokine-driven peripherally derived suppressive population that may contribute to immuneparesis in AD.
Characteristics of infective endocarditis in a cancer population
Authors: Grable Cullen , Yusuf Syed W , Song Juhee , Viola George M , Ulhaq Owais , Banchs Jose , Jensen Corey T , Goel Harsh , Hassan Saamir A 
Published: August 2021

BackgroundInfective endocarditis (IE) is more common in patients with cancer as compared with the general population. Due to an immunocompromised state, the need for invasive procedures, hypercoagulability and the presence of indwelling catheters, patients with cancer are particularly predisposed to the development of IE.ObjectivesLimited information exists about IE in patients with cancer. We aimed to evaluate the characteristics of patients with cancer and IE at our tertiary care centre, including a comparison of the microorganisms implicated and their association with mortality.MethodsA retrospective chart review of patients with cancer who had echocardiography for suspicion of endocarditis was conducted. A total of 56 patients with a confirmed diagnosis of cancer and endocarditis, based on the modified Duke criteria, were included in the study. Baseline demographics, risk factors for developing IE, echocardiography findings, microbiology and mortality data were analysed.ResultsFollowing the findings of vegetations by echocardiography, the median survival time was 8.5 months.Staphylococcus aureuswas the most common organism identified as causing endocarditis. The mitral and aortic valves were the most commonly involved sites of endocarditis. Patients withS. aureusendocarditis (SAE) had a significantly poorer survival when compared with patients without SAE (p=0.0217) over the 12-month period from diagnosis of endocarditis.ConclusionsOverall survival of patients with cancer and endocarditis is poor, with a worse outcome in patients with SAE.
Review of Irish patients meeting ST elevation criteria during the COVID-19 pandemic
Authors: Byrne Luke , Gardiner Roisin , Devitt Patrick , Powell Caleb , Armstrong Richard , Teehan Sinead , O’Connor Stephen 
Published: August 2021

IntroductionThe COVID-19 pandemic has seen the introduction of important public health measures to minimise the spread of the virus. We aim to identify the impact government restrictions and hospital-based infection control procedures on ST elevation myocardial infarction (STEMI) care during the COVID-19 pandemic.MethodsPatients meeting ST elevation criteria and undergoing primary percutaneous coronary intervention from 27 March 2020, the day initial national lockdown measures were announced in Ireland, were included in the study. Patients presenting after the lockdown period, from 18 May to 31 June 2020, were also examined. Time from symptom onset to first medical contact (FMC), transfer time and time of wire cross was noted. Additionally, patient characteristics, left ventricular ejection fraction, mortality and biochemical parameters were documented. Outcomes and characteristics were compared against a control group of patients meeting ST elevation criteria during the month of January.ResultsA total of 42 patients presented with STEMI during the lockdown period. A significant increase in total ischaemic time (TIT) was noted versus controls (8.81 hours (±16.4) vs 2.99 hours (±1.39), p=0.03), with increases driven largely by delays in seeking FMC (7.13 hours (±16.4) vs 1.98 hours (±1.46), p=0.049). TIT remained significantly elevated during the postlockdown period (6.1 hours (±5.3), p=0.05), however, an improvement in patient delays was seen versus the control group (3.99 hours (±4.5), p=0.06). There was no difference seen in transfer times and door to wire cross time during lockdown, however, a significant increase in transfer times was seen postlockdown versus controls (1.81 hours (±1.0) vs 1.1 hours (±0.87), p=0.004).ConclusionA significant increase in TIT was seen during the lockdown period driven mainly by patient factors highlighting the significance of public health messages on public perception. Additionally, a significant delay in transfer times to our centre was seen postlockdown.
Prominent juxtacortical white matter lesion hallmarksNOTCH3-related intracerebral haemorrhage
Authors: Chen Chih-Hao , Hsu Hao-Chia , Cheng Yu-Wen , Chen Ya-Fang , Tang Sung-Chun , Jeng Jiann-Shing 
Published: August 2021

Background and purposeNOTCH3p.R544C mutation accounts for 5% of spontaneous intracerebral haemorrhage (ICH) in East Asian patients. We investigated whether certain CT features are associated withNOTCH3-related ICH.MethodsPatients with spontaneous ICH from a prospective stroke registry were screened forNOTCH3p.R544C mutation. The neuroimaging features on the initial non-contrast CT scans selected to predictNOTCH3p.R544C mutation, including burden of white matter lesion (WML), degree of brain atrophy, number of lacunes, prominent juxtacortical WML and prominent lobar lacunes, were analysed by neuroradiologists blinded to the mutation status.ResultsOf 299 patients with spontaneous ICH (mean age, 61 years; male, 68%; ICH volumes, 14.1±17.8 mL), 13 patients (4.3%) carriedNOTCH3p.R544C mutation. The clinical features, haematoma size and location were similar betweenNOTCH3p.R544C mutation carriers and non-carriers. The CT scan revealed that patients withNOTCH3p.R544C mutation had more severe WML and more frequently had prominent juxtacortical WML (69.2% vs 17.8%, p<0.001), and the effects were not driven by ageing as seen in patients without mutation. Prominent juxtacortical WML (area under receiver operating characteristic curve=0.76) outperformed the total WML score and prominent lobar lacunes and significantly predictedNOTCH3p.R544C mutation in a multivariable-adjusted model (OR, 20.9; 95% CI 4.94 to 88.6).ConclusionIn patients with spontaneous ICH, the severity and topographic distribution of WML can help in identifying potentialNOTCH3mutation-related ICH.