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Introduction: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted., Objective: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research., Methods: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed., Results: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement . Most studies reported activities from multiple categories. Implementation factors included: c linical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation . Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread . Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities., Conclusions: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice., Competing Interests: Competing interests: All authors have completed the ICMJE form for disclosure of competing interests. JTO, ES, SH, HVW have been supported in their work on this paper by grants from the Research Council of Norway, the Western Norway Regional Health Authority, and the Bergen Hospital Trust. MH has been supported in her work on this paper by grants from the Research Council of Norway, and by employment as a researcher by the Fonna Hospital Trust. SH has headed the reference group for the Norwegian Patient Safety Campaign (2011–2014, honorary without payment), and is a paid member of the Regional Committee for Medical Ethics since 2021. PEA has coauthored this paper as part of his work at the Norwegian Centre for Antiobiotic Use in Hospitals, Haukeland University Hospital. He is also an editor of the national guidelines for antibiotic use in hospitals, member of the editorial board of the national guidelines for antibiotic use in primary care, and member of the national breakpoint committee, all without extra funding, as part of his ordinary work. NS has recieved consulting fees as director of London Safety and Training Solutions. RKL has coauthored this paper salaried as an academic librarian at the University of Bergen., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Despite malnutrition being established as a well-known risk for postoperative complications, the lack of screening for nutritional risk remains a challenge. The aim of this study was to investigate whether self-screening for nutritional risk prior to surgery is feasible in a home setting and if it will increase number of patients screened for nutritional risk, and secondly, to compare their screening results with the "in-hospital assessments" conducted by healthcare professionals., Materials and Methods: This was a prospective study involving patients from six randomly selected surgical wards at two Norwegian hospitals as a part of the "Feasibility study of implementing the surgical Patient Safety Checklist the (PASC)". This checklist included a self-reported screening tool based on the Nutritional Risk Screening tool (NRS 2002) to identify "at risk of malnutrition" in patients that will undergo surgery the next 3 months or less. The original screening tool (NRS 2002) was used as a standard routine to identify "at risk of malnutrition" by healthcare professionals at hospital. The interrater reliability between these results was investigated using Fleiss multi rater Kappa with overall agreement and reported with Landis and Koch's grading system (poor, slight, fair, moderate, substantial, and almost perfect)., Results: Out of 215 surgical patients in the home setting, 164 (76.7%) patients completed the self-reported screening tool. A total of 123 (57.2%) patients were screened in-hospital, of whom 96 (44.7%) prior to surgery and 96 (44.7%) were screened both at hospital (pre- and post-surgery) and at home. Self-screening at home improved malnutrition screening participation by 71.9% compared to hospital screening prior to surgery (165 (76.7%) and 96 (44.7%), respectively) and by 34.1% compared to pre- and postoperative in-hospital screening, 165 (76.7%) and 123 (57.2%), respectively). The degree of agreement between patients identified to be "at risk of malnutrition" by the self-reported screening tool and healthcare professionals was poor (κ = - 0.04 (95% CI: -0.24, 0.16), however, the degrees of agreement between the patients and healthcare professionals answers to the initial NRS 2002 questions "low BMI", "weight loss", and "reduced food intake" were almost perfect (κ = 1.00 (95% CI: 0,82, 1.18)), moderate (κ = 0.55 (95% CI: 0.34, 0.75)), and slight (κ = 0.08 (95% CI: - 0.10, 0.25) respectively., Conclusions: Three out of four patients completed the self-screening form and the preoperative screening rate improved with 70%. Preoperatively self-screening in a home setting may be a feasible method to increase the number of elective surgical patients screened for risk of malnutrition., Trial Registration: The trial is registered in ClinicalTrials.gov ID NCT03105713. https://classic.clinicaltrials.gov/ct2/show/NCT03105713., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: ASH has previously received travel re-imbursement for representing the International Federation of Nurse Anaesthetists in the European Society of Anaesthesiology and Intensive Care’s Patient Quality and Safety Committee. All the other authors have declared that no competing interests exist.This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Tangvik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The World Health Organization's Global Patient Safety Action Plan 2021-2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients' involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients' completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial., Methods: This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis., Results: Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway., Conclusions: Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety., Trial Registration: Clinicaltrials.gov: NCT03105713. Registered 10.04.2017., (© 2023. The Author(s).)

Background: Humans struggle to grasp the extent of exponential growth, which is essential to comprehend the spread of an infectious disease. Exponential growth bias is the tendency to linearize exponential functions when assessing them intuitively. Effective public health communication about the nonlinear nature of infectious diseases has strong implications for the public's compliance with strict restrictions. However, there is a lack of synthesized knowledge on the communication of the exponential growth of infectious diseases and on the outcomes of exponential growth bias., Objective: This systematic review identifies, evaluates, and synthesizes the findings of empirical studies on exponential growth bias of infectious diseases., Methods: A systematic review will be conducted using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 statement. Eligibility criteria include empirical studies of exponential growth bias of infectious diseases regardless of methodology. We include studies both with and without interventions/strategies. For information sources, we include the following five bibliographic databases: MEDLINE, Embase, Cochrane Library, PsychINFO, and Web of Science Core Collection. The risk of bias will be assessed using RoB 2 (Risk of Bias 2) and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Data synthesis will be achieved through a narrative synthesis., Results: By February 2022, we included 11 experimental studies and 1 cross-sectional survey study. Preliminary themes identified are the presence of exponential growth bias, the effect of exponential growth bias, and communication strategies to mitigate exponential growth bias. Data extraction, narrative synthesis, and the risk of bias assessment are to be completed by February 2023., Conclusions: We anticipate that this systematic review will draw some lines related to how people comprehend and misperceive exponential growth and its consequences for infectious disease mitigation and communication. Furthermore, the study will conclude with the limitations of the research and suggestions for future research., International Registered Report Identifier (irrid): DERR1-10.2196/37441., (©Siv Hilde Berg, Daniel Adrian Lungu, Kolbjørn Brønnick, Stig Harthug, Jo Røislien. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 24.10.2022.)

Purpose: To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in-hospital antibiotic exposure compared to children from the general population that had not received antibiotics in-hospital., Methods: Explorative data-linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in-Hospital (H+), and one group had not received antibiotics in-hospital (H-). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H- group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation., Results: Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H- group, relative risk (RR) 2.88 (95% confidence interval 2.38-3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H- group, RR 2.77 (2.30-3.33). Comorbidity-adjusted RR was 2.30 (1.84-2.86) before and 2.25 (1.81-2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99-3.26) in children 3 months-2 years, 4.03 (2.84-5.71) in children 3-12 years and 2.07 (1.33-3.20) in children 13-17 years., Conclusions: Children exposed to antibiotics in-hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in-hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs., (© 2022 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.)

Objectives: To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life., Methods: Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases., Results: Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1-2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9-2.2)]. The recurrence use rate in exposed term infants (≥37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4-3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2-3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6-4.9)]., Conclusions: Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity., (© The Author(s) 2022. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Objectives: To evaluate cost-effectiveness of the WHO Surgical Safety Checklist., Background: The clinical effectiveness of surgical checklists is largely understood. Few studies to-date have evaluated the cost-effectiveness of checklist use., Methods: An economic evaluation was carried out using data from the only available randomized controlled trial of the checklist. Analyses were based on 3702 procedures. Costs considered included checklist implementation costs and length and cost of hospital stay, costs of warming blanket use, blood transfusions and antibiotics used in the operating room, and the cost of clinical time in the operating room - all calculated for each procedure and its associated admission. Nonparametric bootstrapping was used to simulate an empirical distribution of the mean effect of the checklist on total admission costs and the probability of observing a complication-free admission and to quantify sampling uncertainty around mean cost estimates., Results: The overall cost of checklist implementation was calculated to be $900 per 100 admissions. Implementation of the WHO checklist resulted in an additional 5.9 complication-free admissions per 100 admissions and an average of 110 bed-days saved per 100 admissions. Accounting for all costs included in the analysis, for every 100 admissions, use of the WHO checklist was estimated to save $55,899., Conclusions: Implementation of the WHO checklist was a cost-effective strategy for improving surgical safety., Competing Interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organizations. ASH is member of the European Society of Anesthesiologists’ Patient Safety & Quality Committee (ESA PSQC) as representative for the International Federation of Nurse Anaesthetists (IFNA). The other authors have no conflicts of interest to declare., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Poor uptake and understanding of critical perioperative information represent a major safety risk for surgical patients. Implementing a patient-driven surgical safety checklist might enhance the way critical information is given and increase patient involvement in their own safety throughout the surgical pathway. The aim of this study was to develop and validate a Surgical Patient Safety Checklist (PASC) for use by surgical patients., Method: This was a prospective study, involving patient representatives, multidisciplinary healthcare professionals and elective surgical patients to develop and validate PASC using consensus-building techniques in two Norwegian hospitals. A set of items intended for PASC were rated by patients and then submitted to Content Validation Index (CVI) analyses. Items of low CVI went through a Healthcare Failure Mode and Effect Analysis (HFMEA) Hazard Scoring process, as well as a consensus process before they were either kept or discarded. Reliability of patients' PASC ratings was assessed using Intraclass Correlation Coefficient analysis. Lastly, the face validity of PASC was investigated through focus group interviews with postoperative patients., Results: Initial development of PASC resulted in a checklist consisting of two parts, one before (32 items) and one after surgery (26 items). After achieving consensus on the PASC content, 215 surgical patients from six surgical wards rated the items for the CVI analysis on a 1-4 scale and mostly agreed on the content. Five items were removed from the checklist, and six items were redesigned to improve PASCs' user-friendliness. The total Scale-level index/Average (S-CVI/Ave) before revision was 0.83 and 0.86 for pre- and post-operative PASC items, respectively. Following revision, these increased to 0.86 and 0.93, respectively. The PASC items reliability score was 0.97 (95% confidence interval 0.96 to 0.98). The qualitative assessment identified that patients who used PASC felt more in control of their situation; this was achieved when PASC was given to them at what they felt was the right time and healthcare professionals took part in its usage., Conclusion: Multidisciplinary perioperative care staff and surgical patients agreed upon PASC content, the checklist ratings were reliable, and qualitative assessment suggested good face validity. PASC appears to be a usable and valid checklist for elective surgical patients across specialties., (© 2022. The Author(s).)

Background & Aims: Being "at risk of malnutrition", which includes both malnutrition and the risk to be so, is associated with increased morbidity and mortality in both surgical and non-surgical patients. Several strategies and guidelines have been introduced to prevent and treat this, but the effects are scarcely investigated. This study aims to evaluate the long-term effects of these efforts by examining trends concerning: 1) the prevalence of patients «at risk of malnutrition» and 2) the use of nutritional support and diagnostic coding related to malnutrition over an 11-year period in a large university hospital. Moreover, we wanted to investigate if there was a difference in trends between surgical and non-surgical patients., Methods: From 2008 to 2018, Haukeland University Hospital, Norway, conducted 34 point-prevalence surveys to investigate the prevalence of patients «at risk of malnutrition», as defined by Nutritional Risk Screening 2002, and the use of nutritional support at the hospital. Diagnostic coding included ICD-10 codes related to malnutrition (E43, E44 and E46) at hospital discharge, which were extracted from the electronic patient journal. Trend analysis by calendar year was investigated using logistic regression models with and without adjustment for age (continuous), gender (male/female) and Charlson Comorbidity Index (none, mild, moderate or severe)., Results: The number of patients included in the study was 18 933, where 52.1% were male and the median (25th, 75th percentile) age was 65 (51, 76) years. Of these, 5121 (27%) patients were identified to be «at risk of malnutrition». Fewer surgical patients (21.2%) were «at risk of malnutrition», as compared to non-surgical patients (30.9%) (p < 0.001). Adjusted trend analysis did not identify any change in the prevalence of patients «at risk of malnutrition» from 2008 to 2018. The percentage of patients «at risk of malnutrition» who received nutritional support increased from 61.6% in 2008 to 71.9% in 2018 (p < 0.001), with a range from 55.6 to 74.8%. This trend was seen for both surgical and non-surgical patients (p < 0.001 for both). Similarly, dietitians were more involved in the patients' treatment (range: 3.8-16.7%), and there was increased use of ICD-10 codes related to malnutrition during the study period (range: 13.0-41.8%) (p < 0.001). These trends were seen for both surgical patients and non-surgical patients (p < 0.001), despite use being less common for surgical patients, as compared to non-surgical patients (p < 0.001)., Conclusions: This large hospital study shows no apparent change in the prevalence of patients «at risk of malnutrition» from 2008 to 2018. However, more patients «at risk of malnutrition», both surgical and non-surgical, received nutritional support, treatment from a dietitian and a related ICD-10 code over the study period, indicating improved nutritional routines as a result of the implementation of nutritional guidelines and strategies., Competing Interests: Conflicts of interest The authors declare that they do not have any conflict of interest., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Implementation of antibiotic stewardship programmes (ASPs) in hospitals is challenging and there is a knowledge gap on how to pursue this process efficiently., Objectives: To evaluate whether audit and feedback (A&F) is a feasible and useful methodology to assess and support the implementation of ASPs in hospitals., Methods: A multidisciplinary team performed document reviews and on-site interviews with professionals involved in the implementation of ASPs. Oral feedback on preliminary findings and areas of improvement were provided on-site, followed by feedback reports summarizing major findings and recommendations. Descriptive statistics were used to present number of hospital trusts, interviewees, professions, disciplines, workload and costs., Results: All 22 hospital trusts in Norway participated in the A&F conducted October 2017 to April 2019. Altogether, 446 leaders and healthcare workers were interviewed: 110 leaders, 336 health professionals of whom 89 were antimicrobial stewardship team members. Median number of days from audits were performed till reporting were 36 (IQR 30-49). Median workload for auditors per visit was 7 days (6-8). Total costs were €133 952. Main audit findings were that ASP structures were established in most hospital trusts, but leadership commitment and implementation of interventions were often lacking. The hospital trusts received feedback on establishing governance structures, setting local targets, implementing interventions and increased involvement of nurses., Conclusions: Nationwide A&F provides a unique and comprehensive insight into the implementation of ASPs in hospitals and is feasible with a reasonable amount of resources. This approach can identify targets for improved implementation of ASPs in hospitals., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Objective: To describe epidemiology and antimicrobial susceptibility testing (AST) data of bacteria causing invasive infections in Norwegian children (0-18 years)., Methods: Population-based observational study using prospectively collected AST data from the Norwegian Surveillance System of Antimicrobial Resistance from 2013 to 2017. We included all clinically relevant bacterial isolates (blood and cerebrospinal fluid), and compared incidence of invasive infections and AST data in isolates from children and adults., Results: We included 1173 isolates from children and 44,561 isolates from adults. Staphylococcus aureus accounted for 220/477 (46.2%, 95% CI: 41.6-50.7) of all isolates in schoolchildren (6-18 years). Compared with Streptococcus pneumonia isolates from adults (N = 2674), we observed higher nonsusceptibility rates to penicillin in isolates from children (N = 151), 11.9% versus 5.8%, P < 0.01; also higher resistance rates to erythromycin (11.3% vs. 4.9%, P < 0.01), clindamycin (9.3% vs. 3.6%, P < 0.001), and trimethoprim/sulfamethoxazole (17.9% vs. 6.4%, P < 0.001). Compared with Escherichia coli isolates in adults (N = 9073), we found lower rates of ESBL in isolates from children (N = 212), 2.4% versus 6.4%, P < 0.05., Conclusion: The study indicates the importance of microbiologic surveillance strategies in children and highlights the need for pediatric AST data. The high rates of nonsusceptibility to commonly used antibiotics among S. pneumoniae in children and the high burden of invasive S. aureus infections in schoolchildren calls for modifications of Norwegian guidelines., Competing Interests: The authors have no conflicts of interests to declare., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the effects of external inspections on (1) hospital emergency departments' clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality., Design: Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis., Setting: Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals., Participants: 7407 patients presenting to hospital emergency departments with sepsis., Intervention: External inspections of sepsis detection and treatment led by a public supervisory institution., Main Outcome Measures: Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality., Results: After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time., Conclusions: External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients., Trial Registration: NCT02747121., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases., Methods: We conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression., Results: Through analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline (OR = 1.44 95% CI 1.04, 2.00), 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy (between hospitals and ER versus ward) and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge., Conclusions: Analysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals.

Objectives: Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel's safety culture perceptions., Setting: A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital., Participants: We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017., Primary and Secondary Outcome Measures: Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded., Results: Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ' Hospital managers' support to patient safety ' from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07-0.21)., Conclusion: The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture., Competing Interests: Competing interests: ASH represent the IFNA in the ESA Patient Safety and Quality Committee. NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisation globally. The other authors report no conflicts of interest. SH had a role as lead of the Scientific Advisory Board appointed by the Norwegian Directorate of Health 2011–2013. IFNA, ESA, London Safety and Training Solutions Ltd., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background & Aims: Although malnutrition is thought to be common among patients with intraabdominal diseases and is recognized as a risk factor for postoperative complications, diagnostic criteria for malnutrition have not been consistent. Thus, the Global Leadership Initiative in Malnutrition (GLIM) has recently published new criteria for malnutrition. The aims of this study were to investigate the prevalence of malnutrition according to weight loss and BMI criteria in GLIM's second step for the diagnosis and their association with severe postoperative complications in patients undergoing gastrointestinal resections., Method: The current study includes adult patients who were prospectively included in the Norwegian Registry for Gastrointestinal Surgery in the period between 2015 and 2018. Exclusion criteria were acute surgery and lack of information regarding preoperative weight and/or postoperative complications. Severe surgical complications were classified according to the Revised Accordion Classification system and malnutrition with the GLIM criteria. Associations were assessed by logistic regression analyses, and the adjusted odds ratio included age (continuous), gender (male/female) and scores from the American Society of Anesthesiologists Physical Status Classification System and the Eastern Cooperative Oncology Group., Results: Out of 6110 patients, 2161 (35.4%) were classified as with malnutrition, 1206 (19.7%) with moderate and 955 (15.6%) with severe malnutrition. Malnourished patients were 1.29 (95% CI: 1.13-1.47) times more likely to develop severe surgical complications, and 2.15 (95% CI: 1.27-3.65) times more likely to die within 30 days, as compared to those who were not., Conclusion: Preoperative malnutrition is common among patients having gastrointestinal resections and is associated with an increased risk of severe surgical complications., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staff's perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored - yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies., Methods: An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis., Results: We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSC's practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded., Conclusion: When the SSC is not integrated within existing risk management strategies, but perceived as an "add on", its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.

Background: Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality., Methods: This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses., Results: Of the study patients, 72.9% (CI 70.7-75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4-47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4-46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2-27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1-17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8-9.1), and 4 hours or later after admission 10.5% (5.7-15.3)., Conclusions: Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis., Competing Interests: The authors have declared that no competing interests exist.

Background: Patients' involvement in patient safety has increased in healthcare. Use of checklists may improve patient outcome in surgery, though few have attempted to engage patients' use of surgical checklist. To identify risk elements of complications based on patients' and healthcare workers' experiences is warranted. This study aims to identify what the patients and healthcare workers find to be the risk elements that should be included in a patient-driven surgical patient safety checklist., Method: A qualitative study design where post-operative patients, surgeons, ward physicians, ward nurses, and secretaries from five surgical specialties took part in focus group interviews. Eleven focus groups were conducted including 25 post-operative patients and 27 healthcare workers at one tertiary teaching hospital and one community hospital in Norway. Based on their experiences, participants were asked to identify perceived risks before and after surgery. The interviews were analysed using content analysis., Results: Safety risk factors were categorised as pre-operative information: pre-operative preparations, post-operative information, post-operative plans and follow-up. The subcategories under pre-operative information and preparations were: contact information, medication safety, health status, optimising health, dental status, read information, preparation two weeks before surgery, inform your surgical ward, planning your own discharge, preparation on admission and just before surgery. The subcategories under post-operative information, further plans and follow-up were: prevention and complications, restriction and activity, medication safety, pain relief, stomach functions, further care and appointments. Both healthcare workers and patients express the need for a surgical patient safety checklist., Conclusion: A broad spectre of risk elements for a patient safety checklist were identified. Developing a surgical safety checklist based on these risk elements might reduce complications and unwanted errors., Trail Registration: The study is registered as part of a clinical trial in ClinicalTrials.gov: NCT03105713.

Background: Discharge conversation is an essential part of preparing patients for the period after hospitalisation. Successful communication during such conversations is associated with improved health outcomes for patients., Objective: To investigate the association between discharge conversation and discharge quality assessed by measuring elderly patients' experiences., Methods: In this cross-sectional study, we surveyed all patients ≥65 years who had been discharged from two medical units in two hospitals in Western Norway 30 days prior. We measured patient experiences using two previously validated instruments: The Discharge Care Experiences Survey Modified (DICARES-M) and The Nordic Patient Experiences Questionnaire (NORPEQ). We examined differences in characteristics between patients who reported having a discharge conversation with those who did not, and used regression analyses to examine the associations of the DICARES-M and NORPEQ with the usefulness of discharge conversation., Results: Of the 1418 invited patients, 487 (34%) returned the survey. Their mean age was 78.5 years (SD=8.3) and 52% were women. The total sample mean scores for the DICARES-M and NORPEQ were 3.9 (SD=0.7, range: 1.5-5.0) and 4.0 (SD=0.7, range: 2.2-5.0), respectively. Higher DICARES-M and NORPEQ scores were found for patients who reported having a discharge conversation (74%) compared with those who did not (15%), or were unsure (11%) whether they had a conversation (p<0.001). Patients who considered the conversation more useful had significantly higher scores on both the DICARES-M and NORPEQ (p<0.001)., Conclusions: Reported discharge conversation at the hospital was correlated with positive patient experiences measurements indicating the increased quality of hospital discharge care. The reported usefulness of the conversation had a significant association with discharge care quality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Discharge Care Experiences Survey (DICARES) was previously developed to measure quality of discharge care in elderly patients (≥ 65 years). The objective of this study was to test the factorial validity of responses of the DICARES, and to investigate its association with existing quality indicators., Methods: We conducted a cross-sectional study at two hospitals in Bergen, Western Norway. A survey, including DICARES, was sent by postal mail to 1,418 patients 30 days after discharge from hospital. To test the previously identified three-factor structure of the DICARES we applied a first order confirmatory factor analysis with corresponding fit indices and reliability measures. Spearman's correlation coefficients, and linear regression, was used to investigate the association of DICARES scores with the quality indicators Nordic Patient Experiences Questionnaire and emergency readmission within 30 days., Results: A total of 493 (35%) patients completed the survey. The mean age of the respondents was 79 years (SD = 8) and 52% were women. The confirmatory factor analysis showed acceptable fit. Cronbach's α between items within factors was 0.82 (Coping after discharge), 0.71 (Adherence to treatment), and 0.66 (Participation in discharge planning). DICARES was moderately correlated with the Nordic Patient Experiences Questionnaire (rho = 0.49, P < 0.001). DICARES overall score was higher in patients with no readmissions compared to those who were emergency readmitted within 30 days (P < 0.001), indicating that more positive experiences were associated with fewer readmissions., Conclusions: DICARES appears to be a feasible instrument for measuring quality of discharge care in elderly patients (≥ 65 years). This brief questionnaire seems to be sensitive with regard to readmission, and independent of comorbidity. Further studies of patients' experiences are warranted to identify elements that impact on discharge care in other patient groups., Competing Interests: The authors have declared that no competing interests exist.

Objective: Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working., Design: An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted., Setting: Operating theatres with different surgical specialities, in three Norwegian hospitals., Participants: Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy., Results: Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC., Conclusion: Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention., Competing Interests: Competing interests: NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisation globally., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinical antibiotic prescribing guidelines are essential in defining responsible use in the local context. Our objective was to investigate the association between adherence to national antibiotic prescribing guidelines and patient outcomes across a wide range of infectious diseases in hospital inpatients., Methods: Over five months in 2014, inpatients receiving antibiotics under the care of pulmonary medicine, infectious diseases and gastroenterology specialties across three university hospitals in Western Norway were included in this observational cohort study. Patient and antibiotic prescribing data gathered from electronic medical records included indication for antibiotics, microbiology test results, discharge diagnoses, length of stay (LOS), comorbidity, estimated glomerular filtration rate (eGFR) on admission and patient outcomes (primary: 30-day mortality; secondary: in-hospital mortality, 30-day readmission and LOS). Antibiotic prescriptions were classified as adherent or non-adherent to national guidelines according to documented indication for treatment. Patient outcomes were analysed according to status for adherence to guidelines using multivariate logistic, linear and competing risk regression analysis with adjustments made for comorbidity, age, sex, indication for treatment, seasonality and whether the patient was admitted from an institution or not., Results: In total, 1756 patients were included in the study. 30-day-mortality and in-hospital mortality were lower (OR = 0.48, p  = 0.003 and OR = 0.46, p  = 0.001) in the guideline adherent group, compared to the non-adherent group. Adherence to guideline did not affect 30-day readmission. In linear regression analysis there was a trend towards shorter LOS when LOS was analysed for patients discharged alive (predicted mean difference - 0.47, 95% CI (- 1.02, 0.07), p  = 0.081). In competing risk analysis of LOS, the adherent group had a subdistribution hazard ratio (SHR) of 1.17 95% CI (1.02, 1.34), p  = 0.025 for discharge compared to the non-adherent group., Conclusions: Adhering to antibiotic guidelines when treating infections in hospital inpatients was associated with favourable patient outcomes in terms of mortality and LOS., Competing Interests: The study was conducted in accordance with the Declaration of Helsinki, national and institutional standards [28]. The study was approved by the local data protection officer (2013/9352) and the regional ethical committee approved the waiver of informed consent (2013/1305). All patients were informed in writing about the study taking place and given the opportunity to withdraw.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Effective use of microbiology test results may positively influence patient outcomes and limit the use of broad-spectrum antibiotics. However, studies indicate that their potential is not fully utilized. We investigated microbiology test ordering practices and the use of test results for antibiotic decision-making in hospitals., Methods: A multicentre cohort study was conducted during five months in 2014 in Medical departments across three hospitals in Western Norway. Patients treated with antibiotics for sepsis, urinary tract infections, skin and soft tissue infections, lower respiratory tract infections or acute exacerbations of chronic obstructive pulmonary disease were included in the analysis. Primary outcome measures were degree of microbiology test ordering, compliance with microbiology testing recommendations in the national antibiotic guideline and proportion of microbiology test results used to inform antibiotic treatment. Data was obtained from electronic- and paper medical records and charts and laboratory information systems., Results: Of the 1731 patient admissions during the study period, mean compliance with microbiology testing recommendations in the antibiotic guideline was 89%, ranging from 81% in patients with acute exacerbations of chronic obstructive pulmonary disease to 95% in patients with sepsis. Substantial additional testing was performed beyond the recommendations with 298/606 (49%) of patients with lower respiratory tract infections having urine cultures and 42/194 (22%) of patients with urinary tract infections having respiratory tests. Microbiology test results from one of the hospitals showed that 18% (120/672) of patient admissions had applicable test results, but only half of them were used for therapy guidance, i.e. in total, 9% (63/672) of patient admissions had test results informing prescription of antibiotic therapy., Conclusions: This study showed that despite a large number of microbiology test orders, only a limited number of tests informed antibiotic treatment. To ensure that microbiology tests are used optimally, there is a need to review the utility of existing microbiology tests, test ordering practices and use of test results through a more targeted and overarching approach., Competing Interests: The Western Regional Committee for Medical and Health Research Ethics in Norway assessed the study, and concluded that no ethical approval was needed. The Committee approved the waiver of informed consent on the condition that all patients received written information about the study, with opportunity to withdraw from it (2013/1305). Data collection was also approved by The Data Protection Officer at all three hospitals (2013/9352).Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objective: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications., Background: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement., Methods: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ test and binary logistic regression., Results: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38-0.72) for intervention procedures, 0.54 (95% CI: 0.37-0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11-0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC., Conclusions: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

Background: A review of the literature reveals a lack of validated instruments that particularly measure quality in the hospital discharge process. This study aims to develop and validate a survey instrument feasible for measuring quality (≥65 years) related to the discharge process based on elderly patients' experiences., Methods: Construction of the Discharge Care Patient Experience Survey (DICARES) was based on 16 items identified by literature reviews. Intraclass correlation for test-retest was applied to assess consistency of the survey. Explorative factors analysis was applied to identify and validate the factor structures of the DICARES. Cronbach's α was used to assess internal reliability. To evaluate the external validity of the final DICARES questionnaire the patients' scores were correlated with scores obtained from the three other questionnaires; the Nordic Patient Experiences Questionnaire, the 12-Item Short-Form Health Survey and Subjective Health Complaints. The DICARES association with readmissions was examined., Results: A total of 270 patients responded (64.4%). The mean age of participants was 77.1 years and 57.8% were men. The exploratory factor analysis resulted in a 10-item instrument consisting of three factors explaining 63.5% of the total variance. The Cronbach's α were satisfactory (≥70). Overall intraclass correlation was 0.76. A moderate Spearman correlation (rho = 0.54, p <0.01) was found between the total mean DICARES score and total mean score of the Nordic Patient Experiences Questionnaire. The total mean DICARES score was inversely associated with the quality indicator based on readmissions (OR 0.62, CI 95: 0.41-0.95, p = 0.028)., Conclusion: We have developed a 10-item questionnaire consisting of three factors which may be a feasible instrument for measuring quality of the discharge process in elderly patients. Further testing in a wider population should be carried out before implementation in health care settings., Competing Interests: The authors have declared that no competing interests exist.

Background: There is limited evidence from multicenter, randomized controlled studies to inform planning and implementation of antibiotic stewardship interventions in hospitals., Methods: A cluster randomized, controlled, intervention study was performed in selected specialities (infectious diseases, pulmonary medicine and gastroenterology) at three emergency care hospitals in Western Norway. Interventions applied were audit with feedback and academic detailing. Implementation strategies included co-design of interventions with stakeholders in local intervention teams and prescribers setting local targets for change in antibiotic prescribing behaviour. Primary outcome measures were adherence to national guidelines, use of broad-spectrum antibiotics and change in locally defined targets of change in prescribing behaviour. Secondary outcome measures were length of stay, 30-day readmission, in-hospital- and 30-day mortality., Results: One thousand eight hundred two patients receiving antibiotic treatment were included. Adherence to guidelines had an absolute increase from 60 to 66% for all intervention wards ( p  = 0.04). Effects differed across specialties and pulmonary intervention wards achieved a 14% absolute increase in adherence ( p  = 0.003), while no change was observed for other specialties. A pulmonary ward targeting increased use of penicillin G 2 mill IU × 4 for pneumonia and COPD exacerbations had an intended increase of 30% for this prescribing behaviour ( p  < 0.001)., Conclusions: Pulmonary wards had a higher increase in adherence, independent of applied intervention. The effect of antibiotic stewardship interventions is dependent on how and in which context they are implemented. Additional effects of interventions are seen when stakeholders discuss ward prescribing behaviour and agree on specific targets for changes in prescribing practice., Competing Interests: The study was conducted in accordance with the Declaration of Helsinki, national and institutional standards [27]. The study was approved by the Data Protection Officer (2013/9352) and the Western Regional Committee for Medical and Health Research Ethics approved the waiver of informed consent (2013/1305). All patients received written information about the study, with opportunity to withdraw from the study. The study was not registered in a clinical trial database as randomization was conducted at cluster level only, with primary aim of investigating the effect of interventions on ward prescribing behaviour. Individual patient treatment was at the discretion of the treating physician.Not applicableJ.S.W received a 3-month grant in patient safety research for preparation of the manuscript, but the funder has not played any role in the design, execution, analysis or reporting of the research. Competing interests for other authors: None to declare.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Surgical site infections (SSI) are amongst the most common health care-associated infections and have adverse effects for patient health and for hospital resources. Although surgery guidelines recognize poor nutritional status to be a risk factor for SSI, they do not tell how to identify this condition. The screening tool Nutritional Risk Screening 2002 is commonly used at hospitals to identify patients at nutritional risk. We investigated the association between nutritional risk and the incidence of SSI among 1194 surgical patients at Haukeland University Hospital (Bergen, Norway). This current study combines data from two mandatory hospital-based registers: a) the incidence of SSI within 30 days after surgery, and b) the point-prevalence of patients at nutritional risk. Patients with more than 30 days between surgery and nutritional risk screening were excluded. Associations were assessed using logistic regression, and the adjusted odds ratio included age (continuous), gender (male/female), type of surgery (acute/elective) and score from The American Society of Anesthesiologists Physical Status Classification System. There was a significant higher incidence of SSI among patients at nutritional risk (11.8%), as compared to those who were not (7.0%) (p = 0.047). Moreover, the incidence of SSI was positively associated with the prevalence of nutritional risk in both simple (OR 1.76 (95% CI: 1.04, 2.98)) and adjusted (OR 1.81 (95% CI: 1.04, 3.16)) models. Answering "yes" to the screening questions regarding reduced dietary intake and weight loss was significantly associated with the incidence of SSI (respectively OR 2.66 (95% CI: 1.59, 4.45) and OR 2.15 (95% CI: 1.23, 3.76)). In conclusion, we demonstrate SSI to occur more often among patients at nutritional risk as compared to those who are not at nutritional risk. Future studies should investigate interventions to prevent both SSI and nutritional risk among surgical patients.

Introduction: Inspections are widely used in health care as a means to improve the health services delivered to patients. Despite their widespread use, there is little evidence of their effect. The mechanisms for how inspections can promote change are poorly understood. In this study, we use a national inspection campaign of sepsis detection and initial treatment in hospitals as case to: (1) Explore how inspections affect the involved organizations. (2) Evaluate what effect external inspections have on the process of delivering care to patients, measured by change in indicators reflecting how sepsis detection and treatment is carried out. (3) Evaluate whether external inspections affect patient outcomes, measured as change in the 30-day mortality rate and length of hospital stay., Methods and Analysis: The intervention that we study is inspections of sepsis detection and treatment in hospitals. The intervention will be rolled out sequentially during 12 months to 24 hospitals. Our effect measures are change on indicators related to the detection and treatment of sepsis, the 30-day mortality rate and length of hospital stay. We collect data from patient records at baseline, before the inspections, and at 8 and 14 months after the inspections. We use logistic regression models and linear regression models to compare the various effect measurements between the intervention and control periods. All the models will include time as a covariate to adjust for potential secular changes in the effect measurements during the study period. We collect qualitative data before and after the inspections, and we will conduct a thematic content analysis to explore how inspections affect the involved organisations., Ethics and Dissemination: The study has obtained ethical approval by the Regional Ethics Committee of Norway Nord and the Norwegian Data Protection Authority. It is registered at www.clinicaltrials.gov (Identifier: NCT02747121). Results will be reported in international peer-reviewed journals., Trial Registration: NCT02747121; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The estimated number of in-hospitals deaths due to adverse events is often different when using data from deceased patients compared with that of a population experiencing adverse events., Methods: The study was conducted at three hospitals in the Bergen Hospital Trust, including a 950-bed university hospital. The objective was to study the reported deaths and investigate the probable number of deaths caused by adverse events. Information about all patients who died in the hospitals during 2011 was retrieved from the electronic patient data management system and the medical records. All deaths were classified into two groups according to Norwegian law based on whether or not the death was sudden and/or unexpected. The cause of death in the latter group was further classified as being due to either natural or unnatural causes according to national requirements. An expert review panel screened the patient records for information regarding adverse events and possible (≥ 50%) preventability. Age, length of hospital stay, and Charlson Comorbidity Index were also registered., Results: There were 59,605 unique patients admitted in 2011 and 1185 registered deaths (1.98%). The mean and median ages of the deceased were 73,8 and 78 years, respectively, and the median length of stay was 5.6 days (range). Of these deaths, 290 (24.5%) were considered sudden and/or unexpected and 218 were considered to be due to natural causes. Of the 72 unnatural deaths, 16 (1.4%) were classified as preventable or probably preventable. For 18 deaths (%) it was impossible to confirm or rule out preventability., Conclusions: Using this method, we identified a small proportion of hospital deaths that could be classified as unnatural. Furthermore, there was a ≥ 50% chance or more that 34 deaths (2.9%) were due to causes that could have been prevented.

Background: Studies from several countries indicate that the incidence and mortality of bloodstream infection (BSI) have been increasing over time., Methods: We studied the burden of disease and death related to BSI in a defined geographical area of Mid-Norway, where BSI episodes were prospectively recorded by the same microbiological department during 12 consecutive years. Death from BSI was defined as death within 30 days of BSI detection. Age and sex standardized incidence and mortality rates and case fatality rates were calculated., Results: Between 2002 and 2013, 1995 episodes of BSI in 1719 patients aged 16 to 99 years were included. The overall incidence of BSI was 215 per 100,000 person-years. The incidence increased exponentially with age, particularly in males. The incidence increased from 205 to 223 per 100,000 person-years from 2002-07 to 2008-13. Escherichia coli was the most frequently isolated infective agent, followed by Streptococcus pneumoniae and Staphylococcus aureus. The rate of S. pneumoniae BSI decreased over time in males (on average by 9.2% annually), but not in females. The total rate of BSI microbes with acquired resistance increased slightly over time, but did not exceed 2 episodes per 100,000 person-years. The mortality of BSI was 32 per 100,000 person-years, higher in males than in females (36 vs. 28 per 100,000 person-years) and was significantly higher in old age, particularly in males. The total BSI mortality was similar in the first and second halves of the study period, but the mortality of S. pneumoniae BSI decreased in males (15.0% annually). The crude case fatality decreased from the first to the second half of the study period (17.2% to 13.1%; p = 0.014). The rate of blood culture sampling increased more than twofold during the study period., Conclusions: The mortality of BSI remained stable during 2002-2013. At the same time, BSI incidence increased and case fatality rate decreased, perhaps because an increased rate of blood culture sampling may have led to improved detection of milder BSI episodes. Very low, yet slightly increasing rates of microbes with acquired resistance were observed.

Background: The occurrence of bloodstream infection (BSI) and antimicrobial resistance have been increasing in many countries. We studied trends in antimicrobial resistance and empiric antibiotic therapy at a medium-sized general hospital in Mid-Norway., Methods: Between 2002 and 2013, 1995 prospectively recorded episodes of BSI in 1719 patients aged 16-99 years were included. We analyzed the antimicrobial non-susceptibility according to place of acquisition, site of infection, microbe group, and time period., Results: There were 934 community-acquired (CA), 787 health care-associated (HCA) and 274 hospital-acquired (HA) BSIs. The urinary tract was the most common site of infection. Escherichia coli was the most frequently isolated infective agent in all three places of acquisition. Second in frequency was Streptococcus pneumoniae in CA and Staphylococcus aureus in both HCA and HA. Of the BSI microbes, 3.5% were non-susceptible to the antimicrobial regimen recommended by the National Professional Guidelines for Use of Antibiotics in Hospitals, consisting of penicillin, gentamicin, and metronidazole (PGM). In contrast, 17.8% of the BSI microbes were non-susceptible to cefotaxime and 27.8% were non-susceptible to ceftazidime. Antimicrobial non-susceptibility differed by place of acquisition. For the PGM regimen, the proportions of non-susceptibility were 1.4% in CA, 4.8% in HCA, and 6.9% in HA-BSI (p < 0.001), and increasing proportions of non-susceptibility over time were observed in HA-BSI, 2.2% in 2002-2005, 6.2% in 2006-2009, and 11.7% in 2010-2013 (p = 0.026), mainly caused by inherently resistant microbes. We also observed increasing numbers of bacteria with acquired resistance, particularly E. coli producing ESBL or possessing gentamicin resistance, and these occurred predominantly in CA- and HCA-BSI., Conclusions: Generally, antimicrobial resistance was a far smaller problem in our BSI cohort than is reported from countries outside Scandinavia. In our cohort, appropriate empiric antibiotic therapy could be achieved to a larger extent by replacing second- and third-generation cephalosporins with penicillin-gentamicin or piperacillin-tazobactam.

Background: Hospital-associated infections (HAIs) are reported to increase patient mortality and incur longer hospital stays. Most studies to date have focused on specific groups of hospitalised patients with a rather short follow-up period. In this repeated cross-sectional study, with prospective follow-up of 19,468 hospitalized patients, we aimed to analyze the impact of HAIs on mortality 30 days and 1 year after the prevalence survey date., Methods: The study was conducted at Haukeland University Hospital, Norway, a large combined emergency and referral teaching hospital, from 2004 to 2011 with follow-up until November 2012. Prevalence of all types of HAIs including urinary tract infections (UTI), lower respiratory tract infections (LRTI), surgical site infections (SSI) and blood stream infections (BSI) were recorded four times every year. Information on the date of birth, admission and discharge from the hospital, number of diagnoses (ICD-10 codes) and patient's mortality was retrieved from the patient administrative data system. The data were analysed by Kaplan-Meier survival analysis and by multiple Cox regression analysis, adjusted for year of registration, time period, sex, type of admission, Charlson comorbidity index, surgical operation, use of urinary tract catheter and time from admission to the prevalence survey date., Results: The overall prevalence of HAIs was 8.5 % (95 % CI: 8.1, 8.9). Patients with HAIs had an adjusted hazard ratio (HR) of 1.5 (95 % CI: 1.3, 1.8,) and 1.4 (95 % CI: 1.2, 1.5) for death within 30-days and 1 year, relative to those without HAIs. Subgroup analyses revealed that patients with BSI, LRTI or more than one simultaneous infection had an increased risk of death., Conclusions: In this long time follow-up study, we found that HAIs have severe consequences for the patients. BSI, LRTI and more than one simultaneous infection were independently and strongly associated with increased mortality 30 days and 1 year after inclusion in the study.

A systematic infection control program is found to be an important tool to reduce hospital-associated infections (HAIs) and surveillance of infection is a significant part of it. The aim of this paper was to present the result from 17 years continuous prevalence studies after implementation of a systematic infection control program, to examine trends of hospital-associated infections and to study possible risk factors for different sites of infection. Data from 61399 in-patients at Haukeland University Hospital, Norway, from 1994 to 2010 was included in the study. Overall prevalence of HAIs was 7.6%. There was a reduction in HAIs from 8.3% in 1994 to 7.1% in 2010 (relative decrease 14.4%), mostly attributable to a significant reduction in the prevalence of urinary tract infections (UTI). For surgical site infections (SSI) we found a borderline significant increase (p=0.05). Male gender (except for UTI), urinary tract catheter and surgical operation were all strong predictors for HAIs. Higher age was a risk factor for all infection types, except for BSI. In conclusion, repeated prevalence surveys demonstrated a significant reduction in HAIs but no decrease in hospital-associated BSI, LRTI and SSI. There was, however, a rapid decline of UTI and other less severe HAIs., (Copyright © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.)

Objectives: We hypothesized reduction of 30 days' in-hospital morbidity, mortality, and length of stay postimplementation of the World Health Organization's Surgical Safety Checklist (SSC)., Background: Reductions of morbidity and mortality have been reported after SSC implementation in pre-/postdesigned studies without controls. Here, we report a randomized controlled trial of the SSC., Methods: A stepped wedge cluster randomized controlled trial was conducted in 2 hospitals. We examined effects on in-hospital complications registered by International Classification of Diseases, Tenth Revision codes, length of stay, and mortality. The SSC intervention was sequentially rolled out in a random order until all 5 clusters-cardiothoracic, neurosurgery, orthopedic, general, and urologic surgery had received the Checklist. Data were prospectively recorded in control and intervention stages during a 10-month period in 2009-2010., Results: A total of 2212 control procedures were compared with 2263 SCC procedures. The complication rates decreased from 19.9% to 11.5% (P < 0.001), with absolute risk reduction 8.4 (95% confidence interval, 6.3-10.5) from the control to the SSC stages. Adjusted for possible confounding factors, the SSC effect on complications remained significant with odds ratio 1.95 (95% confidence interval, 1.59-2.40). Mean length of stay decreased by 0.8 days with SCC utilization (95% confidence interval, 0.11-1.43). In-hospital mortality decreased significantly from 1.9% to 0.2% in 1 of the 2 hospitals post-SSC implementation, but the overall reduction (1.6%-1.0%) across hospitals was not significant., Conclusions: Implementation of the WHO SSC was associated with robust reduction in morbidity and length of in-hospital stay and some reduction in mortality.

Background: Patient involvement in health care decision making is part of a wider trend towards a more bottom-up approach to service planning and provision, and patient experience is increasingly conceptualized as a core dimension of health care quality.The aim of this multi-level study is two-fold: 1) to describe and analyze how governmental organizations expect acute hospitals to incorporate patient involvement and patient experiences into their quality improvement (QI) efforts and 2) to analyze how patient involvement and patient experiences are used by hospitals to try to improve the quality of care they provide., Methods: This multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews and non-participant observation of key meetings and shadowing of staff at the meso and micro levels in two purposively sampled Norwegian hospitals. Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012)., Results: Governmental documents and regulations at the macro level demonstrated wide-ranging expectations for the integration of patient involvement and patient experiences in QI work in hospitals. The expectations span from systematic collection of patients' and family members' experiences for the purpose of improving service quality through establishing patient-oriented arenas for ongoing collaboration with staff to the support of individual involvement in decision making. However, the extent of involvement of patients and application of patient experiences in QI work was limited at both hospitals. Even though patient involvement was gaining prominence at the meso level - and to a lesser extent at the micro level - relevant tools for measuring and using patient experiences in QI work were lacking, and available measures of patient experience were not being used meaningfully or systematically., Conclusions: The relative lack of expertise in Norwegian hospitals of adapting and implementing tools and methods for improving patient involvement and patient experiences at the meso and micro levels mark a need for health care policymakers and hospital leaders to learn from experiences of other industries and countries that have successfully integrated user experiences into QI work. Hospital managers need to design and implement wider strategies to help their staff members recognize and value the contribution that patient involvement and patient experiences can make to the improvement of healthcare quality.

Background: Health authorities in several countries have decided that the health care services should be evidence-based. Recent research indicates that evidence-based practice may be more successfully implemented if the interventions overcome identified barriers., Aims: The present study aimed to examine factors influencing the implementation of evidence-based practice among nurses in a large Norwegian university hospital., Methods: Cross-sectional data was collected from 407 nurses during the period November 8 to December 3, 2010, using the Norwegian version of Developing Evidence-based Practice questionnaire (DEBP). The DEBP included data on various sources of information used for support in practice, on potential barriers for evidence-based practice, and on self-reported skills on managing research-based evidence. The DEBP was translated into Norwegian in accordance with standardized guidelines for translation and cultural adaptation., Results: Nurses largely used experienced-based knowledge collected from their own observations, colleagues and other collaborators for support in practice. Evidence from research was seldom used. The greatest barriers were lack of time and lack of skills to find and manage research evidence. The nurse's age, the number of years of nursing practice, and the number of years since obtaining the last health professional degree influenced the use of sources of knowledge and self-reported barriers. Self-reported skills in finding, reviewing and using different sources of evidence were positively associated with the use of research evidence and inversely related to barriers in use of research evidence., Conclusion: Skills in evidence-based practice seem to reduce barriers to using research evidence and to increase use of research evidence in clinical practice.

Background: How hospital health care personnel perceive safety climate has been assessed in several countries by using the Hospital Survey on Patient Safety (HSOPS). Few studies have examined safety climate factors in surgical departments per se. This study examined the psychometric properties of a Norwegian translation of the HSOPS and also compared safety climate factors from a surgical setting to hospitals in the United States, the Netherlands and Norway., Methods: This survey included 575 surgical personnel in Haukeland University Hospital in Bergen, an 1100-bed tertiary hospital in western Norway: surgeons, operating theatre nurses, anaesthesiologists, nurse anaesthetists and ancillary personnel. Of these, 358 returned the HSOPS, resulting in a 62% response rate. We used factor analysis to examine the applicability of the HSOPS factor structure in operating theatre settings. We also performed psychometric analysis for internal consistency and construct validity. In addition, we compared the percent of average positive responds of the patient safety climate factors with results of the US HSOPS 2010 comparative data base report., Results: The professions differed in their perception of patient safety climate, with anaesthesia personnel having the highest mean scores. Factor analysis using the original 12-factor model of the HSOPS resulted in low reliability scores (r = 0.6) for two factors: "adequate staffing" and "organizational learning and continuous improvement". For the remaining factors, reliability was ≥ 0.7. Reliability scores improved to r = 0.8 by combining the factors "organizational learning and continuous improvement" and "feedback and communication about error" into one six-item factor, supporting an 11-factor model. The inter-item correlations were found satisfactory., Conclusions: The psychometric properties of the questionnaire need further investigations to be regarded as reliable in surgical environments. The operating theatre personnel perceived their hospital's patient safety climate far more negatively than the health care personnel in hospitals in the United States and with perceptions more comparable to those of health care personnel in hospitals in the Netherlands. In fact, the surgical personnel in our hospital may perceive that patient safety climate is less focused in our hospital, at least compared with the results from hospitals in the United States.

Background: An association between use of hand hygiene products and health care-associated infection rates was investigated in a large Norwegian university hospital., Methods: We conducted an ecologic study by combining data from purchasing and admission systems with data from 32 point prevalence surveys (27,248 patients) in 1998-2005. Data on purchase of hand disinfectants and soap, and patient-days, were collected for 20 bed wards similar to those of the prevalence surveys., Results: The prevalence of infections was 7.1%. We found no significant decline in overall infections (P = .19), but use of hand hygiene products significantly increased from 28.5 L per 1000 patients-days in 1998 to 43.3 L per 1000 patient-days in 2005 (P < .001). After examining a linear dose-response relation between use and infection rates, we observed a borderline significant decline in infections from 8% to 6% with increased use of hand hygiene products (P = .05). This association appeared stronger for wards that were registered with infections >9% at study start in 1998 (P < .001)., Conclusion: These data suggests that infection rates may be reflected by amount of hand hygiene products used. Quantification of such products over time may serve as an indicator for hand hygiene performance in hospitals.

Background: Due to the emergence and spread of antibiotic resistance, several infectious diseases are no longer treatable with standard drugs, and in many cases there are no adequate therapeutic options. Even though the situation in the Nordic countries is considerably better than in large parts of the world, we must also contribute to fight this development. In addition to continuing the prudent use of antibiotics, it is important to strengthen certain infection control strategies. WHO has stated that antibiotic resistance is a global health problem., Material and Methods: The article is based on personal experience from infection control and infectious diseases, and impressions from discussions in National and Nordic forums during the last years. We have also reviewed literature retrieved from non-systematic database searches., Results and Interpretation: The introduction of pneumococcal vaccine in the Norwegian Childhood Vaccination Programme will probably contribute to both reducing the use of antibiotics, and preventing the spread of pneumococci that are resistant to antibiotics. Increased influenza vaccination uptake, standard barrier precautions (hand hygiene etc.) against infections in health care institutions, isolation and surveillance of resistant bacteria are among the most important infection control measures that should be strengthened if we are to succeed.

The recent increase in the incidence of methicillin-resistant Staphylococcus aureus in all the Nordic countries prompted the Scandinavian Society for Antimicrobial Chemotherapy (SSAC) to create the 'SSAC Working Party on MRSA' with the objective to identify methods to keep the invasive MRSA infections in the Nordic countries below 1%. The lack of common definitions was recognized as a major obstacle for a joint Nordic effort to combat MRSA. The aim of this publication is to present proposals for epidemiological definitions of individual cases, for how to report MRSA frequency per country, and for communication of MRSA strain characteristics between the countries.

Background: Bloodstream infection is a common cause of hospitalization, morbidity and death in children. The impact of antimicrobial resistance and HIV infection on outcome is not firmly established., Methods: We assessed the incidence of bloodstream infection and risk factors for fatal outcome in a prospective cohort study of 1828 consecutive admissions of children aged zero to seven years with signs of systemic infection. Blood was obtained for culture, malaria microscopy, HIV antibody test and, when necessary, HIV PCR. We recorded data on clinical features, underlying diseases, antimicrobial drug use and patients' outcome., Results: The incidence of laboratory-confirmed bloodstream infection was 13.9% (255/1828) of admissions, despite two thirds of the study population having received antimicrobial therapy prior to blood culture. The most frequent isolates were klebsiella, salmonellae, Escherichia coli, enterococci and Staphylococcus aureus. Furthermore, 21.6% had malaria and 16.8% HIV infection. One third (34.9%) of the children with laboratory-confirmed bloodstream infection died. The mortality rate from Gram-negative bloodstream infection (43.5%) was more than double that of malaria (20.2%) and Gram-positive bloodstream infection (16.7%). Significant risk factors for death by logistic regression modeling were inappropriate treatment due to antimicrobial resistance, HIV infection, other underlying infectious diseases, malnutrition and bloodstream infection caused by Enterobacteriaceae, other Gram-negatives and candida., Conclusion: Bloodstream infection was less common than malaria, but caused more deaths. The frequent use of antimicrobials prior to blood culture may have hampered the detection of organisms susceptible to commonly used antimicrobials, including pneumococci, and thus the study probably underestimates the incidence of bloodstream infection. The finding that antimicrobial resistance, HIV-infection and malnutrition predict fatal outcome calls for renewed efforts to curb the further emergence of resistance, improve HIV care and nutrition for children.

Background: On the basis of new National Guidelines for Hand Hygiene, a project was started in 2004 in a medical ward at Haukeland University Hospital. The aims were to improve the personnel's compliance with hand hygiene guidelines and to transfer from soap hand wash to a disinfectant alcohol-based hand rub., Material and Methods: Two interventions were implemented: information about hand hygiene and increased availability of alcohol-based hand rub. The personnel's hand hygiene performance was recorded through 3 questionnaire-based interviews. The effect was assessed with a paired t-test, by comparing scores 2 and 9 months after the interventions with those before the interventions. Effect was also measured as changes in expenditure on alcohol-based hand rub compared with those for hand soap., Results: Significant improvements were found for hand hygiene before (p = 0.02) and after (p = 0.01) direct contact with patients, after contact with objects near the patient (p = 0.002), before medicine distribution (p = 0.007) and for two subscores when evaluated after 2 months. The 9-month evaluation maintained most of these results, and for some questions the results improved. The expenditure on hand soap decreased, while the expenditure on alcohol-based hand rub increased significantly from 16 to 26 L/1000 treatment days (p = 0.02). There was little change in the total consumption of hand soap and alcohol-based hand rub., Interpretation: Information about hand hygiene and increased availability of alcohol-based hand rub led to improved hand hygiene at all levels of staff.

Background: Resistance to third generation cephalosporins due to acquisition and expression of extended spectrum beta-lactamase (ESBL) enzymes among Gram-negative bacteria is on the increase. Presence of ESBL producing organisms has been reported to significantly affect the course and outcome of an infection. Therefore infections due to ESBL isolates continue to pose a challenge to infection management worldwide. The aim of this study was to determine the existence and to describe phenotypic and genotypic characteristics of ESBLs in an Intensive Care Unit (ICU) setting in Tanzania., Methods: Between October 2002 and April 2003, clinical information and samples were collected from patients suspected to have nosocomial infections in an Intensive Care Unit of a tertiary hospital in Tanzania. The isolates were identified, tested for antimicrobial susceptibility and analysed for presence of ESBL genes., Results: Thirty-nine Gram-negative bacteria were isolated from clinical samples of 39 patients. These isolates included 13 Escherichia coli, 12 Enterobacter spp, 5 Pseudomonas spp, 4 Proteus spp, 2 Klebsiella. pneumoniae, 2 Citrobacter freundii and 1 Chryseomonas luteola. Eleven (28.2%) of these isolates were ESBL producing. The ESBL genes characterised were SHV-12, SHV-28 and CTX-M-15. The ESBL producing isolates were more resistant to gentamicin and ciprofloxacin than non-ESBL producing isolates., Conclusion: This study shows the presence of ESBL genes among Gram-negative bacteria in the ICU setting in Tanzania. There is a need to institute strict hospital infection control policy and a regular surveillance of resistance to antimicrobial agents.

Background: In Norway, around 20 % of the elderly live in long-term care facilities. The risk of acquiring a nosocomial infection increases by age and the consequences of infections become more severe. This article describes the epidemiology of nosocomial infections and the use of antibiotics in long-term care facilities. Infection control measures are recommended., Material and Methods: We used data from the national prevalence surveys of nosocomial infections and from the national surveillance system for communicable diseases. In addition we reviewed current literature., Results: The prevalence of nosocomial infection is similar in hospitals and long-term care facilities in Norway, between 5 % and 10 %. Legal regulations require all health institutions in Norway to have an infection control programme, but little attention has been given to prevention of nosocomial infections in long-term care facilities. Less than 50 % of them have implemented the mandatory infection control programme. The vaccination coverage for influenza is only about 30 %. The coverage of pneumococcal vaccination is even lower., Interpretation: The following actions are recommended for all long-term care facilities: improved hand hygiene by introducing hand disinfection, implementation of infection control programmes, and improved coverage of pneumococcal and influenza vaccination. Employing more health care personnel, nurses as well as doctors, should be a goal.

The urgent need to treat presumptive bacterial or fungal infections in neutropenic patients has meant that initial therapy is empiric and based on the pathogens most likely to be responsible, and drug resistance. The traditional empirical treatment in Norway has been penicillin G and an aminoglycoside, and this combination has been criticized over recent y. We wished to analyse the microbiological spectrum and susceptibility patterns of pathogens causing bacteraemia in febrile neutropenic patients. This was a prospective multicentre study. During the study period of 2 y, a total of 282 episodes of fever involving 243 neutropenic patients was observed. In 34% of episodes bacteraemia was documented. Overall, 40% of the episodes were caused by Gram-positive organisms, 41% by Gram-negative organisms and 19% were polymicrobial. The most frequently isolated bacteria were Escherichia coli (25.6%), a- and non-haemolytic streptococci (15.6%), coagulase-negative staphylococci (12.4%) and Klebsiella spp. (7.4%). None of the Gram-negative isolates was resistant to gentamicin, meropenem, ceftazidime or ciprofloxacin. Only 5 coagulase-negative staphylococci isolates were resistant to both penicillin G and aminoglycoside. The overall mortality rate was 7%, and 1.2% due to confirmed bacteraemic infection.